Randomised controlled trial of two antenatal care models in rural Zimbabwe. Combining specialist and primary health care teams for HIV positive patients: retrospective and prospective studies. Staged diabetes management. Toward an integrated model of diabetes care. Collaborative Depression Trial (CADET): multi-centre randomised controlled trial of collaborative care for depression--study protocol. Toward managed care for persons with severe mental illness: implications from a cost-effectiveness study. Participatory supervision model: building health promotion capacity among health officers and the community. An innovative approach to geriatric acute care delivery: the Choate-Symmes experience. Outcome of case management based on the strengths model compared to standard care. A randomised controlled trial. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. Children in foster care: factors influencing outpatient mental health service use. A population-based, randomized clinical trial on back pain management.
To compare a five-visit antenatal care (ANC) model with specified goals with the standard model in a rural area in Zimbabwe.
                Cluster randomised controlled trial with the clinic as the randomisation unit.
                Primary care setting in a developing country where care was provided by nurse-midwives.
                Women booking for ANC in the clinics were eligible.
                Number of antenatal visits, antepartum and intrapartum referrals, utilization of health centre for delivery and perinatal outcomes.
                Twenty-three rural health centres were stratified prior to random allocation to the new (n = 11) or standard (n = 12) model of care.
                We recruited 13,517 women (new, n = 6897 and standard, n = 6620) in the study, and 78% (10,572) of their pregnancy records were retrieved. There was no difference in median maternal age, parity and gestational age at booking between women in the standard model and those in the new model. The median number of visits was four for both models. The proportion of women with five or less visits was 77% in the new and 69% in the standard model (OR 1.5; 95% CI 1.08-2.2). The likelihood of haemoglobin testing was higher in the new model (OR 2.4; 95% CI 1.0-5.7) but unchanged for syphilis testing. There were fewer intrapartum transfers (5.4 versus 7.9% [OR 0.66; 95% CI 0.44-0.98]) in the new model but no difference in antepartum or postpartum transfers. There was no difference in rates of preterm delivery or low birthweight. The perinatal mortality was 25/1000 in standard model and 28/1000 in new model.
                In Gutu district, a focused five-visit schedule did not change the number of contacts but was more effective as expressed by increased adherence to procedures and better use of institutional health care. To develop and evaluate a model of health care for HIV positive patients involving specialist, hospital based teams and primary health care teams.
                One year retrospective and a 2 1/2 year prospective study.
                Two hospitals in West London and 88 general practitioners in 72 general hospitals.
                209 adults with HIV infection.
                General practitioners enrolled in the project were faxed structured outpatient clinic summaries. When hospital inpatients were discharged, a brief discharge summary was faxed. General practitioners had access to consultant physicians skilled in HIV medicine through a 24 hour mobile telephone service. An HIV/AIDS management and treatment guide containing relevant local information was produced. Quarterly discussion forums for general practitioners were held, and a regular newsletter was produced.
                Hospital attendance and general practitioner consultations; perceived benefits and problems of patients and general practitioners.
                The average length of a hospital inpatient stay was halved for those patients who had participated in the project for two years, and the average number of visits to the outpatient clinic per month fell for patients with AIDS. There was a substantial increase in the number of visits to general practitioners by patients with AIDS and symptomatic HIV infection. Patients and general practitioners both felt that the standard of health care provided had improved.
                This model of health care efficiently and effectively utilised existing teams of hospital and primary health care professionals to provide care for HIV positive patients. Simple, prompt, and regular communication systems which provided information relevant to the needs of general practitioners were central to its success. This paper introduces a new and innovative approach to diabetes management in the primary-care setting. Staged diabetes management (SDM) represents a four-year effort to develop and test a data-based approach to diabetes management that could be easily adapted to a variety of health-care settings in which diabetes management is principally under the direction of primary-care physicians was limited access to specialists. After testing under controlled circumstances at the International Diabetes Center (Minneapolis, MN), SDM was subjected to substantial field trials under conditions that represent the scope and variety of primary-care practices in diabetes. The following represents the work of several investigators who independently undertook a review of SDM. Comprising of both organisational and patient level components, collaborative care is a potentially powerful intervention for improving depression treatment in UK primary Care. However, as previous models have been developed and evaluated in the United States, it is necessary to establish the effect of collaborative care in the UK in order to determine whether this innovative treatment model can replicate benefits for patients outside the US. This Phase III trial was preceded by a Phase II patient level RCT, following the MRC Complex Intervention Framework.
