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PubMed2006

Health and safety intervention with first-time mothers.

A health education program was evaluated which used child development specialists as home visitors and served a population of first-time mothers living in rural communities. The evaluation compared health and safety outcomes between intervention and control groups. The research staff, separate from the intervention staff, collected data in the homes of 156 intervention and 107 control mothers when the infants were 6 and 12 months old. Significant group differences were found on health and safety outcomes. As compared with controls, the intervention mothers (i) had safer homes; (ii) were more likely to use birth control, thus had fewer pregnancies since birth of their first child; (iii) reported smoking fewer cigarettes; (iv) knew more about effects of smoking on their child's health and (v) were more likely to use health department services. In sum, mothers who received early education home visits from child development specialists experienced positive health and safety outcomes. It is highly recommended that a program such as this be implemented as part of health delivery program with new mothers and infants.

Adult↗

PubMed2006

Rural surgical services in two Canadian provinces.

OBJECTIVE: Contrast alternative health delivery systems and the use of differently trained physician providers in the supply of surgical services to rural residents in 2 Canadian provinces. METHODS: Four surgical procedures (carpal tunnel release, inguinal herniorrhaphy, appendectomy and cholecystectomy) provided to rural residents of Alberta and Northern Ontario were identified between 1997/98 and 2001/02. Surgical staff were identified as specialists or non-specialists. Rural populations were mapped into the catchment areas of rural acute care facilities. Rural surgical programs were characterized by the level of surgical service available locally. RESULTS: Alberta and Northern Ontario have a similar number of rural surgical programs staffed by Canadian-certified general surgeons (10 and 12, respectively). However, Alberta has 27 smaller rural surgical programs staffed by non-specialist surgeons and Northern Ontario has only 4. These non-specialist surgeons play a significant role in Alberta, often in collaboration with specialist surgeons. In Northern Ontario the non-specialist surgeons play a minor role. The small rural surgical programs in Northern Ontario that are staffed by specialist surgeons are significantly more successful in retaining the local surgical caseload compared with similar programs in Alberta. CONCLUSIONS: The principal differences between Alberta and Northern Ontario in the delivery of rural surgical services are the greater number of small rural surgical programs in Alberta, and the substantial role of non-specialist surgical staff in these programs.

Alberta↗

PubMed1994

Enhancing specialist preparation for the next century.

While the curricula of clinical nurse specialist (CNS) programs have proved to be successful in meeting past and current health care needs of specialty populations, the needs of children requiring care by the CNS have changed greatly over the past few years. Because of advanced technology, more children are surviving, although they may have serious physical, developmental, and psychosocial disabilities. At the same time, the educational, health, and social services for these children have become harder to access. A conceptual model, Family-Focused Pediatric Transitional Care (FFPTC), was used to interpret a survey of graduates of a pediatric clinical specialist program and their employers. Recommendations regarding possible changes in pediatric clinical nurse specialist curricula are offered to guide future educational agendas. Advanced skills in clinical decision making and coordinating care across the continuum from the hospital to the community and to the home have become essential role competencies for the clinical nurse specialist.

Clinical Competence↗

PubMed1997

Teledermatology and underserved populations.

BACKGROUND: The dermatologic needs of many communities in the United States and worldwide are underserved. Telemedicine enables physicians and non-physician primary care providers to use modern telecommunications devices to gain access to specialist consultations promptly and with much less travel. The independently developed telemedicine programs described herein support 3 traditionally underserved populations: Pacific Islanders, migrant farmworkers, and prison inmates. OBSERVATIONS: In 3 independently designed telemedicine programs, dermatology emerged as the specialty most used by remote practitioners. Patients were presented for both diagnosis and treatment and in the setting of initial evaluation and as part of follow-up care. CONCLUSION: Teledermatology is a useful way to provide dermatologic support to remote or underserved communities.

Dermatology↗

PubMed2000

Interdisciplinary approach to a total knee replacement program.

An orthopedic clinical nurse specialist facilitated an interdisciplinary evaluation, design, and implementation of best practice initiatives for the total knee replacement patient population using the Center for Advanced Nursing Practice's Evidence-Based Practice Model. The interdisciplinary team approach enhanced the total joint program by achieving positive patient outcomes, demonstrating financial stewardship of resources, and facilitating inter- and intradisciplinary communication.

Anticoagulants↗

PubMed2006

Population health as a framework for forensic nursing curriculum.

The American Association for the Colleges of Nursing (AACN) has recommended that master's level graduate programs prepare nurses as generalists. There is, however, a gap in the educational ladder at the master's level when current master's clinical nurse specialist (CNP) and nurse practitioner (NP) programs are reconfigured as doctoral programs. To fill this gap, a curriculum model using population health as a framework is proposed.

