Need For Rates Research Articles

Results of Lapidus Arthrodesis and Locked Plating With Early Weight Bearing

In the endeavor toward Lapidus fusion, the authors have studied a new application of locked plating for the first tarsometatarsal joint. The goal was to assess the time to fusion, time to ambulation, rate of delayed union/nonunion, rate of revision, and need for hardware removal following the use of locked-plate technology in the fusion of the first tarsometatarsal joint. The findings denoted an average of 6.95 weeks to radiographic fusion, an average of 2 weeks to ambulation, a 9.52% rate of asymptomatic mal-union, a 0% rate of delayed union or nonunion, and a 0% rate of revision. The rate of need for hardware removal was 4.76%.

Predictors of ADL Disability in Culturally Diverse Older Adults

The purpose of this study was to utilize the disablement pathway model to examine the contribution of physical function, dyspnea, and pain to disability in activities-of-daily-living (ADL) in culturally diverse older adults. Participants were 51 older adults (age = 69.0 years ± 9.7; 76.5% African-American, 51.0% < high school education, 52.9% < $20,000 annual income) from an urban community center and an independent living housing facility for seniors. Participants completed the Functional Status Index (FSI), which provides ratings of need for assistance (FSIA) and pain (FSIP) with ADL, the Continuous Scale Physical Functional Performance 10-item Test (CS-PFP10), and an analog dyspnea scale. Hierarchical multiple regression analyses revealed that facility, physical function, pain, and dyspnea accounted for 50.5% of the variance in disability and that pain (β = .43, p < .01) and physical function (β = -.39, p < .01) were the only significant predictors. In the second model, facility, dyspnea, and pain explained 27.6% of the variance in physical function, and facility (β = .39, p < .01) and dyspnea (β = -.26, p = .05) were the only significant predictors. Based on the disablement pathway model, physical functional improvement and pain prevention and management should be targeted when designing culturally appropriate strategies for delaying disability and maintaining independent life.

The relationships between user, carer and staff perceptions of need in an assertive outreach team

Background: There has been little research into the experience of people caring for the mentally ill. This study compared CANSAS ratings of need made by service users, carers and staff in an ACT team.Method: Participating service users and care coordinators completed independent CANSAS ratings of need and all carers were asked to rate service users they cared for using CANSAS.Results: Seventy-eight (92%) service users and 32 carers (91%) participated. Similar levels of need were rated by service users with and without a carer. Among those with a carer, staff and carers reported higher levels of need, than service users. Carers rated higher needs in care of the home and self care, than service users or staff. Levels of agreement between service user and staff ratings were at least “good” in 16/22 domains. Agreement between service users and carers was markedly lower. Agreement between staff and carer need ratings was similar to service user/carer levels.Conclusion: Assessing need from the perspectives of service user, carer and staff highlights discrepancies and may reveal important information. “Triangulated” assessment helps to produce more comprehensive care planning and this should support carers in their role, strengthening their alliance with mental health services.Declaration of interest: None.

Bedarf und Inanspruchnahme psychosozialer Betreuung nach Lebertransplantation

Studies on the need of psychosocial support after liver transplantation (LTX) are rare. At our centre we conducted a survey regarding this question in a one year period with a consecutive sample of 146 patients on average 38 month (SD = 28) after liver transplantation. An assessment of the need was estimated in self-assessment, in a rating after completion of an interview, by the estimate of the attending physicians and with the help of standardized questionnaires. 44.5 % of the patients expressed either a present need (15 %) or a need at an earlier time (29.5 %). The physicians classified 20 % as in need of psychosocial care and from the interviewer's point of view 50 % of the patients needed care. The rating correlated to r = 0.32 (physician) and r = 0.55 (interviewer) with the self-assessment. In the modified Hornheider questionnaire 18 % of the patients were classified as in need of care. In the German version of the Hospital Anxiety and Depression Scale (HADS-D) 25 % of the patients exhibit increased anxiety values and 16 % of the patients depressive symptoms. The results of the questionnaires are highly intercorrelated and correlated low (estimate of physicians) to medium high (estimate of interviewer) with the ratings of need. Grouped according to their self-assessment of need, the groups of patients differ significantly in the applied questionnaires. Patients who do not indicate any need show the lowest anxiety and depression values and report the fewest problems. The offer of psychosocial support in the survey period was utilized by 27 of the participating patients (19 %). Altogether we can estimate the current need at a certain time between 15 and 20 % and a total need after LTX up to 50 %. These results require further examination and the appropriate form of psychosocial offers for these patients should be developed in further research.

