When Social Program Responsibilities Trickle Down: Impacts of Devolution on Local Human Services Provision

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) shifted responsibility for public assistance from the federal government to the states. This study examined early impacts of this devolution and related program reductions on local service authorities in Illinois. Based on surveys from 101 large townships responsible for administering General Assistance, medical assistance, and emergency needs programs, we found that 60 percent of these localities experienced increased service demands. These demands not only placed pressure on limited local programming funds, but also transformed local service populations in subtle and unintended ways. Reports of bureaucratic mistreatment and confusion also were common as states implemented PRWORA changes. Local responses to increased service demands were variable, with many localities increasing expenditures but expressing reservations about longer term funding given local tax limits. Follow-up surveys with 40 township officials two years later found that a declining economy and impending Temporary Assistance for Needy Families (TANF) five-year time limits were intensifying township program concerns. The implications of these findings for the development and monitoring of state and local public assistance systems are discussed

Dietary Supplement Polypharmacy: An Unrecognized Public Health Problem?

Excessive and inappropriate use of medications, or ‘polypharmacy’, has been recognized as a public health problem. In addition, there is growing use of dietary supplements in the United States; however, little is known about the patterns of supplement use. Recent reports in the literature of cases of excessive or inappropriate use of herbal dietary supplements leading to the term ‘polyherbacy’. The clinical vignettes described in this article highlight the need for further research on the nature and extent of multiple and inappropriate dietary supplement use or ‘dietary supplement polypharmacy’. Clinical interviewing and population surveys both address this issue in complementary ways, and provide a further understanding of dietary supplement use patterns

Advance Access Publication

Excessive and inappropriate use of medications, or 'polypharmacy', has been recognized as a public health problem. In addition, there is growing use of dietary supplements in the United States; however, little is known about the patterns of supplement use. Recent reports in the literature of cases of excessive or inappropriate use of herbal dietary supplements leading to the term 'polyherbacy'. The clinical vignettes described in this article highlight the need for further research on the nature and extent of multiple and inappropriate dietary supplement use or 'dietary supplement polypharmacy'. Clinical interviewing and population surveys both address this issue in complementary ways, and provide a further understanding of dietary supplement use patterns

Selection bias and subject refusal in a cluster-randomized controlled trial

Abstract Background Selection bias and non-participation bias are major methodological concerns which impact external validity. Cluster-randomized controlled trials are especially prone to selection bias as it is impractical to blind clusters to their allocation into intervention or control. This study assessed the impact of selection bias in a large cluster-randomized controlled trial. Methods The Improved Cardiovascular Risk Reduction to Enhance Rural Primary Care (ICARE) study examined the impact of a remote pharmacist-led intervention in twelve medical offices. To assess eligibility, a standardized form containing patient demographics and medical information was completed for each screened patient. Eligible patients were approached by the study coordinator for recruitment. Both the study coordinator and the patient were aware of the site’s allocation prior to consent. Patients who consented or declined to participate were compared across control and intervention arms for differing characteristics. Statistical significance was determined using a two-tailed, equal variance t-test and a chi-square test with adjusted Bonferroni p-values. Results were adjusted for random cluster variation. Results There were 2749 completed screening forms returned to research staff with 461 subjects who had either consented or declined participation. Patients with poorly controlled diabetes were found to be significantly more likely to decline participation in intervention sites compared to those in control sites. A higher mean diastolic blood pressure was seen in patients with uncontrolled hypertension who declined in the control sites compared to those who declined in the intervention sites. However, these findings were no longer significant after adjustment for random variation among the sites. After this adjustment, females were now found to be significantly more likely to consent than males (odds ratio = 1.41; 95% confidence interval = 1.03, 1.92). Conclusions Though there appeared to be a higher consent rate for females than for males, the overall impact of potential selection bias and refusal to participate was minimal. Without rigorous methodology, selection bias may be a threat to external validity in cluster-randomized trials. Trial registration NCT01983813 . Date of registration: Oct. 28, 2013

Additional file 1: of Selection bias and subject refusal in a cluster-randomized controlled trial

Sample screening form. The standardized form that study coordinators completed for each patient screened for eligibility. (PDF 213 kb

Additional file 2: of Selection bias and subject refusal in a cluster-randomized controlled trial

ICARE study protocol. A document describing the full study protocol, including screening and recruitment procedures. (PDF 6937 kb