Curriculum↗

PubMed2003

Dental education and dentistry system in Iran.

Before 1979, there were only 5 undergraduate dental schools in Iran with a total admission of 200 students per year, and only 2,000 dentists and about 50 specialists practicing in the country. Currently, there are 18 dental schools with a total admission of 750 undergraduate students, 5 postgraduate programs in 10 disciplines with a total of 100 students, more than 11,000 dentists (1 dentist per 5,500 population) and nearly 1,000 specialists in the country. Two new schools have recently begun offering specialty training courses in 2 disciplines. The length of the dentistry curriculum is 6 years. Students take general and basic science courses during the first 2 years, then continue on the predental and dental courses for the remaining 4 years. The curriculum has been revised over the past 20 years to establish intership and specialty programs and introduce courses reflecting current trends in the dental profession. Dental services in Iran are provided by both public and private sectors. Oral health care was integrated into the Public Health Care network by 1997, and 4 levels of a Dental Health Care Delivery System were established. The first level is concerned with primary prevention at 'health houses', where auxiliary health workers called 'behvarzes' provide periodic examinations, referrals, and oral health education. At the next level, oral hygienists and dentists in 'health centers' perform basic oral health care services such as fillings, scaling, and extraction. At the third level, dentists manage and treat oral diseases in 'urban health centers', while the last level is for advanced treatment by specialists in university health centers in the cities.

Curriculum↗

PubMed1996

Psychiatric clinical nurse specialists as intensive case managers for the seriously mentally ill.

The government estimates the number of seriously mentally ill as high as three million, with annual cost for the care of this population approaching billions of dollars. This article describes a program for the seriously mentally ill in the community using psychiatric clinical nurse specialists as intensive case managers. Interventions regarding disease relapse symptomology and early recognition of medication side effects assist clients to seek earlier intervention. Desired outcomes include earlier hospitalizations at less serious stages, reduced length of stay, higher functioning, improved self-care skills, and improvement in obtaining and receiving medical service. With clinical nurse specialists in case management roles, clients receive treatment at more appropriate and less costly service levels.

Case Management↗

PubMed1993

Application of a model for public health nursing program planning.

Community health nurse (CHN) specialists have advanced educational preparation in both nursing and the public health sciences. They are called on to perform numerous advanced practice roles in public health and other community agencies, one of which is program planning. To perform this role effectively, CHN specialists should use conceptual models to guide application of the nursing process in a population-based practice. One such model developed by a nurse for use in planning community health programs is the McLaughlin model. It was used to address the community diagnosis of risk for childhood lead poisoning, a long-standing public health problem currently receiving renewed attention from federal public health authorities. Applications of conceptual models in practice settings can test such model's efficacy, enrich the scientific basis of community health nursing practice, and ultimately improve the health of the community.

Community Health Nursing↗

PubMed2004

Preparing the singing voice specialist revisited.

In review of singing voice specialist preparation, discussion can be chronicled prior to the establishment of Arts Medicine in 1987. Although discussion began in 1984 (and earlier), no formal academic program currently exists to train the singing voice specialist. The need now is greater than ever for a formal program of study to prepare a person who seeks to be a singing voice specialist. The question of adequate preparation continues to be in need of an appropriate answer because no formal training programs or fellowships are available. It is essential to first define the role of singing voice specialists and the populations that they will encounter. To meet the needs of a diverse population, care of the professional voice demands cross-disciplinary training. Knowledge from the fields of music, science, medicine and communication disorders and experience/observation, clinical preparation, and research would provide for optimal preparation. To meet this need, development of a Masters degree program seems highly desirable. The structure of such a program is proposed, along with specific requirements outlined from the music and singing voice pathology components for a Masters Degree in Arts Medicine with a concentration in voice.

Curriculum↗

PubMed1975

Determination of regional manpower requirements in obstetrics and gynecology.

The number of trainees produced by a residency program must relate directly to manpower needs in a specialty, not to the service needs of the training institution. In order to avoid geographic maldistribution of specialists, it is preferable to determine correct trainee output on a regional basis and combine such information inductively to determine overall national needs. A model for determination of the number of residents appropriate to train in obstetrics and gynecology by 1985 in the University of Utah program has been constructed in the setting of regional requirements. Components of this model include detailed population growth forecasts at the county level, consideration of the impact of increased urbanization, age-specific data for attrition of regional specialists by death or retirement, and estimation of the proportion of regional requirements to be met by the University of Utah program on the basis of distribution data of previous graduates.

Education, Medical, Graduate↗

PubMed2000

Opportunities and challenges in Medicaid managed care: the experience in Maryland.

