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PubMed2001

Advanced practice in pediatric nursing: blending roles.

In the past, pediatric advanced practice nurse's roles were the Clinical Nurse Specialist (CNS) in the inpatient setting and the Nurse Practitioner (NP) in the outpatient setting. With health care system changes, such as the shifting and blurring boundaries between inpatient and outpatient care, changes were required in the graduate curricula to blend the CNS and NP roles into an advanced practice nurse (APN) role. This article describes the model at Rush University, the advantages of the CNS/NP blended role, the revised APN curriculum, and examples of blended-role APNs in action. The curriculum change to blend the CNS/NP roles addresses the need for the blended APN role in changing health care systems.

Ambulatory Care↗
PubMed1993

Back pain in primary care. Outcomes at 1 year.

Outcomes of primary care back pain patients (N = 1128) were studied at 1 year after seeking care. Changes in depression depending on outcome, and predictors of poor outcome were evaluated. Less than one back pain patient in five reported recent onset (first onset within the previous 6 months). One year after seeking care, the large majority of both recent and nonrecent-onset patients reported having back pain in the previous month (69% vs. 82%). A significant minority of both recent and nonrecent-onset patients had either a poor functional outcome (14% vs. 21%) or continuing high intensity pain without appreciable disability (10% vs. 16%). Predictors of poor outcome included pain-related disability, days in pain, lower educational attainment, and female gender. Among initially dysfunctional patients with persistent pain, one half were improved and one third had a good outcome at the 1-year follow-up. Among initially dysfunctional patients who experienced a good outcome, elevated depressive symptoms improved to normal levels at follow-up. The outcome of back pain was predicted by pain-related disability and days in pain rather than by recency of onset, so it may be more meaningful to distinguish characteristic levels of pain intensity, pain-related disability, and pain persistence than to classify patients as acute or chronic.

Adult↗
PubMed1997

Is the patient's right to die evolving into a duty to die?: Medical decision making and ethical evaluations in health care.

When patient or family requests for continued life-sustaining treatments conflict with doctor recommendations, different conclusions as to what is beneficial for the patient may arise. Past practices usually accepted patient or family requests based on the principle of autonomy or that the doctor's primary responsibility is to the individual patient. Many patients die in intensive care units after doctors forego life-prolonging interventions. Health care changes and cost containment have led to a change in the classical ethical model of the patient-doctor relationship such that concerns for societal requirements increasingly overrule those for individual patient needs. The ability to keep patients alive with little likelihood of recovery and the recognition of escalating health costs have led to calls for the needs of society and distributive justice to be taken into account. A tendency to justify a duty to die for these patients has arisen. Recent legal decisions in cases with conflicts between families and health care providers and institutions over foregoing life-sustaining therapies have decided for the families against doctors and hospitals, compelling institutions and their staff to act contrary to their ethical views. Value judgments of doctors are sometimes confused with medical indications for therapy. Doctors have defined therapies as futile or non-beneficial based on their own values and even withdrawn life-sustaining treatments without patient or family input. In some cases, the right to die is leading to the duty to die even against patient or surrogate wishes. Such observations indicate the need for rigorous analyses of medical decision making in this context and for ethical evaluations in health care in general.

Attitude to Death↗
PubMed1991

One year later: evaluating a changing delivery system.

One year after the introduction of primary nursing on four medical and surgical units in the tertiary hospital, a 23-item survey was distributed to primary and associate nurses on these units to evaluate the nurses' perceptions of the status of this change in nursing care delivery. Lewin's theory of change provided direction for evaluation of the change. The survey assessed improvements in patient care, changes in nursing practice, and interactions with other disciplines. The majority of nurses surveyed reported that patient care had improved under primary nursing; 100% of the primary nurses agreed that care had improved. The nurses identified continuity of care, communications, and awareness of patient problems as specific areas of improvement. They also identified improved interactions with many members of the healthcare team; the greatest were with dietitians, social workers, and physicians. The authors reported both positive and negative perceptions of how practice had changed under primary nursing. Results from the survey provided suggestions for continued support for staff nurses in this change in nursing care delivery within the studied facility, and suggested the need for future assessment and further evaluation.