Transparent criteria for specialist level adolescent psychiatric care

Rising health care costs and long waiting lists pose a challenge to public specialist level health services. In Finland, the Ministry of Social Affairs and Health required all medical specialities to create a priority-rating tool for elective patients, preferably giving a numerical rating ranging 0-100, with 50 as an entry threshold. To create and test the psychometric properties of a point-count measure for prioritising entry to public specialist level adolescent psychiatric services. Around 710 referred adolescents were given ratings on 17 items focusing on symptom severity, problem behaviours, functioning, progress of adolescent development and prognosis. The structured ratings were compared to an overall assessment of need for treatment on a VAS scale. In order to ensure that the tool was not inappropriately sensitive to confounding by non-disturbance related factors, the associations between the structured priority rating and sex, age, referring agent, study site and diagnosis were analysed. Of the 17 items, 15 were included in the final priority-rating tool. The requirement than threshold score for entry to services being set at 50 points necessitated scoring factors rather than individual items. Four blocks of items were formed: symptoms and risks; impaired functioning; other relevant issues, and prognosis without specialist level treatment. Most of the referred adolescents scored over the threshold of 50. When diagnosis was controlled for, scoring over 50 was largely independent of age, sex, referring agent or study site. The structured priority ratings corresponded well with clinical global rating of need for care. The tool was not inappropriately sensitive to age, sex, referring agent or study site. In the future, follow-up studies will be needed to evaluate the predictive value of priority ratings.

Safe restraint of the child passenger

The aim of this study was to understand the need for, and use of, booster seats in the 4-12 years age group and to identify risk factors for booster seat-non-use. A cross-sectional sample of 1101 children aged 4-12 years travelling in 663 privately owned vehicles was taken from the Auckland region. Auckland is New Zealand's largest population centre, with a population of over 1.5 million. Information was gathered using a short questionnaire followed by direct inspection to identify those children using booster seats. The SafetyBeltSafe USA '5-step rule' was used to look at those children not using a booster seat to determine whether one was still required. While booster seat use has improved significantly in younger children since a similar study in 1992, only 40% of sampled children requiring a booster seat were using one. Booster seat use by children requiring them declined sharply as age increased. While 93% of 5- to 8-year-olds required a booster, only 30% were using one. The requirement for booster seats fell dramatically to 34% of 9- to 12-year-olds, but only 3% were using one. The high rate of need for booster seats and the lack of use of booster seats in children aged 5-8 years is a strong argument for legislation and education programmes targeting this age group. While the proportion of 9- to 12-year-olds needing a booster drops sharply, there would likely be benefits from educating parents on the '5-step rule' or similar method to help identify the 30% of these older children that would continue to benefit from a booster seat. Rear seating should be promoted alongside booster seat use in the age group 4-12 years.

If at First or Second You Don’t Succeed: Mastectomy?