OBJECTIVE: The effects of the Maryland Medicaid mandatory managed care programs on Medicaid beneficiaries are examined with the main objective of gaining insight into the initial experience and beneficiary satisfaction with Maryland's Medicaid program. The background of the Maryland Medicaid system, initial implementation, results of beneficiary satisfaction surveys, and future concerns are discussed. STUDY DESIGN: An observational study based on survey data. DATA AND METHODS: Beneficiary surveys mailed to adult and child participants in HealthChoice and the Rare and Expensive Case Management (REM) Medicaid programs in Maryland are analyzed. Descriptive univariate and bivariate data statistics are used. RESULTS: The 4 questions rating satisfaction with primary care provider (PCP), relevant specialists, all providers, and the overall health plan indicate high levels of satisfaction in both adult and child populations. CONCLUSIONS: The Maryland Medicaid programs appear to have met the goal of providing a comprehensive, coordinated healthcare system of quality care during their first year of operation. The satisfaction of these beneficiaries suggests that with an appropriate risk-adjusted capitation approach, managed care organizations (MCOs) can successfully provide for even the most complex needs of Medicaid members.

Community Health Services↗

PubMed2003

Screening for diabetic retinopathy in James Bay, Ontario: a cost-effectiveness analysis.

BACKGROUND: Retinopathy is a common complication of diabetes mellitus that if detected early by regular retinal examinations can be treated; thus, blindness can be delayed or prevented. Providing high-quality retinal screening is difficult, especially in rural and remote areas. Canada's First Nations population has a higher prevalence of diabetes and is, in general, more geographically isolated than the broader Canadian population. We modelled the cost-effectiveness of retinopathy screening by travelling retina specialists versus retinal photography with a portable digital camera in an isolated First Nations cohort with diabetes. METHODS: The 2 screening programs were modelled to run concurrently for 5 years, with outcomes evaluated over 10 years. To construct economic models for the population of Cree individuals living in the western James Bay area of northern Ontario, we used available data on the prevalence of diabetes in the area and estimates of the incidence of retinopathy derived from the published literature. We compared the screening models and calculated total costs, visual outcome, costs per sight-year saved and costs per quality-adjusted life year (QALY). We also estimated the costs of implementing a screening program for all First Nations individuals in Ontario with diabetes and no access to an ophthalmologist. RESULTS: From the perspective of the health care system the camera program was preferable to the specialist-based program. Over 10 years, 67 v. 56 sight years were saved, compared with no screening, at costs of 3900 Canadian dollars v. 9800 Canadian dollars per sight year and 15,000 Canadian dollars v. 37,000 Canadian dollars per QALY. Generalizing these results to the province of Ontario, the camera system could allow most isolated First Nations people with diabetes to be screened for 5 years for approximately 1.2 million Canadian dollars. INTERPRETATION: A portable retinal camera is a cost-effective means of screening for diabetic retinopathy in isolated communities of at-risk individuals.

Cost-Benefit Analysis↗

PubMed1997

Nutritional screening for the elderly: a CNS role.

Detection and treatment of nutritional disorders has surfaced as a major health concern for older persons. This article explores how one clinical nurse specialist (CNS) used advanced practice knowledge and skills to develop a nutritional screening program for an elderly population served by a nursing clinic. A study was conducted to determine the prevalence of risk factors for poor nutritional status in these elderly clients according to the Nutritional Screening Initiative. Eighty-two percent of the clients in the study presented with two or more risk factors for poor nutritional status. Therefore, a proposal was developed for a standardized screening and treatment program.

Aged↗

PubMedDate not supplied

The impact of managed care on the physician marketplace.

OBJECTIVE: To examine the impact of managed care on the employment and compensation of primary care and specialty physicians, as measured by changes in income, physician-to-population ratios, and specialty choices. METHODS: The authors used data from the American Medical Association's Socioeconomic Monitoring System survey, a nationally representative 1% random survey of post-residency patient-care physicians, and location data from the AMA Masterfile to evaluate the relationship between the growth in managed care from 1985 to 1993 and (a) inflation-adjusted physician incomes and (b) physician-to-population ratios for primary care physicians and specialists. They also used data from the National Residency Matching Program for 1989 through 1995 to look at trends in available positions and specialty choices. RESULTS: Primary care incomes grew 4.78% annually ($33,526 cumulatively) in states with the highest managed care growth, compared to 1.20% ($7448 cumulatively) in the lowest quartile of managed care growth. The difference in income growth for medical and surgical subspecialists between the highest and lowest quartiles was not statistically significant. The incomes of radiologists, anesthesiologists, and pathologists (RAPs) rose 0.14%, or $1700, in the highest quartile versus 4.14% ($58,558) in the lowest. Subspecialists per capita did not differ by quartile of managed care growth; but RAPs per capita increased fastest in states in the lowest quartile. Between 1989 and 1995, the number of family practice and pediatric residency positions that were filled rose 32%, while the number filled remained stable for medical and surgical subspecialists and the number of RAP positions filled fell 14%. CONCLUSIONS: The growth in managed care has been associated with significant changes in physician incomes and practice locations. Between 1985 and 1993, states with the fastest growth in managed care penetration saw the highest rate of growth in primary care physicians' income and the slowest rate of growth in RAP physicians' income. At the same time, the number of RAP physicians grew most rapidly in those states with the lowest rate of managed care growth. Finally, between 1989 and 1995, there was a dramatic increase in the number of primary care residency positions filled and a marked decrease in the number of RAP residency positions filled across the country.