Attitude of Health Personnel↗
PubMed2001

Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP).

A group from the European Working Party on Quality in Family Practice (EQuiP), working with over 20 European colleges of primary care, has assessed what, in their view, is needed to improve the quality of care at the interface between general practice and specialists. Experiences and ideas from a wide range of people were gathered through focused group discussions. From these it was clear that, for real improvement at the interface of care, changes are needed in the system of care and in the ways that doctors view their roles and their performance. All providers of care need to be able to see the care system from the patients' perspective if they are to help their patients make sense of and benefit from an increasingly complex system. This paper outlines the EQuiP recommendations on how cooperation between general practitioners and specialists might be improved. This includes strategic perspectives and both targets for improvement and methods for teaching, training and development that are all independent of country and health care system. The 10 targets for development identified by the group are: leadership, initial shared care approaches, task division, mutual guidelines, patient perspective, informatics, education, team building, quality monitoring systems, and cost effectiveness. Working towards these targets could provide an effective approach to improving the cooperation between the interfaces of care. Getting effective leadership is a necessary first step as implementation of such a strategy will involve significant change. Responsibility lies primarily with the medical profession.

Continuity of Patient Care↗
PubMed1985

Probable future funding priorities in maternal and child health: a modified Delphi National Survey.

Recent enactment of program consolidation block grants proposed by the Reagan administration has left many observers of public health services wondering about the impact of such a change on categorical programs in maternal and child health (MCH). This study first presents predictions about the future of 23 specific MCH services, derived from a modified Delphi Survey of MCH experts, and then examines the implications of these predictions for future public health.

Adult↗
PubMed1997

Gender differences in satisfaction with primary care physicians in a managed care health plan.

This study examines whether the formation of satisfaction with primary care physicians in a managed health care plan differs for men and women. Findings indicate that there are significant differences in the formation of satisfaction. For both men and women, the probability that an individual is satisfied is influenced by the type of plan enrolled in, number of problems experienced and beliefs about the quality of and access to benefits. Income and additional insurance coverage affects the probability of satisfaction for women only. Simulation analysis shows how satisfaction changes as individual characteristics and experience with managed care change.

Adult↗
PubMed1997

Therapeutic rigid bronchoscopy allows level of care changes in patients with acute respiratory failure from central airways obstruction.

OBJECTIVE: To determine whether emergency rigid bronchoscopic intervention, including Nd-YAG laser resection or stenting, immediately affected the need for continued mechanical ventilation or intensive care level of support in critically ill patients with acute respiratory failure from malignant or benign central airways obstruction. DESIGN: Retrospective review of medical records of all patients with acute respiratory failure and malignant or benign tracheobronchial obstruction necessitating intubation, mechanical ventilation, or hospitalization in the ICU prior to referral for therapeutic bronchoscopy. SETTING: University of California San Diego, a tertiary care institution specialized in airway management. PATIENTS: Medical records of 32 patients with malignant or benign central airways obstruction requiring admission to the ICU prior to rigid bronchoscopic intervention between January 1994 and April 1996. INTERVENTIONS: Emergent rigid bronchoscopy with dilatation, Nd-YAG laser resection, or silicone stent insertion performed in the operating room under general anesthesia. RESULTS: Thirty-two patients with central airways obstruction requiring emergent hospitalization in the ICU were referred for therapeutic rigid bronchoscopy. Airway strictures were caused by benign disease in 18 patients, and by primary bronchogenic lung cancer in 14. Of the 19 patients who were mechanically ventilated, bronchoscopic intervention allowed immediate discontinuation of mechanical ventilation in 10 (52.6%). Twenty-five patients had indwelling artificial airways (12 endotracheal tubes, 13 tracheotomy tubes). Two, however, were considered tracheotomy-dependent because of neuromuscular disease. Of the remaining 23 patients, immediate extubation or decannulation was possible in seven (30.4%). Of seven patients with no indwelling airway, five (71.4%) were immediately transferred to a lower level of care after intervention. Of the 32 total patients, 20 (62.5%) were immediately transferred to a lower level of care immediately after intervention. CONCLUSIONS: Emergency laser resection or stent insertion can favorably affect health-care utilization in patients with acute respiratory distress from central airways obstruction. Treatment may be lifesaving and allows successful withdrawal from mechanical ventilation, hospitalization in a lower level of care environment, relief of symptoms, and extended survival in critically ill patients. In patients with regionally advanced cancer, the palliative nature of this procedure postpones death by respiratory distress and may prompt consideration for institution of conservative comfort measures to reduce patient suffering.

