Urinary incontinence (UI) is a commonly underreported and underdiagnosed condition. The purpose of this trial was to implement and evaluate behavioral management for continence (BMC), an intervention to manage symptoms of UI with older rural women in their homes. Participants were randomized into BMC or a control group, and 178 were followed for between 6 and 24 months. The intervention involved self-monitoring, bladder training, and pelvic muscle exercise with biofeedback. The primary outcome variable-severity of urine loss-was evaluated by pad test. Secondary variables were episodes of urine loss, micturition frequency, voiding interval, quality of life, and subjective report of severity. Urine loss severity at baseline evaluation was not significantly different in the two groups. But using the generalized linear mixed model analysis, at the four follow-ups, severity of urine loss, episodes of urine loss, quality of life, and subjective report of severity were significantly different. At 2 years the BMC group UI severity decreased by 61%; the control group severity increased by 184%. Self-monitoring and bladder training accounted for most of the improvement. The results support the use of simple strategies based on bladder diaries before implementing more complex treatments.

No abstract

Abstract-This study developed and implemented the Transition Assistance Program (TAP) for stroke caregivers. The program is composed of (1) skill development, (2) education, and (3) supportive problem solving. Sixty-one dyads (n = 122) participated: thirty-nine from Puerto Rico and twenty-two from Texas. Participants were randomly assigned to the TAP treatment or a control group. As caregiver satisfaction with the TAP increased, strain and depression decreased, and caregivers reported a very high rate of program satisfaction (9.5 out of 10). The TAP effectively reduced caregiver strain at the 3-month follow-up. When controlling for baseline differences, we found that the treatment group had lower depression (p = 0.07) than the control group at follow-up and that the TAP may have had a preventative effect on depression for caregivers who had not been depressed at discharge, although this visual trend did not reach statistical significance. Among veterans with low functioning at baseline, veterans whose caregivers had received the TAP improved in functioning more than did veterans whose caregivers had been in the control group, although this visual trend was not significant. Functioning in veterans with stroke was also significantly linked to caregiver satisfaction with the TAP. The findings from the current study warrant further evaluation of the TAP intervention.

We sought to determine whether the prophylactic use of amphotericin B products (conventional amphotericin B and liposomal amphotericin B) reduces the incidence of fungal infections in high-risk liver transplant recipients, and if so, whether this lowers the cost of care. The study sample comprised 232 adult orthotopic liver transplants performed from 1994 to 2005 at a single center for patients classified as being at high risk for fungal infections. High-risk patients who received transplants with a prophylaxis regimen of amphotericin B (n ϭ 58 transplants) were compared with high-risk patients who received no prophylaxis (n ϭ 174 transplants). Fungal infections occurred in 3 transplants (5.17%) of those who received amphotericin B and 28 transplants (16.09%) in those without prophylaxis (P ϭ 0.0432). Regression models were used to analyze fungal infection and costs for the 232 high-risk transplants. Failure to offer prophylaxis conferred a 4-fold greater risk of fungal infection (P ϭ 0.046) compared with those who received amphotericin B. A fungal infection in a high-risk recipient increased mean costs by 46.48%. The indirect effect of prophylaxis (operating through infection reduction) is estimated to reduce overall costs in high-risk patients by 8.73%.

No abstract

Cross-sectional studies show that a small percentage of children consume a large portion of the health care dollar. However, little is known about the persistence of high health care expenditures among children enrolled in Medicaid health maintenance organizations (HMOs) or in primary care case management (PCCM) programs. This study found substantial expenditure persistence during a 3-year period. Among Temporary Aid to Needy Families (TANF) children in HMOs in the top 10 percent of the expenditure distribution in 2003, 34 percent remained in the top 10 percent in 2004, and 23 percent remained in the top 10 percent in 2005. Similar patterns were observed for TANF children in the PCCM. Expenditure persistence varied based on the enrollees' enabling and need characteristics, providing opportunities to identify children with high health care expenditures who may benefit from care coordination.

Abstract-During fiscal years 2000 and 2001, the VeteransHealth Administration provided veterans with more than 131,000 wheelchairs and scooters at a cost of $109 million. This national study is the first to investigate Veterans Health Administration costs in providing wheelchairs and scooters and to compare regional prescription patterns. With a retrospective design, we used descriptive methods to analyze fiscal years 2000 and 2001 National Prosthetics Patient Database data (cleaned data set of 113,724 records). Wheelchairs were categorized by function, weight, and adjustability options for meeting individual needs (e.g., axle position, camber, position of wheels, tilt, and recline options). Results displayed a cost distribution that was negatively skewed by low-cost accessories coded as wheelchairs. Of the standard manual wheelchairs, 3.5% could be considered beyond the customary cost. Regionally, 71% to 86% of all wheelchairs provided were manual wheelchairs, 5% to 11% were power wheelchairs, and 5% to 20% were scooters. The considerable variation found in the types of wheelchairs and scooters provided across Veterans Integrated Service Networks may indicate a need for evidencebased prescription guidelines and clinician training in wheeledmobility technologies.

Our research showed significant variation in the provision of AT devices to veterans poststroke, and it showed that patient characteristics accounted for only 6.2% of the variation. VHA administrative region and disability severity accounted for equivalent amounts of the variation. Our findings suggest the need for improvements in the process for providing AT and/or provider education concerning device provision.