                A multi-centre controlled trial with cluster-randomised allocation of GP practices. GP practices will be randomised to usual care control or to "collaborative care" - a combination of case manager coordinated support and brief psychological treatment, enhanced specialist and GP communication. The primary outcome will be symptoms of depression as assessed by the PHQ-9.
                If collaborative care is demonstrated to be effective we will have evidence to enable the NHS to substantially improve the organisation of depressed patients in primary care, and to assist primary care providers to deliver a model of enhanced depression care which is both effective and acceptable to patients. Over the past two decades various models of community-based care for persons with severe mental illness have been developed. This study, which represents the first comparison of the most successful care approach (Program of Assertive Community Treatment or PACT adaptation model) with other, less intensive approaches (clinical team and intensive broker models) in a community service system, indicates that client outcomes were more positive in the PACT adaptation model in terms of enhanced psychosocial functioning and reduced acute and subacute care costs. The PACT model was not significantly more expensive in terms of the costs of providing supportive services compared with the clinical team approach and the intensive broker model of care. The Thai traditional health supervision model has been developed since 1991. However, many supervisors lack supervisory knowledge and skills. This study aimed to compare and identify the strengths and challenges of two different supervision models, in order to determine their effects on enhancing the health promotion capacity of health officers in two primary care units (PCU) in Chiang Mai Province, northern Thailand.
                The two models were implemented at two PCU in one semi-district, Chiang Mai Province, over a six-month period. The first model involved supervisors from the district level, with the full participation of health officers at the sub-district level. The second model was designed with the addition of community involvement in the supervision process. Before implementing the models, the district supervisors attended a retraining course to enhance their supervisory knowledge and ability. Questionnaires were used to assess health officers' job satisfaction, clients' perceived service quality and care satisfaction. Semi-structured interviews and qualitative observations were used to explore the involvement of health officers and the community, and to determine the strengths and challenges of each supervisory model.
                Both before and after the intervention, the PCU health officers appeared to have good and comparable job satisfaction levels. Bivariate analysis indicated that after the intervention, both supervisory models appeared effective in terms of clients' perceived service quality and satisfaction with care, among those who utilized the PCU. However, the second model, which allowed the community to participate in the supervision process, achieved better results. The qualitative findings suggested that the involvement of health officers caused a rapid change and improvement after the supervision. The involvement of the community helped the community itself to identify problems and formulate alternatives to meet the community's needs.
                This study shows positive outcomes for two forms of participatory supervision in a rural setting. There appear to be additional positive outcomes for the model that involved community participation. To ensure successful implementation, several issues, such as the supervisor's knowledge and ability, health officer workload and supervisory communication skills, need to be improved. Hospitals, like those described in this study, must develop alternative models of health care delivery that allow them to respond to many challenges while providing high-quality health care to geriatric patients. In this program, 10-bed geriatric units were established in two hospitals, and patients age 65 and older were selected at random for admission to the units. Following comprehensive assessment, self-reliance was fostered using individualized interventions. Discharge planning began at admission. A multidisciplinary approach with regular team conferences including families was also used. Results of this approach suggest that such intervention can reduce length of stay without affecting quality of care. This paper describes the delivery model in detail, focuses on issues related to the implementation of the intervention, and highlights the lessons learned by Choate-Symmes personnel through their demonstration of the model. The outcome of less intensive case management services, such as the strengths model, is still inconclusive, which suggests a need for more controlled studies. The aim of the present study was to investigate the outcome of a strengths model of case management service (SCM) compared to standard care.
                Seventy-seven clients with a mental illness and a serious impairment in functioning in social contacts, housing or work situation were randomly allocated to SCM or standard care. Outcome was assessed with regard to use of psychiatric services, changes in symptomatology, psychosocial functioning, social network, needs for care, quality of life and client satisfaction with care. The follow-up period was 36 months.