Bronchial Diseases↗
PubMed2001

From concept to application: the impact of a community-wide intervention to improve the delivery of preventive services to children.

OBJECTIVE: To improve health outcomes of children, the US Maternal and Child Health Bureau has recommended more effective organization of preventive services within primary care practices and more coordination between practices and community-based agencies. However, applying these recommendations in communities is challenging because they require both more complex systems of care delivery within organizations and more complex interactions between them. To improve the way that preventive health care services are organized and delivered in 1 community, we designed, implemented, and assessed the impact of a health care system-level approach, which involved addressing multiple care delivery processes, at multiple levels in the community, the practice, and the family. Our objective was to improve the processes of preventive services delivery to all children in a defined geographic community, with particular attention to health outcomes for low-income mothers and infants. DESIGN: Observational intervention study in 1 North Carolina county (population 182 000) involving low- income pregnant mothers and their infants, primary care practices, and departments of health and mental health. An interrupted time-series design was used to assess rates of preventive services in office practices before and after the intervention, and a historical cohort design was used to compare maternal and child health outcomes for women enrolled in an intensive home visiting program with women who sought prenatal care during the 9 months before the program's initiation. Outcomes were assessed when the infants reached 12 months of age. INTERVENTIONS: Our primary objective was to achieve changes in the process of care delivery at the level of the clinical interaction between care providers and patients that would lead to improved health and developmental outcomes for families. We selected interventions that were directed toward major risk factors (eg, poverty, ineffective care systems for preventive care in office practices) and for which there was existing evidence of efficacy. The interventions involved community-, practice-, and family-level strategies to improve processes of care delivery to families and children. The objectives of the community-level intervention were: 1) to achieve policy level changes that would result in changes in resources available at the level of clinical care, 2) to engage multiple practice organizations in the intervention to achieve an effect on most, if not all, families in the community, and 3) to enhance communication between, among, and within public and private practice organizations to improve coordination and avoid duplication of services. The objective of the practice-level interventions was to overcome specific barriers in the process of care delivery so that preventive services could be effectively delivered. To assist the health department in implementing the family-level intervention, we provided assistance in hiring and training staff and ongoing consultation on staff supervision, including the use of structured protocols for care delivery, and regular feedback data about implementation of the program. Interventions with primary care practices focused on the design of the delivery system within the office and the use of teamwork and data in an "office systems" approach to improving clinical preventive care. All practices (N = 8) that enrolled at least 5 infants/month received help in assessing performance and developing systems (eg, preventive services flow sheets) for preventive services delivery. Family-level interventions addressed the process of care delivery to high-risk pregnant women (<100% poverty) and their infants. Mothers were recruited for the home visiting intervention when they first sought prenatal care at the community health center, the county's largest provider of prenatal care to underserved women. The home visiting intervention involved teams of nurses and educators and involved 2 to 4 visits per month through the infant's first year of life to provide parental education on fetal and infant health and development, enhance parents' informal support systems, and link parents with needed health and human services. We included training in injury prevention and discipline, and home visitors assisted mothers in obtaining care from one of the primary care offices. RESULTS: There were high levels of participation, changes in the organization of the delivery system, and improvements in preventive health outcomes. Agencies cooperated in joint contracting, staff training, and defining program eligibility. All 8 eligible practices agreed to participate and 7/8 implemented at least 1 new office system element. Of eligible women, 89% agreed to participate, and outcome data were available on 80% (180/225). After adjusting for differences in baseline characteristics, intervention group women were significantly more likely than comparison group women to use contraceptives (69% vs 47%), not smoke tobacco (27% vs 54%) and have a safe and stimulating home environment for their children. Intervention group children were more likely to have had an appropriate number of well-child care visits (57% vs 37%) and less likely to be injured (2% vs 7%). Intervention mothers also received Aid to Families with Dependent Children for fewer months after the birth of their child (7.7 months vs 11.3 months). CONCLUSIONS: We observed a number of positive effects at all 3 levels of intervention. Policy-level changes at the state and community led to lasting changes in the organization and financing of care, which enabled changes in clinical services to take place. These changes have now been expanded beyond this community to other communities in the state. We were also able to engage multiple practice organizations, reduce duplication, and improve the coordination of care. Changes in the process of preventive services delivery were noted in participating practices. Finally, the outcomes of the family-level intervention were comparable in direction and magnitude to the outcomes of previous randomized trials of the intervention. All the changes were achieved over a relatively brief 3-year study period, and many have been sustained since the project was completed. Tiered, interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children.