In this issue of Annals of Surgical Oncology, Menses et al. 1 reviewed factors associated with local recurrence after breast-conservation surgery in 459 patients treated for invasive and in situ carcinoma of the breast. Overall, the authors reported a local recurrence in 28 patients (6%) at 5 years. Nearly 50% of patients (n = 229) in this series had at least 1 reexcision, and only 22 patients had 2 or more reexcisions. The local recurrence rate in the 22 patients re-excised 2 or more times was 13.4%, compared with 5.6% of patients with 1 re-excision and 3.5% without a re-excision at 5 years. On multivariate analysis, the authors also found, in addition to the number of reexcisions, that age younger than 50 years and omission of radiotherapy were also independent factors associated with an increased local recurrence rate. The results of this study are intuitive to the surgical oncologist who routinely performs breast-conservation surgery. Many of us will continue to perform multiple attempts at breast conservation if removal of additional tissue is unlikely to cause a severe deformity and the patient has a very strong commitment to preserve her breast. This sometimes makes us feel uncomfortable because we are concerned that we may actually miss the specific margin that was found to be positive by the pathologist during the re-excision or that there may be a large amount of otherwise unidentified additional occult disease and because we are aware that the patients tumor size is an independent risk factor for obtaining positive margins during surgery. 2 Notwithstanding, in the absence of postmastectomy irradiation, it is important to be aware that larger invasive tumors are also associated with increased local recurrence rates in patients receiving mastectomy as the initial form of local therapy. 3 The answer to the question of what to do if we do not get negative margins on our first or subsequent attempted excision is simple: try, try again. If we had evidence that performing additional re-excisions adversely affected survival, then the answer would be different. So where do we go from here? With extensive intraoperative pathologic and radiographical processing, the rate of need for re-excision for margin control in patients receiving breast-conserving surgery at M. D. Anderson Cancer Center for ductal carcinoma-in-situ has been reduced to 22%. 4 It is not known whether the approximately 40% of patients who had re-excision at the initial operation for close or positive margins in the M. D. Anderson Cancer Center study 4 are at less risk for a local recurrence compared with patients who would have required a subsequent operation for re-excision. However, most patients would prefer one operation compared with two or more surgical procedures. Because the region of local recurrence in the breast is almost always at the area of initial excision, might patients requiring multiple re-excisions be candidates for an additional radiation boost at this site in an attempt to decrease local recurrence? 5 It is likely that better systemic therapies for both ductal carcinomain-situ and invasive breast cancer will further reduce rates of in-breast local recurrences. Accelerated partial breast irradiation using three-dimensional conformal radiation and brachytherapy is being tested in a randomized trial by the National Surgical Adjuvant Breast and Bowel Project and the Radiation Therapy Oncology Group. 5 Will more conformal radiation

Psychosocial needs of boys in secure care for serious or persistent offending

The mental health of child offenders who are detained in secure settings is a matter of great public and professional concern but there has been little systematic longitudinal research on the outcomes of these problems once the young person has returned to the community. The aims of the present study were to describe the psychosocial outcomes of boys in secure care and to establish if these outcomes were correlated with criminal outcomes. Prospective cohort study of 97 boys whose average age was 14 years when they were admitted to secure units in the North West of England. The boys were followed up on average 2 years later, when outcome data were obtained on 81/97 (83%) cases. The main outcome measure was a standardised assessment of mental health, social and educational needs obtained by interview with the young person and corroborated in most cases by information from informants. All data were then reviewed by experienced clinicians who made best-estimate ratings of need 'blind' to the findings from the first phase of the study. The average number of needs requiring an intervention at follow-up (mean=3.4, sd=3.0) was much lower than before admission to secure care (mean=8.2, sd=2.5) (mean difference 4.9 needs, 95% CI 4.0 to 5.7). Educational and occupational needs were particularly well dealt with. However, many mental health problems persisted or worsened. For example, 31% had a need for treatment of substance abuse, a significant increase compared with when they were in secure care (percentage difference 21%, 95% CL 9.0% to 32.7%). No mental disorder predicted subsequent offending. Boys who have been in secure care continue to have a high rate of mental health problems. The mental health needs of this group are not, however, static but change over time and with changing circumstances. Services need to be designed to meet these changing needs.

Self-Assessment in the Measurement of Public Health Workforce Preparedness for Bioterrorism or other Public Health Disasters

The purpose of this study was to examine effective ways to evaluate public health workers' competence for preparedness. The Public Health Ready project, developed by the National Association of County and City Public Health Officials and the Centers for Disease Control and Prevention, is a pilot program designed to prepare local public health agencies to respond to emergency events. Workers at a Public Health Ready site (N=265) rated their need for training and their competence in meeting generic emergency response goals. Cluster analysis of cases was conducted on the self-assessed need for training. Three groups of workers emerged, differing in their overall ratings of need for training. A given worker tended to report similar needs for training across all training goals. In this study, workers' ratings of need for training may reflect an overall interest in training rather than need for training in a particular area. Caution should be exercised in interpretation when generic goals and self-assessment are used to measure need for training. Future assessments of training needs may be more effective if they use objective measures of specific local plans.

