In This Issue:
- Foster Care Reunification
- Improving Minority Health Statistics
- Women and Drug Testing
- Emergency Department Use
INTENSIVE FOSTER CARE REUNIFICATION PROGRAMS
It is widely presumed that the preferred course of action for most children in foster care is a quick reunification with the child's biological family. Although the majority of children are eventually reunified, there is much room for improvement. Problems include that few specialized services are provided for reunified families; that the child welfare system is overloaded, so reunification may be delayed; and that some children remain in foster care "drift," with little action taken to ensure their permanent placement. Increasingly, however, states and localities are focusing on the development of intensive foster care reunification programs to reduce lengthy, costly stays in foster care and to lessen re-entries into foster care.
The report, Intensive Foster Care Reunification Programs, is an exploratory study that examines the characteristics of these programs, the effectiveness of intensive foster care reunification services, and the role these programs play in the reunification process. The project involved reviewing literature on family reunification, foster care re-entry, and permanency planning; conducting telephone discussions with experts in the field; and performing site visits to nine programs in California, Connecticut, Michigan, Oregon, and Washington that were identified as particularly innovative.
The study finds that there is no standard definition of family reunification, nor is there a common understanding of how these programs fit into the broader context of permanency planning in the child welfare system. Of the nine programs reviewed, the study finds that most tend to be new and small; that most draw on the experiences and components of family preservation (foster care prevention) programs; that most serve pre-adolescent children; and that most aid children and families with numerous and severe social and economic problems. Most of the programs focus on the whole family rather than just the child but stress permanency planning for the child over family reunification.
Very little has been documented in the way of program outcomes. Of the nine sites studied only three could provide statistics about their reunification rates. One program experienced a 38 percent reunification rate after two years, while the remaining two had a 74 percent and a 68 percent reunification rate after their first year.
The data indicate that these programs are addressing some of the factors linked to children's re-entry into foster care, such as parents' ambivalence about their role in reunification, unplanned discharges, and inappropriate case management. In dealing with these issues, the reunification programs provide parenting skills training, counseling, and linkages to community support systems; they attempt to provide a more rational, planned reunification process than does the traditional child welfare system; they focus on how the family is approached in the intervention; and they attempt to make the family a major partner in the planning process. These programs have not been able to address all of the issues identified by research as contributing to foster care reunification, however. Most serve younger children even though older children are more prone to re-entry, and the degree to which they serve multi-problem families may depend on the health of the community infrastructure and on the accessibility of community resources.
The study was conducted by Macro International, Inc., under contract to the Office of the Assistant Secretary for Planning and Evaluation. The study's project officer, Karl Ensign, can be reached on 202-690-6805. Copies of the final report, #4369, are available from PIC.
IMPROVING MINORITY HEALTH STATISTICS: REPORT OF THE PHS TASK FORCE ON MINORITY HEALTH DATA
Estimates indicate that by the year 2000 black persons, Asian- Americans and Pacific Islanders, and American Indians and Alaska Natives will comprise 17.6 percent of the population and that Hispanics will make up another 11.3 percent. A major area of public health concern is the persistent racial disparity in health status documented by the Report of the Secretary's Task Force on Black and Minority Health in 1985 and by Healthy People 2000 in 1990. Both reports emphasized the need to improve data on racial and ethnic populations in the United States in order to understand the causes of these disparities in health status and to develop ways of overcoming them.
The report, Improving Minority Health Statistics: Report of the PHS Task Force on Minority Health Data, contains the findings of a panel that was established by the Assistant Secretary for Health. The PHS Task Force was charged with conducting a policy-oriented review of the Public Health Service's (PHS) minority health data plans and activities, identifying gaps in data, and recommending ways to address high-priority needs.
The review indicates that PHS agencies sponsor a wide variety of activities that provide data on minority health. Still, however, there are significant unmet data needs for each minority group. These gaps encompass all areas of health statistics, including health status, health resources, health care utilization, program management, health care expenditures, and socioeconomic data.
The report also finds that most PHS surveys and epidemiological research activities include the Office of Management and Budget (OMB) classification for race and ethnicity that is required for use in all federally sponsored data collection and reporting activities involving questions on race and ethnicity. This classification has done much to promote comparable minority health data among federal agencies; however, it is a minimum standard. Each of the OMB categories includes many diverse racial and ethnic subpopulations, and the use of these broad groups in the collection, tabulation, and analysis of minority health data can obscure major differences in health status among subgroups within these categories.
Finally, the Task Force concluded that many users are unaware of the significant amount of minority health data that do exist; that the quality of race and ethnicity information on birth and death records needs to be improved; and that national data on the prevalence of diseases, impairments, and disabilities concerning minority groups are limited. Information on health service use and on the numbers and practice characteristics of minority health care personnel also is lacking.
The report includes more than 40 recommendations to address gaps in knowledge and other crosscutting issues in minority health data throughout PHS. The recommendations encompass eight priority areas: organizing and planning for minority health data, understanding the causes of racial disparities in health, improving the measurement of race and ethnicity, improving the analysis and dissemination of existing minority health data, addressing data gaps through improved data collection systems, promoting the development of state- and community-level data, improving program management data, and enhancing data quality.
