General Radiographic Artifacts: A Visual Review

The primary role of the Military Health System is to assure readiness by protecting the health of the force by providing expert care to wounded, ill, and injured service members. In addition to this mission, the Military Health System (both directly through its own personnel and indirectly, through TRICARE) provides health services to millions of military family members, retirees, and their dependents. Women's preventive health services are an important part of comprehensive health care to reduce rates of disease and premature death and were included in the 2010 Patient Protection and Affordable Care Act's (ACA) expanded coverage of women's preventive health services, based on the best available evidence and guidelines. These guidelines were updated by the Health Resources and Services Administrations and the American College of Obstetrics and Gynecology in 2016. However, TRICARE is not subject to the ACA, and therefore, TRICARE's provisions or the access of TRICARE's female beneficiaries to women's preventive health services was not directly changed by the ACA. This report compares women's reproductive health care coverage under TRICARE with coverage available to women enrolled in civilian health insurance plans subject to the 2010 ACA. Three recommendations are proposed to ensure that women who are TRICARE beneficiaries have access to and receive preventive reproductive health services that are consistent with Health Resources and Services Administration recommendations as implemented in the ACA. Each recommendation has strengths and weaknesses that are described in detail in the body of this paper. In covering contraceptive drugs and devices, TRICARE appears to reflect the scope of coverage found in ACA-compliant plans but, by not incorporating the term "all FDA-approved methods" of contraception, TRICARE leaves open the possibility that a narrower definition could be adopted at a future date. There are important differences in how TRICARE and ACA-compliant plans address reproductive counseling and health screening, including TRICARE's more restrictive counseling benefit and some limits to preventive screening. By not aligning with policies related to the provision of clinical preventive services established under the ACA, TRICARE allows health care providers in purchased care to diverge from evidence-based guidelines. Although the ACA respects medical judgment when providing women's preventive services, standards restrict the extent to which health care systems and providers can depart from evidence-based screening and prevention guidelines essential to optimizing quality, cost, and patient outcomes.

In Flanders, as in the entire industrialized world, the population is eldering and chronic conditions and comorbidities are increasing importantly. Today, non-communicable diseases (NCD’s) have an important negative impact on the quality of life and represent the most important cause of premature and/ or preventable death. Moreover, they also put an enormous burden on the health care system, in terms of need for health professionals, procedures and medicines, short and long term care institutions as well as on the affordability of the health care system. The knowledge that the majority of these NCD’s can be avoided by prevention, through a healthy lifestyle and early detection, calls for more emphasis on and means for preventive health care. Traditionally and still today, the primary and secondary care practice in Flanders is focused on curation and preventive health care is mainly practiced by others, such as school health services and Maternal and child health services. The fundamental principles of curative and preventive care are very different. Curative care is based on an individual approach and is driven by individual demands. However preventive health care is mainly based on population health management and driven by, often not expressed, population needs. When it comes to implementation of preventive care, the WHO advocates a Health in all Policies approach, in which preventive care is implemented in all life settings surrounding the citizen, in order to achieve an integrated preventive care policy that is supported by all policy domains and is part of daily life. One of these settings is health care. In this workshop we want to exchange experiences on implementation of preventive health care into primary healthcare and to explore the opportunities, hurdles and policy needs to come to a successful adoption of preventive health care in the setting of primary healthcare. To introduce the debate, the session will start with two short presentations of 10-15 minutes in which experiences in two different health care systems, i.e. a national health care system and a predominant private health care system, are shared with the participants.