                The results showed a greater reduction in needs for care in clients receiving SCM. No differences in clinical or social outcome were shown. Clients receiving SCM also used significantly less days in psychiatric inpatient services and were generally more satisfied with the psychiatric services offered.
                SCM failed to improve clinical and social outcome compared to standard care, but was more successful in reducing days spent in hospital, and the clients were also more satisfied with the service compared to standard care. There are approximately 4 million neonatal deaths and half a million maternal deaths worldwide each year. There is limited evidence from clinical trials to guide the development of effective maternity services in developing countries.
                We performed a cluster-randomized, controlled trial involving seven subdistricts (talukas) of a rural district in Pakistan. In three talukas randomly assigned to the intervention group, traditional birth attendants were trained and issued disposable delivery kits; Lady Health Workers linked traditional birth attendants with established services and documented processes and outcomes; and obstetrical teams provided outreach clinics for antenatal care. Women in the four control talukas received usual care. The primary outcome measures were perinatal and maternal mortality.
                Of the estimated number of eligible women in the seven talukas, 10,114 (84.3 percent) were recruited in the three intervention talukas, and 9443 (78.7 percent) in the four control talukas. In the intervention group, 9184 women (90.8 percent) received antenatal care by trained traditional birth attendants, 1634 women (16.2 percent) were seen antenatally at least once by the obstetrical teams, and 8172 safe-delivery kits were used. As compared with the control talukas, the intervention talukas had a cluster-adjusted odds ratio for perinatal death of 0.70 (95 percent confidence interval, 0.59 to 0.82) and for maternal mortality of 0.74 (95 percent confidence interval, 0.45 to 1.23).
                Training traditional birth attendants and integrating them into an improved health care system were achievable and effective in reducing perinatal mortality. This model could result in large improvements in perinatal and maternal health in developing countries.
                Copyright 2005 Massachusetts Medical Society. To determine factors influencing outpatient mental health service use by children in foster care.
                Detailed survey and administrative data were collected on 480 children who entered long-term foster care in San Diego County from May 1990 through October 1991. These data were linked with claims data from Medicaid and San Diego County Mental Health Services information systems. A Poisson regression model was used to determine whether the following factors influenced outpatient mental health service use: age, race/ethnicity, gender, maltreatment history, placement pattern, and behavioral problems as measured by the Achenbach Child Behavior Checklist (CBCL).
                Except for maltreatment history, all independent variables included in the multivariate regression model were statistically significant. The total number of outpatient mental health visits increased with age, male gender, and non-relative foster placements. Relative to Caucasians, visits were lower for Latinos, and Asian/Others, but comparable for African-Americans. Concerning maltreatment history, differences were only found in one category; children experiencing caretaker absence received fewer visits compared to children who did not experience caretaker absence. Children with CBCL Total Problem Scale T-scores of 60 or greater had significantly more visits than those with a score less than 60.
                Both clinical and non-clinical factors influence outpatient mental health service use by foster children. Limitations imposed by gender, race/ethnicity, and placement setting need to be addressed by child welfare policies. These finding suggest that guidelines are needed to systematically link children in foster care with behavioral problems to appropriate services. Population-based randomized clinical trial.
                To develop and test a model of management of subacute back pain, to prevent prolonged disability.
                The present management of back pain seems inadequate, and development of innovative models has been urged.
                A model for the treatment of subacute work-related back pain has been developed and evaluated in a population-based randomized clinical trial. Workers (n = 130) from eligible workplaces in the Sherbrooke area (N = 31), who had been absent from work for more than 4 weeks for back pain, were randomized, based on their workplace, in one of four treatment groups: usual care, clinical intervention, occupational intervention, and full intervention (a combination of the last two). The duration of absence from regular work and from any work was evaluated using survival analysis. Functional status and pain were compared at study entry and after 1 year of follow-up.
                The full intervention group returned to regular work 2.41 times faster than the usual care intervention group (95% confidence interval 1.19-4.89; P < 0.01). The specific effect of the occupational intervention accounted for the most important part of this result, with a rate ratio of return to regular work of 1.91 (95% confidence interval = 1.18-3.10; P < 0.01). Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups, compared with the trend in the usual care intervention group.
                Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain.
Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.