Need for Eye Care Among Older Adults With Diabetes Mellitus in Fee-for-Service and Managed Medicare

To compare rates of need for eye care among Medicare beneficiaries with network-model Medicare+Choice (MC) and fee-for-service (FFS) health insurance. Cross-sectional study of a random sample of MC and FFS community-dwelling Medicare beneficiaries with diabetes who are older than 65 years of age in Los Angeles County. Study ophthalmologists masked to the participants' type of health insurance performed standardized dilated eye examinations and indicated the need for ophthalmic care during the next 6 months. To evaluate the association between type of insurance and need for treatment, we constructed logistic regression models adjusted for participant sociodemographic and clinical characteristics. The 311 MC and 107 FFS respondents reported comparable rates of eye care provider visits and preexisting eye diseases. However, on masked clinical examination, MC respondents were more likely to have diabetic retinopathy, visually significant cataract, glaucoma, or suspected glaucoma than FFS participants (68% vs 46%, P<.001). In multivariate analyses, persons enrolled in MC were significantly more likely than FFS participants to require further treatment during the next 6 months (42% vs 24%, P = .01). Data from standardized study ophthalmic examinations suggest high rates of unrecognized and untreated eye diseases among Medicare beneficiaries enrolled in both FFS and MC and significantly higher rates of need for care among MC participants.

Use of mental health services by men injured through community violence.

The aim of this study was to assess the use of mental health services and predictors of use among men injured through community violence. This one-year prospective study examined use of mental health services in a sample of 231 men who were injured through community violence and hospitalized at an urban trauma center. Predictors of mental health service use that were examined included age, ethnicity, income, neuroticism, injury severity, previous mental health service use, and need for services. Need for services was defined objectively by self-report of symptoms of posttraumatic stress disorder (PTSD) and subjectively by perception of an injury-related emotional problem. Univariate logistic regression analysis showed that older age, non-Latino ethnicity, previous use of services, and need for services predicted service use in the year after the injury. In a multivariate logistic regression analysis, objective and subjective need for services and older age predicted postinjury service use. In the subset of men who were symptomatic postinjury, only older age and objective need predicted use of mental health services. Despite high rates of need for services related to PTSD after violent injury in this sample, the rate of mental health service use was low. Psychoeducation about postinjury reactions and attention to structural barriers to services may help increase rates of care in this population.

Inverse care for mentally ill prisoners: unmet needs in forensic mental health services

Previous studies have demonstrated increasing levels of psychiatric morbidity among the UK prison population. Few studies of this population have been conducted using systematic needs assessment instruments. We tested the hypotheses that mentally disordered offenders (MDOs) who go into prison from the community differ significantly from general adult patients in having (1) more needs and (2) more unmet needs. We compared 73 consecutive male patients who had psychotic illness and were transferred from prison with 84 male patients who had psychotic illness and were in the community. Patients were interviewed using the Camberwell Assessment of Need schedule (CAN). Inmate medical records were examined and prison healthcare staff were interviewed. The results showed that the prison group had significantly more total needs on average and significantly more unmet needs than their general adult patient counterparts. The greater unmet needs were in the following domains: psychotic symptoms, psychological distress, welfare benefits, money, daytime activities, company and food. The results suggest an inverse care law so that MDOs in the community have high rates of need and low levels of treatment and care.

Air Transport Pilots' Information Priorities for Surface Moving Maps

The use of a surface map display for operations on or near the airport surface (taxi out, takeoff, final approach and landing, taxi in) is expected to enhance safety. There is a lack of research, however, detailing how the airport surface should be depicted to air transport pilots during taxi operations. In order to address this question, an information analysis was conducted in which air transport pilots provided self-reported ratings of need for display elements found on current airport diagrams or made available on prototype surface map displays for operations on or near the airport surface. The ratings highlighted the value of presenting runway location and traffic information across all operational phases and showed the changing utility for display elements across different phases of operations. Comparison of the air transport pilot ratings with general aviation pilot ratings showed general agreement as to which display elements were of high value. Differences between the two groups were largely attributable to differences in the nature of operations.

The needs of older people with mental health problems according to the user, the carer, and the staff.

