Public–Private Collaboration in Health and Human Service Delivery: Evidence from Community Partnerships

The collaboration among public–private partnerships that applied to the Community Care Network (CCN) demonstration program of the Hospital Research and Educational Trust is examined. These partnerships link broad-based community coalitions with health and human service providers in efforts to improve community health and local service delivery. Although they willingly collaborated in identifying community health needs, coordinating services, and reporting to the community, partnership participants showed less alacrity in joining forces to reduce redundancy and increase efficiency. Such patterns suggest that organizations might best profit from working together on activities that maintain existing power relations and that have the potential to add prestige and attract new clients. Collaboration in these areas may be essential to building a foundation of trust that leads to future cooperation in more sensitive areas.     

A phase I randomized,double‐blind,single subcutaneous dose escalation study to determine the safety,tolerability, and pharmacokinetics of rezafungin in healthy adult subjects

Rezafungin is a novel echinocandin being developed for the treatment and prevention of invasive fungal infections. The objectives of this randomized, double‐blind study in healthy adults were to determine the safety, tolerability, and pharmacokinetics of rezafungin after subcutaneous (s.c.) administration. The study design consisted of six sequential cohorts of eight subjects, except for the first cohort with four subjects. The subjects were randomized in a 3:1 ratio of rezafungin to placebo and were to receive a single dose of 1, 10, 30, 60, 100, or 200 mg. The most common adverse events (AEs) were increased alanine aminotransferase and sinus bradycardia (unsolicited) and erythema at the injection site (solicited). Unsolicited AEs were generally mild to moderate and not rezafungin‐related. Although the study was terminated after the 10 mg dose cohort due to concerns of potential increased severity of injection site reactions, no predetermined dose escalation halting criteria were met. Following the 10 mg single s.c. dose of rezafungin (n = 6), the geometric mean (GM) maximum concentration (C _max) was 105.0 ng/ml and the median time to C _max was 144 h. The GM area under the concentration‐time curve was 32,770 ng*h/ml. The median estimated terminal half‐life was 193 h. The GM apparent oral clearance was 0.255 L/h and the GM apparent volume of distribution was 68.5 L. This study demonstrates that a single s.c. dose of rezafungin in healthy adult subjects: (1) did not result in serious AEs, death, or withdrawal from the study due to an AE; and (2) produced a pharmacokinetic profile with long exposure period postadministration. In an effort to reduce the occurrence of injection site reactions, a re‐evaluation of the rezafungin s.c. formulation could be considered in the future.

Study Highlights

• WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC?

Currently marketed antifungal agents of the echinocandin class are dosed by i.v. once daily and are therefore not practical for prolonged or outpatient prophylaxis. Rezafungin is an investigational echinocandin (currently in phase III trials studying once‐weekly i.v. administration) that has excellent activity against clinically relevant Candida and Aspergillus spp. and Pneumocystis jirovecii, a prolonged half‐life allowing for longer dosing intervals, and a stability/solubility profile that allows for the possibility of subcutaneous (s.c.) dosing.

• WHAT QUESTION DID THE STUDY ADDRESS?

The objectives of this randomized, double‐blind study in healthy adults were to determine the safety, tolerability, and pharmacokinetics (PKs) of rezafungin after s.c. administration.

• WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE?

This study provided safety data regarding s.c. administration of rezafungin. Despite common solicited injection site reactions, s.c. administration of 10 mg of rezafungin did not result in serious adverse event (AEs), death, or withdrawals due to an AE in healthy adult subjects. The study also showed that rezafungin had a PK profile with a long exposure period.

• HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE?

In an effort to reduce the occurrence of injection site reactions, these findings may lead to a future re‐evaluation of the s.c. formulation of rezafungin.     

The importance of health insurance as a determinant of cancer screening: evidence from the Women's Health Initiative

BACKGROUND: Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort. METHODS: Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years. RESULTS: Positive determinants of reporting cancer screening were age, ethnic origin, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening. CONCLUSIONS: In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.     

Consumers and quality-driven health care: a call to action

A key strategy for driving improvements in health care quality is providing comparative quality information to consumers. This strategy will not work, and could even be counterproductive, unless (1) consumers are convinced that quality problems are real and consequential and that quality can be improved; (2) purchasers and policymakers make sure that quality reporting is standardized and universal; (3) consumers are given quality information that is relevant and easy to understand and use; (4) the dissemination of quality information is improved; and (5) purchasers reward quality improvements and providers create the information and organizational infrastructure to achieve them.     

Altered chromatin landscape in circulating T follicular helper and regulatory cells following grass pollen subcutaneous and sublingual immunotherapy

1. Download : Download high-res image (285KB)
2. Download : Download full-size image

     

Qualitative research methods.

The use of rigorous qualitative research methods can enhance the development of quality measures, the development and dissemination of comparative quality reports, as well as quality improvement efforts. This paper describes how such methods have been and can be used, and identifies how to improve the use of such methods in studying quality of care. Focus groups and cognitive interviews are now a standard part of the development of valid and reliable survey instruments. They are particularly useful in developing surveys to gather data on the experiences and responses of patients and consumers to plans, services, and providers. These two methods have also been adapted and applied to improve the development and dissemination of comparative quality reports to consumers and other audiences, while key informant interviews and focus groups have been critical in the exploratory assessment of stakeholder responses to reports and their effects on consumers. Interviews have also been used to identify best practices found in health plans receiving high scores on the Consumer Assessment of Health Plans Surveys and measures of effectiveness in the Health Employer Data and Information Set. It would be valuable to widen the use of qualitative methods, especially structured observations, to document in detail the delivery of services designed to improve quality, so the implementation of complex processes can be more carefully measured and related to outcomes. The design and conduct of rigorous qualitative research takes a skilled and experienced team. Issues commonly faced in quantitative work must also be addressed in qualitative studies, including study design, specification of the unit of analysis, sampling, instrument design and administration, and, in particular, data analysis. It is especially critical that the analysis and interpretation process be deliberate and thorough to avoid the use of initial impression rather than detailed examination of the raw data.     

A GIS-based methodology for improving needle exchange service delivery

Background

A variety of legal, social and logistical factors can prevent individuals from accessing formal needle exchange programmes. One common solution to this problem is satellite exchange, which involves collaborating with people who already use an exchange to deliver needles and other supplies to those unable to access the exchange. While this approach can be very successful, one potential problem is that those most willing to deliver needles to their peers are often members of social networks that are already well connected with the needle exchange, leading to duplication of effort.In this paper we describe a simple and novel method for identifying groups of people who are demonstrably in need of improved access to needles, and for re-targeting efforts to meet the needs of those people. The method described was piloted at the Homeless Youth Alliance, San Francisco, USA, and further refined at Clean Needles Now, Los Angeles, USA.

Methods

People accessing needle exchange sites were asked to participate in a survey with two questions: “where were you and what time was it last time someone borrowed a needle from you?” and “where were you and what time was it last time you had to borrow a needle from someone else?” Responses were geocoded, and maps produced showing ‘hotspots’ where people were frequently finding themselves without needles.

Results

Satellite needle exchange was refined from an ad-hoc activity into one which focused on delivering needles to those with empirically demonstrable need. Maps produced in the process also proved valuable in discussions with local officials and other agencies about funding, as well as needle provision policy and practices.

Conclusion

We describe a method for rapidly assessing, describing, and responding to unmet and under-met need among injecting drug users. The method is particularly well-suited to organizations with extremely limited resources.