Economics, Medical↗

PubMed2006

Developing a care program to better know the chronically critically ill.

Patients requiring prolonged periods of intensive care and mechanical ventilation are termed chronically critically ill. These patients present a challenge to the healthcare team. In the fast-paced environment of the intensive care unit, their slow progress can be a source of frustration. At the University Hospital Geneva, a team, led by a clinical nurse specialist, addressed this problem by implementing a new care program with a goal to better know this patient population and improve their care. Values of emancipatory practice development guided the project, which utilized an action research methodology. Key assessment tools included a nursing focused patient history at admission and weekly nursing rounds, which allowed for periodic holistic assessment and care planning. New interventions focused on communication, physical care, and providing a context of understanding for the patient beyond hospitalisation, operationalised as a patient diary. The structure of the new program allowed the nurses to develop new skills and provided an environment for dynamic reflection. The care of this demanding patient population is beginning to be perceived by nurses as challenging and interesting.

Benchmarking↗

PubMed2001

Asthma screening as part of a routine school health assessment in the Australian Capital Territory.

OBJECTIVE: To determine the feasibility and performance of a routine screen for childhood asthma in new entrants to primary school relative to diagnosis by a paediatrician. DESIGN: Cross-sectional study with a validation substudy. PARTICIPANTS AND SETTING: All 4539 new primary school entrants (mean age, 5.72 years; 95% CI, 5.71-5.74) in the Australian Capital Territory (ACT) in 1999; 180 of these children (73% of the 248 contacted) participated in the validation substudy. MAIN OUTCOME MEASURE: Performance of the screening test relative to a paediatrician's diagnosis of current asthma (defined as a history of wheeze suggestive of a clinical diagnosis of asthma within the past 12 months) based on history and examination. RESULTS: 3748 of the 4539 new primary school entrants (83%) returned completed asthma and respiratory questions. The screening test was positive in 38% of children. Estimated sensitivity was 92% (95% CI, 75%-99%); specificity, 76% (95% CI, 72%-80%); positive predictive value, 51% (95% CI, 41%-63%); negative predictive value, 98% (95% CI, 90%-100%); positive likelihood ratio, 3.8 (95% CI, 2.8-4.8); and negative likelihood ratio, 0.14 (95% CI, 0.02-0.33). CONCLUSIONS: It is feasible to conduct population screens for asthma that have good diagnostic test performance against a specialist paediatrician's diagnosis through school health programs. This approach could facilitate monitoring changes in asthma prevalence over time.

Asthma↗

PubMed1998

Team approaches to treating children with disabilities: a comparison.

OBJECTIVE: To investigate differences in team functioning between the multidisciplinary and transdisciplinary models when treating children with disabilities. DESIGN: A crossover trial. SETTING: An outpatient educational and rehabilitation program in a rehabilitation institute based at a university medical center. PARTICIPANTS: A population-based sample of 19 rehabilitation specialists and educators. INTERVENTION: Participants attended four team meetings using the multidisciplinary approach and then attended four team meetings using the transdisciplinary approach. OUTCOME MEASURES: Behavioral ratings of team participation (Transdisciplinary Team Rating Scale) and self-report instruments of team development (Team Assessment Questionnaire) and treatment planning and goal development (Staff Perception Questionnaire). RESULTS: Results of t tests confirmed the hypothesis that there was more team member participation during transdisciplinary meetings than during multidisciplinary meetings (p=.027). There were no differences in levels of team development (p=.329); however, staff members favored the transdisciplinary model for treatment planning and goal development (p < .001). CONCLUSION: This study provides evidence of the effectiveness of the transdisciplinary model. Further research is now needed to investigate outcome variables such as rate of success in attaining treatment goals when using this model.

Child, Preschool↗