Individual assessment of needs has been recognised as the most appropriate way to allocate health and social care resources. These assessments, however, are often made by the staff or by a carer who acts as an advocate for the user themselves. Little is known about how these proxy measures compare to how individual patients perceive their own needs. The aim of this study was to measure and compare ratings of need for older people with mental health problems by the older person themselves, their carer, and an appropriate staff member. One-hundred and one older people were identified from various mental health services and 87 users, 57 carers, and 95 staff were interviewed using the Camberwell Assessment of Need for the Elderly (CANE) to identify met and unmet needs. Users identified significantly fewer of their needs (5.5) than either staff (8.1) or carers (8.3) did, but this difference was accounted for by people with dementia reporting less needs. Users identified fewer psychological or social needs (e.g. daytime activities, company, or carer distress) than staff or carers did. The average Kappa indicating level of agreement between staff and user was 0.52, between user and carer was 0.53, and between carer and user was 0.58. This showed only a fair level of reliability between different ratings of need. User perspectives should be given a high priority when assessing individual needs. Fears that assessment of need would be unduly time-consuming or would simply reflect individual demands should be allayed. A user-based assessment will assist healthcare providers to prioritise needs according to what the user themselves consider to be most important, beneficial, and acceptable to them. Reliance solely on assessment by staff or carers may not lead to the most equitable or appropriate use of services.

Variations in mental health needs and fee-for-service reimbursement for physicians in Ontario.

The study examined the match between mental health needs and physician fee-for-service reimbursements for mental health care within age and gender groups and health planning regions in Ontario, Canada. Indicators of need (mental disorder, reported disability, and self-rated mental health) from an epidemiologic survey of 9,953 Ontario household residents were compared with per capita reimbursement rates derived from an administrative data set containing all fee-for-service expenditures for mental health care paid by the provincial health plan. Few gender differences were found in overall need, but need varied significantly by age. Those in greatest need were adolescent males and females, who had rates of need from two to four times higher than older respondents. Regional variations in need were less evident. By contrast, per capita reimbursement showed marked gender differences, with rates for women generally twice the rates for men. Considerable variations in reimbursement were also found across age groups; these variations did not match variations in need. Highly urbanized areas had per capita reimbursement rates between two and four times the rates for less populated areas. Despite Ontario's universal-access health care system, notable discrepancies between need and resource use are evident for males, adolescents, and residents of less urbanized areas. Solutions require a combination of public education, provider training, attention to physician availability and practice patterns, and continuous monitoring of how resources are allocated relative to need.

Influences on Teacher Referral of Children to Mental Health Services

Sixty-four third-, fourth-, and fifth-grade teachers read vignettes describing boys and girls with (1) externalizing and internalizing disorders and (2) externalizing and internalizing problems of less severity. Teachers rated whether the child described in each vignette needed to be referred for mental health treatment and indicated whether they had referred a similar child for treatment. Teachers' ratings of need for referral did not differ for boys and girls, and there was no gender effect on the teachers' reported referral experience. However, teachers reported having referred more children with externalizing problems than with internalizing problems for treatment, even though they did not rate externalizing problems as needing referral more than internalizing problems. Such discrepancies are discussed in terms of the different effect of internalizing and externalizing problems on the classroom environment.

II. The Colorado Social Health Survey of mental health service needs: Sampling, instrumentation, and major findings

A stratified probability sample of 4,745 adult Colorado household residents was surveyed using three measures of need for alcohol, drug abuse, and mental health (ADM) services: diagnosable disorders assessed by the Diagnostic Interview Schedule, dysfunction in everyday living assessed with locally developed scales, and “demoralization” assessed with the Center for Epidemiologie Studies — Depression (CES-D) scale. The interviews, collectively termed the Colorado Social Health Survey (CSHS), were conducted in 48 randomly selected small areas of the state (metropolitan census tracts or rural census county divisions) to obtain estimates of prevalence of need for ADM services in those areas and for the state as a whole. The overall response rate for the survey was 72%. Concurrent validity as measures of need for services was apparent from significantly higher mean need scores for current users of ADM outpatient and inpatient services in comparison to nonusers. Results indicated that 26.5% of Colorado's general population was in need of ADM services by at least one measure. Statewide mean need prevalence rates were 16.3% for diagnosable disorders, 11.1% for everyday dysfunction, and 11.0% for demoralization. Importantly, there was only limited overlap in need “caseness” assessed by each of the three measures for both service-users and nonusers; these measures appear to assess substantially independent constructs or domains of need. Interestingly, diagnosable disorder alone was unrelated to respondents' use of ADM specialty services. Instead, combinations of “caseness” by two or more need measures were more typical for service users. Variation in need prevalence across the 48 subareas was substantial, ranging from 3 % to 30% for diagnosable disorders, from 1% to 25% for everyday dysfunction, and from 3% to 28% for demoralization. These findings challenge the usual assumption of a uniform rate of need for ADM services in all subareas of a state.