As a by-product of its work, the Task Force also developed a directory of minority health data resources of the Public Health Service. Additional information is available from James Scanlon, one of the co-chairs of the Task Force. He can be reached on 202-690-7100. Copies of the final report, #4866, are available from PIC, as is the companion study, Directory of Minority Health Data Resources of the Public Health Service.
WOMEN'S HEALTH: FDA NEEDS TO ENSURE MORE STUDY OF GENDER DIFFERENCES IN PRESCRIPTION DRUG TESTING>
Drug therapy is the most common and one of the most important means of providing medical treatment. Because of physiological differences, drug interactions with women's hormones, and women's use of oral contraceptives, however, men and women may respond differently to the same drug. Although there is evidence that a person's gender can affect drug response, some pharmaceutical firms may not be studying clinical trials data for these gender-linked differences.
The report, Women's Health: FDA Needs to Ensure More Study of Gender Differences in Prescription Drug Testing, examines whether enough women participate in clinical trials to detect significant gender-related responses to drugs; reviews whether test data are analyzed for evidence of such reactions; and determines whether studies have investigated drugs' interactions with women's varying hormonal status and their oral contraceptive use. The report was prompted by concerns that women could be at risk if the Food and Drug Administration (FDA) approves drugs on the basis of clinical trials in which women are underrepresented.
Literature reviews, a survey of drug manufacturers, and interviews with officials of FDA and the National Institutes of Health indicate that FDA recommends that pharmaceutical firms test new drugs on representative patient groups; however, the agency does not define "representative," and drug companies do not apply the guidelines consistently. One-fourth of the drug firms surveyed do not deliberately recruit representative numbers of women for drug trials. More than half said FDA asked them to include women in drug trials, while the remainder had not been requested to do so.
Women participated in clinical trials for all the drugs reviewed in this report, although they were generally underrepresented; in fact, the number of women in some clinical trials fell below the minimum level recommended by FDA. Even when women were included, firms did not review data from more than half the trials to determine whether women and men reacted differently to medications. In addition, companies often do not study whether their drugs specifically interact with women's hormones, including the hormones often found in oral contraceptives.
Accordingly, the report advises that the Commissioner of Food and Drugs issue more explicit policy guidance regarding the inclusion of women in clinical trials, along with information on how to determine when enough women are involved in testing to assess possible differences in drugs' safety and efficacy by gender. In response, FDA stated it believes its guidelines for submitting new drug applications are clear in calling for firms to assess gender-related differences in a drug's effectiveness. It added, however, that its guidelines are not clear in calling for assessments of gender-related differences in the safety of new drugs. The agency also agreed that more scientific data are needed regarding the effects of hormones on drug response.
The report was compiled by the General Accounting Office. Copies of the final report, #4773, are available from PIC.
EMERGENCY DEPARTMENTS: UNEVENLY AFFECTIVED BY GROWTH AND CHANGE IN PATIENT USE
In 1990, some 5,300 general medical hospitals nationwide provided emergency care, most through an emergency department (ED) or unit. Recent studies and reports by the news media have raised concerns about long waits and crowded conditions at these facilities; however, comprehensive data to suitably assess the state of these departments have not been available.
The report, Emergency Departments: Unevenly Affected by Growth and Change in Patient Use, determines the extent to which these problems exist, with special emphasis on changes in patients' use of EDs, sources of payment for ED services, and EDs' timeliness in providing patient care. The study entailed visiting 21 EDs in seven states and surveying 689 nonfederal general medical adult and children's facilities about ED conditions between 1985 and 1990.
Nationwide, hospitals reported that their ED caseloads rose dramatically during the period, with much of the growth caused by increased use among the uninsured, elderly, and more seriously ill individuals. Nearly 85 percent of facilities also experienced increased use among patients with nonurgent conditions; in 1990, for example, more than 40 percent of ED patients had injuries or illnesses that could be classified as nonurgent. The largest increases in ED visits were by Medicaid patients, who traditionally have high rates of ED use for nonurgent conditions.
The mix of patients' insurance coverage -- a key determinant of hospitals' patient revenue and reimbursement -- changed from 1985 to 1990 to include more Medicaid, Medicare, and uninsured patients. During this time there was also little, if any, growth in the number of patients with private insurance, which often reimburses at or above hospital costs. This unbalanced growth may make it more difficult for hospitals to offset or absorb losses that accrue as a result of unreimbursed ED patient care costs.
In 1990, 89 percent of patients received ED care on a timely basis, regardless of the severity of their condition. Some 56 percent of hospitals reported delays, especially for patients with less serious illnesses or injuries. EDs in urban areas were most likely to make patients wait a long time for medical treatment, to have larger shares of uninsured patients, and to experience increased demands for service among patients with conditions related to acquired immunodeficiency syndrome (AIDS), alcohol, use of illicit drugs, and violence. Rural EDs, on the other hand, were least likely to have long delays in delivering care and had the highest percentage of Medicare patients.
The report was compiled by the General Accounting Office. Copies of the final report, #4858, are available from PIC.
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SERVICES AVAILABLE FROM THE PIC
The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research and; policy-oriented projects conducted by HHS as well as other Federal departments and agencies. The PIC on-line database provides project descriptions of these studies. It is available on-line at: http://aspe.hhs.gov/PIC/. Inquiries regarding PIC services should be directed to Carolyn Solomon, Technical Information Specialist, at 202-690-5694. Or E-mail PIC at: email@example.com