Major changes in medical care challenge health care professionals to discover new ways to address health needs in primary care and prevention (Berkman, 1996). Replacing fragmented systems with coordinated networks of care is one of the greatest challenges. Ensuring that underserved and vulnerable populations have access to comprehensive care is another. Both call for the development of creative partnerships among traditional health care providers, social services professionals, and members of the community. Building and participating in partnerships will require retooling for many professionals. MODELS THAT WORK Recognizing the urgent need for partnerships, the Human Resources and Services Administration's (HRSA, 1996) Bureau of Primary Health Care in the U.S. Department of Health and Human Services is leading a partnership of 36 national foundations, associations, and nonprofit organizations in a Models That Work campaign. The campaign seeks to increase access to primary and preventive health care for underserved and vulnerable populations by encouraging communities to establish comprehensive primary health care programs that are creative, responsive to the community, and transferable to other communities. The following six examples are partnerships that communities have developed to achieve these objectives in a variety of settings. First, the partnerships involve community members in the design and delivery of services. The Cure/Heart, Body and Soul program in Baltimore uses trained neighborhood health workers to carry out prevention efforts in urban African American communities. Workers complement traditional systems of primary care by providing preventive screening, health education, referral, follow-up, advocacy, and community organization. Similarly, the Camp Health Aide Program in Michigan enlists migrant farmworkers to provide culturally appropriate health education, advocacy, outreach, referral, and follow-up services. The Community Health Advisor program in Mississippi uses trained natural helpers who live and work in rural communities to provide health information and advice; organize self-help action projects; and connect neighbors, families, and friends to needed services. This program has reduced infant mortality in one county by 16 percent. Second, the partnerships identify people at risk for health problems during crisis events. In a poverty-stricken neighborhood of St. Paul, Minnesota, HouseCalls identifies families at risk of homelessness through referrals from housing inspectors, outreach workers, and traditional service providers. A staff social worker and the family develop a crisis intervention plan to identify housing priorities as well as health needs related to inadequate prenatal care, delayed immunizations, and overdue well-child checks. Home visits, transportation, and other support services are provided to facilitate access to housing and health services. The Adolescent Community Services project in Binghamton, New York, provides reproductive health services, health education, counseling, and transitional housing supports to pregnant, parenting, and high-risk adolescents and their families. Intervention during this crisis-prone stage of life reduces teenage pregnancy rates, lowers foster care placements, and increases high school completion rates. Third, the partnerships reach out to people by providing coordinated health services in accessible community sites or in the homes of families. For example, Enloe Hospital in Chico, California, offers a wide array of health and social services at a community center for migrant farmworkers and their families. This approach decreases pediatric visits to emergency rooms by increasing access to primary and preventive care. In the Arkansas Delta Community Integrated Service System, a family care coordination team uses a home-visiting model to improve access to services, pregnancy outcomes, and infant health in rural areas. …

This study seeks to analyse the uptake of preventive and curative child health services in three health centres in Maputo, Mozambique. Within the context of overall social and economic change, Mozambique has given priority to Primary Health Care as the driving force of its newly developed National Health Service, with a principal focus on maternal and child health. Three health centres were selected from areas of contrasting environmental quality. Data were collected from over 6000 women attending the curative and preventive child health services at these centres. It was found that the women using curative services had significantly higher child mortality rates, had lived less time in Maputo City and had children of lower weight status than their counterparts attending for preventive care. Additionally, levels of child mortality were found to increase as environmental quality decreased. It is argued that the lower users of preventive care are, as in the U.K., precisely those who appear to have an increased risk of mortality and morbidity. It is concluded that integration between the curative and preventive health services must be increased in order to overcome the user inertia which militates against the poorer population using the facilities for prevention to the best advantage. This would fit in both with national strategies (1) and WHO recommendations (2-4) in the field of primary health care.

Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis

BackgroundWomen involved in the criminal legal (CL) system in the United States have much higher levels of chronic and infectious illness than women in the general population. Over 80% of women in the CL system are on community supervision, which means they receive health care in community settings. While the use of Emergency Department care among CL involved populations has been examined fairly extensively, less is known about engagement in routine and preventive medical care among people on community supervision.MethodsWe conducted a longitudinal study of health care utilization among women with Medicaid who were currently or previously sentenced to probation in Alameda County, CA (N = 328). At baseline, 6- and 12-months, we interviewed participants about every medical care visit in the six months prior, and about potential influences on health care utilization based on the Behavioral Model for Vulnerable Populations (BMVP). Associations between BMVP factors and utilization of routine or preventive care were estimated using Poisson regression models with robust standard errors. Generalized estimating equations (GEE) were used account for repeated measures over time.ResultsA diagnosis of one or more chronic illnesses was reported by 82% of participants. Two-thirds (62%) of women engaged in routine or preventive care in the six months prior to interview. A quarter of women engaging in routine or preventive care did not have a primary care provider (PCP). Having a PCP doubled the likelihood of using routine or preventive care (adjusted Relative Risk [adjRR] 2.27, p < 0.001). Subsistence difficulty (adjRR 0.74, p = 0.01) and unmet mental health care need (adjRR 0.83, p = 0.001) were associated with a lower likelihood of using routine or preventive care.ConclusionFindings underscore the importance of meeting the basic needs of women on community supervision and of connecting them with primary health care providers.

Spinal cord injury (SCI) creates unique needs that if not recognized and addressed timely can have detrimental effects on the health and quality of life (QOL) of people living with a SCI. Primary preventive health care is shown to decrease morbidity and mortality, yet the SCI population reportedly faces challenges getting access to this care. This area in SCI health care is still largely understudied with no consensus on the ideal way or which health care provider is best to provide primary care for this population. Preventive care is generally provided by general primary care providers, but not all primary care providers are trained in recognizing and addressing spinal cord injury-specific needs. SCI providers generally are not trained in addressing all aspects of preventive care. Knowing the recommended preventive care screenings, recognizing and managing specific conditions seen after a SCI, and seamless coordination of care between general practitioners and SCI specialists are some of the interventions to help prevent health complications, decrease morbidity and mortality, improve health outcomes, and promote QOL in this patient population. Prioritized focus on preventive care is necessary for a positive impact on the overall health and QOL in this population. Addressing the knowledge gap reported by primary care providers and SCI providers may help increase the probability of SCI patients getting their preventive and specialty care needs addressed. We present a "cheat sheet" of recommendations for the preventive care evaluation of a person living with a SCI.