I. Validation of indirect methods to estimate need for mental health services: Concepts, strategy, and general conclusions

This first of six articles presents a summary and overview of a large-scale needs-assessment research project in Colorado. Its primary goal was to test empirically the validity of a number of statistical procedures or “models” currently available for indirectly estimating the need for alcohol, drug abuse, and mental health (ADM) services in an entire state or region and across its geographic subareas. The models examined included both “social-indicator” and “syntheticestimation” types, several of which are currently used by state public mental health systems as part of their mental health services planning and funding procedures. The validating criteria of need, against which predictions of the various models were tested, were provided by the Colorado Social Health Survey (CSHS), a household-based probability sample of 4,745 adults aged 18 and over. The survey used three different measures of need: (1) diagnosable disorders as assessed by the Diagnostic Interview Schedule, (2) project-developed scales for dysfunction in everyday living, and (3) “demoralization” as assessed with the Center for Epidemiologic Studies — Depression (CES-D) Scale. These assessments were intercorrelated only slightly, suggesting multiple types or components of need for ADM services and indicating an overall current prevalence rate of 26.5% for all categories of need for services. While few of the models as originally constructed performed well in predicting to different categories of need for services across the 48 Colorado subareas surveyed, most displayed considerable potential for improving the accuracy of needs estimation when compared to using a uniform or “flat” rate of need for services in all subareas. After model parameters were adjusted to provide the best possible fit with survey results, two existing models and two new models were selected as most promising for use by states and others interested in indirectly estimating need for ADM services. Use of such models for making the best available estimates of need is strongly recommended.

Differences in ratings associated with differences in measures of rater's difficulty with the task

ABSTRACTRatings of need for improvementt in project descriptions, ratings of difficulty in performing the task, and total time spent completing the task were examined to determine whether these measures of task difficulty had any bearing on ratings of social value. The few significant group differences in project value ratings and in hypothetical allocations reflecting research values adn priorities are quite possibly attributable to chance occurrence. The absence of any significant group differences in global project ratings leads to our conclusion that global ratings of project's social value appear to be independent from the amount of difficulty experienced in assigning those ratings. For more specific aspects of a project's social value, there is a slight indication that raters who experience little difficulty with the task, particularly those who indicate little need for improvement in project descriptions, give lower ratings that raters who experience moderate difficulty

TETANUS

The 68-year Charity Hospital experience with tetanus has been reviewed with particular emphasis on the past 8 years. There were 2,449 cases treated at Charity Hospital from 1906 through 1974. The mortality rate has remained high. There were 24 cases in the past 8 years, with a 58% case fatality rate. Clues to our high mortality rate could be: 1) many cases with a short period of onset, 2) none of our 24 cases received treatment at time of injury, and 3) there were more severe cases, as judged by the high rate of need for tracheostomy. The method of management emphasizes: 1) wound care, 2) neutralization of the toxin, 3) antibiotic therapy, 4) supportive measures including good nursing care with control of convulsions and seizures, and 5) completion of active immunization. Prophylaxis is stressed, with particular emphasis on wound debridement and toxoid. The decreasing incidence of the disease is encouraging, probably related directly to proper immunization. However, the mortality rate remains high and the solution to the problem of tetanus is still prophylaxis. Epidemiologic considerations were discussed with particular emphasis on tetanus in the five Gulf States, the South in general, and the decreasing incidence in endemic areas.