IntroductionThere is potential for health gain by Aboriginal and Torres Strait Islander people in Australia through better primary health service in urban areas. Preventive health care delivered with social sensitivity is critical to addressing chronic disease. In the mainstream urban general practice setting, three key linked processes of Indigenous identification, health checks and immunisation for Indigenous people should be improved.BackgroundThe history and current lived experience of Aboriginal and Torres Strait Islander people influence access to mainstream health care services. Known access facilitators in urban areas are low cost, convenience and delivery in a culturally safe setting by practitioners with compatible values and professional culture. In contrast to community controlled health services, mainstream general practices have few practitioners with Indigenous care experience, and low levels of Indigenous identification and Indigenous health check delivery.This thesis presents the development, implementation and evaluation of an intervention in Brisbane designed to address known and suspected barriers to Indigenous people’s access to preventive care in mainstream urban general practice.The following research questions were considered:1. Based on the best evidence, what intervention by Division of General Practice and Public Health Unit staff was appropriate and feasible to promote increased coverage of Indigenous health checks and immunisation in mainstream urban general practices?2. What were the effects of the intervention targeting mainstream practitioners on Indigenous identification, immunisation and health checks, and what were the other effects?3. How could existing barriers to immunisation and health checks in mainstream general practice be overcome?MethodsThe Promoting Indigenous Preventive Care in General Practice (PIPCGP) study used a realist-inspired framework of enquiry and a mixed methods approach. Division of General Practice and Public Health Unit staff used existing resources to provide intensive practice support through an educational workshop, package of activity support materials, progressive audit and feedback, and ongoing contact over twelve months. Seventeen General Practices in two intervention groups were enrolled. Audit data were gathered at the practice, returned to practices, and collated for evaluation purposes. In-depth interviews were conducted with 35 participants, including clinical and non-clinical staff of practices and Indigenous community members.ResultsThe inner suburban group had low attrition, showed a steep rise (78%) in Indigenous patient numbers, and increased health check delivery. Half the Indigenous children aged 2 to 5 years had immunisation data missing from their record prior to intervention, which was rectified. Child immunisation coverage for all vaccines, including Indigenous-specific vaccines, was 46% at the end of the period. The outer suburban group had a high attrition rate of 50%.Preventive care processes for over two thousand Indigenous patients were included in the study. Increased Indigenous identification came from both current and new patient groups. Practices with higher health check activity had staff experienced in Indigenous health, were already delivering checks prior to intervention, and increased their activity. Few low activity practices had previously undertaken checks, and half of these commenced. Difficulties reported were a low level of patient willingness to undergo a check, and organisational processes: poorly adapted electronic records, long consultation time, and uncertainty about sharing assessment components between team members.Indigenous identification was welcomed, was associated with acknowledgement of culture, and helped build relationships. Providers experienced in Indigenous health aligned with patients in emphasising the staff-patient relationship as a barrier to preventive care, and provided guidance on relationship building. Other providers focused solely on practical barriers. Most providers and community members expressed the need for links between practices, the Indigenous community, and Indigenous organisations.DiscussionThe PIPCGP study confirms that Indigenous identification can be quickly improved in mainstream General Practices, and highlights an additional range of practical and social issues to be addressed in increasing access to preventive care. These include knowledge of the Indigenous immunisation schedule, improved completeness of immunisation record keeping, and teamwork to plan adequate time and cooperation for health checks. Information system deficits exist in Indigenous identification recording, on-screen activity prompt and recall/ reminder. The success factor of staff experienced in Indigenous health enabled a patient relationship-building focus and influenced system change in the practice.ConclusionMainstream practice efforts to strengthen patient-centred care of chronic disease, should include Indigenous cultural and relationship-focused training for staff, Indigenous patient service planning and quality improvement. A continued dialogue and partnership between Community Controlled Health Services and Primary Health Networks, with the assistance of Public Health Services, is essential to support practices with concentrations of Indigenous patients. Supply of general practice information systems in Australia which support tailored care for Indigenous people could be another lever for change, as could more detailed activity monitoring linked to financial incentives to provide high quality preventive care.

Health insurance is one of social health guarantees programs provided to the society in accessing health services in Indonesia. This program is implemented as a solution of equality problems on health services. This paper aims to analyze effect of health insurance ownership on accessibility health services to people with disabilities who included as vulnerable communities. This research have 1.288 respondents of people with disabilities from Indonesia Family Life Survey that analyzed by multinomial logit regression models. The results show that health insurance ownership of disabilities are not effective enough in accessibility of disabilities health services. To access health service, people with disabilities have main obstacle factor namely physical mobiltity services. Furthermore head of household, chronic disease, transportation costs, and years education variables have significant effect on preventive and curative health services to people with disabilities. Whereas sex and unemployed status significant effect on preventive health services. Keywords : People with Disabilities1, Health Insurance2, Accessibility3, Health Service4

Patients seen in a dermatology clinic have unmet preventive health care needs

As public housing residents age in place, they require health and social services outside of those traditionally offered by housing authorities. A promising response to these emerging needs is for housing authorities to collaborate with local public health departments to deliver coordinated services to older adult residents. Aging residents’ health needs include health promotion activities, preventive health services, health education, and mental health services, among others. From 2001–2004 the New York City Department of Health and Mental Hygiene (DOHMH) and the New York City Housing Authority (NYCHA) collaborated to implement the Senior Wellness Project. This outreach program integrated health and social services provided by DOHMH and NYCHA, and delivered these services to older adult residents on site in 21 New York City public housing developments. Services were rendered at senior centers located in the housing developments and in residents’ apartments. The program also referred residents to community healthcare providers to address special needs such as addiction. This article retroactively applies a formal model for interagency collaboration, the Stages of Collaboration, to describe and analyze the process of collaboration between DOHMH and NYCHA. It identifies the successes and shortcomings of the collaborative process, and explores the theory that successful collaboration leads to inherent challenges for implementation. Recommendations are then made for other public housing and public health agencies that have considered collaborating to address the needs of public housing residents who are aging in place.

Introduction: Prior studies have shown that preventative health issues are neglected in patients with inflammatory bowel disease. In 2017, the American College of Gastroenterology (ACG) published comprehensive 14-point guidelines regarding preventive care measures (PCMs) in IBD. The adherence to these guidelines has not been assessed. We aimed to evaluate adherence to PCMs outlined by ACG in IBD patients at our center. Methods: We conducted retrospective quality improvement study including IBD patients who had received care at our gastroenterology outpatient clinics between September, 2017 to October, 2017. Baseline patient characteristics and data regarding adherence to preventative health care measures was noted. Results: A total of 94 patients were included. Mean age was 47.6 years and 34% were males. 49% of the patients had Crohn's disease (CD), while 51% had ulcerative colitis. 58.5% of the patients were on long-term steroids, while 45.7% and 44.6% of the patients were on immunomodulators and biologics respectively. Majority of the patients (88%) had a PCP, and 56.6% of the female patients were established with a gynecologist. Adherence with appropriate PCMs as indicated was: Influenza 58.5%, pneumococcal: 56.3%, herpes zoster 19.5%, varicella zoster 11.6%, meningococcal 100%, Tetanus, Diphtheria and Pertussis (Tdap) 55.3%, HAV: 58.5%, HBV 80.5%, HPV 80%, depression screening: 55.3%, melanoma screening: 30.8%. In women on immunosuppressive therapy, 51.6% underwent annual cervical cancer screening, and 33.3% of patients on immunomodulators had non-melanoma skin cancer screening. Bone mineral density testing was performed 67.2% of patients in whom it was indicated, and smoking cessation was advised to 76.9% of CD patients who used tobacco. Conclusion: Despite comprehensive guidelines, PCMs in IBD patients continue to be neglected. There continues to be debate whether preventative care in IBD is best addressed by PCP or gastroenterologists. Although our sample size is small, our results demonstrate significant room for improvement. There is a trend towards better preventive care in patients with IBD who have a PCP in addition to a gastroenterologist. Our next steps include: feedback to our physicians regarding adherence to PCMs, development of electronic health record reminders, and placing flyers in patient rooms. We plan to collect post-intervention data to assess if our interventions lead to improvement in preventive health care delivery to IBD patients.619_A Figure 1. Adherence to preventive care measures in patients with IBD619_B Figure 2. Comparison between gastroenterology fellow and faculty in regards to adherence to preventive care measures in IBD

Someone once said that travel broadens the mind and it would be harder to think about a broader set of responsibilities or challenges than those faced by the World Health Organisation (WHO) who addresses the broadest definition of health and well-being for the broadest range of countries, ethnicities and contexts. The Director of Service Delivery and Safety, Dr Edward Kelly, launched the interim report of a global strategy on people-centred and integrated care in Edinburgh on Friday 27 March 2015 which will be presented to the World Health Assembly alongside a global health workforce strategy in 2016.1 The report starts from the premise that the case for integrated care is sound and the benefits include: increased service efficiency, decreased costs, improved equity in service uptake, better health literacy and self-care, increased satisfaction with care, improved relationships between patients and their providers and an improved ability to respond to health care crises such as Ebola. The choice of Scotland for the launch was timely since the following week, 1 April, marked the implementation of legislation2 to reallocate a minimum two thirds of the entire spending for adult health and social services to Integration Joint Boards. These boards have equal representation of National Health Service (NHS) and Local Authority members and will instruct NHS and Local Authority executives on strategies to achieve people-centred and integrated care. The Integrated Joint Boards have responsibility for a defined area (coterminosity), and are expected to engage with patients and community stakeholders to identify and plan to meet the needs of their populations through joined-up services. A number of interesting observations can be made. This is not another pilot, small-scale intervention in integrated care. At a minimum, it includes 60% of the total revenue for adult health and social services. It would not be possible without bi-partisan political support in the Scottish parliament. It applies to rural as well as metropolitan areas and builds on agreements and systems for the sharing of information when it is needed. It builds upon sensible decisions about service and community boundaries and upon long-term and more recent investments in information and related systems. Perhaps most importantly, it recognises that doing nothing in health system development is a prescription for more beds, more specialist services, fewer satisfied patients and more unhappy tax payers. Countries with broadly unitary health systems in which preventive, primary, secondary and tertiary services are funded from the same purse have the advantage in integrating care. It is no surprise that the leading international services such as Kaiser Permanente, the US Department of Veterans Administration and Clalit Health Services in Israel have registered clients, capitation payment systems and operate in contexts where dissatisfied consumers can switch to another provider who will be more responsive to their wants or needs. These organisations have been successful in moving care from hospitals to primary and community care settings and then to the home, making use of telephone and Internet as well as face-to-face consultations. In doing so they have made progress towards the triple aim of population health improvements, better patient care and reduced costs of care. Countries and health care providers who accept responsibility for the quality and cost of services pay particular attention to the roles and performance of preventive and primary health services since they seek to address health risks before they become health conditions and require expensive secondary and tertiary interventions. Reorienting health care systems away from an inpatient and acute focus requires improved engagement with populations and communities. This may imply moving beyond traditional town hall meetings to engagement using the web, smart phone apps and other social media. All this seems a tall order for an Australian health care system that could best be described as provider centred and fragmented. The challenge is to focus on the goal of population-centred and integrated care in which rural communities may have the advantage of scale: in some instance, small scale may prove helpful with fewer providers to engage. If rural communities can lead, we will all benefit whether as providers, patients, citizens or indeed all three.

Independent foundations' primary focus is grant making.In general, their assets come from the gift of an individual or family.Community foundations' assets usually come from many donors rather than a single source, and grant making is limited to a particular region.Community foundations are usually classified as private charities under the tax law and are subject to different rules and regulations than are other private foundations. Access To CareAccording to 1988 Census Bureau estimates, over thirty-one million Americans are without health insurance.The demographics of these people are diverse, and their ranks continue to grow as the service industry burgeons and as competition in health care increases.Regional disparities in access also exist.Foundation funding in this area ranges from economic analyses of the problem to direct provision of care.

To identify how dentists and their teams adopt evidence-based preventive care. A qualitative study using grounded theory methodology was conducted. We interviewed 23 participants working in eight dental practices about their experience and work processes, while adopting evidence-based preventive care. During the study, Charmaz's grounded theory methodology was employed to examine the social process of adopting preventive dental care in dental practices. Charmaz's iteration of the constant comparative method was used during the data analysis. This involved coding of interview transcripts, detailed memo-writing and drawing diagrams. The transcripts were analyzed as soon as possible after each round of interviews in each dental practice. Coding was conducted primarily by AS, supported by team meetings and discussions when researchers compared their interpretations. Participants engaged in a slow process of adapting evidence-based protocols and guidelines to the existing logistics of the practices. This process was influenced by practical, philosophical, and historical aspects of dental care, and a range of barriers and facilitators. In particular, dentists spoke spontaneously about two deeply held 'rules' underpinning continued restorative treatment, which acted as barriers to provide preventive care: (i) dentists believed that some patients were too 'unreliable' to benefit from prevention; and (ii) dentists believed that patients thought that only tangible restorative treatment offered 'value for money'. During the adaptation process, some dentists and teams transitioned from their initial state - selling restorative care - through an intermediary stage - learning by doing and educating patients about the importance of preventive care - and finally to a stage where they were offering patients more than just restorative care. Resources were needed for the adaptation process to occur, including: the ability to maintain the financial viability of the practice, appropriate technology, time, and supportive dental team relationships. The findings from this study show that with considerable effort, motivation and coordination, it is possible for dental practices to work against the dental 'mainstream' and implement prevention as their clinical norm. This study has shown that dental practice is not purely scientific, but it includes cultural, social, and economic resources that interfere with the provision of preventive care.