Adult↗
PubMed1999

Polypharmacy management in Medicare managed care: changes in prescribing by primary care physicians resulting from a program promoting medication reviews.

OBJECTIVE: To examine the effects of medication reviews by primary care physicians on prescriptions written for elderly members of a Medicare managed care organization who were at risk for polypharmacy. STUDY DESIGN: Prospective study with follow-up survey. PATIENTS AND METHODS: We conducted a study in 1995 to demonstrate the prevalence of polypharmacy (defined as receiving 5 or more prescription medications during the 3-month study period) among elderly members of our managed care organization. Two years later, elderly members identified as being at risk for polypharmacy were sent a letter encouraging them to schedule a medication review with their primary care physician. Each primary care physician was provided with clinical practice guidelines on polypharmacy and patient-specific medication management reports. Patients and physicians were subsequently mailed a survey to assess the impact of the medication review program on prescribing practices. RESULTS: Of 37,372 elderly members screened, 5737 (15%) were at risk for polypharmacy. Of these, 2615 (46%) responded to the follow-up survey. Of the survey respondents, 1087 (42%) had gone to their primary care physician for a medication review. During the review, 96% of patients discussed their prescription medications and 72% discussed nonprescription medications they were taking. Twenty percent reported that their physician discontinued medications, 29% reported that the physician changed the dose of a medication, and 17% informed their physician about a new prescription or nonprescription medication they were taking. Of the 275 primary care physicians surveyed, 56 (20%) returned the questionnaire. Of these, 61% reported that the medication review program was "very" or "somewhat useful." Thirty-five percent reported discontinuing unnecessary medications, and 23% reported decreasing the frequency of dosing. Overall, 45% of physicians reported making at least one change in their prescribing to a member at risk for polypharmacy. CONCLUSIONS: Our program promoting medication reviews between primary care physicians and their elderly patients resulted in significant changes in prescribing by physicians. This type of program is likely to decrease the risk of polypharmacy among older members of a Medicare managed care organization.

Aged↗
PubMed1992

Shanghai needs to improve its perinatal care.

In view of the situation that the perinatal mortality rate of Shanghai keeps dropping, doctor Hua Jiazeng from the Shanghai No. 1 Maternity Hospital told the reporter recently that to further lower down the perinatal mortality rate in Shanghai, the perinatal care should be improved through replacing maternity facilities and equipments, keeping the mother and her baby together in the same ward in hospital, and raising the breastfeeding rate. According to the latest statistics, the maternity mortality rate is now 23.8/100.000 in Shanghai, and the perinatal mortality rate has been 12-13/1000 in the past 10 years. These numbers show that there is still a gap between Shanghai and some developed countries regarding perinatal care. There are 3 reasons behind this: 1) since the early 1980s, Shanghai has been in the birth peak period and each year there are 180,000 babies born on the average, as a result, short of beds and lack of staff, the quality of puerperium monitoring and parturition treatment is impaired; 2) maternity facilities and equipments in quite a few hospitals are obsolete and do not suit the needs of modern maternity care anymore, and many hospitals still put newly-born babies together in a big ward which make babies easy to be infected; and 3) breastfeeding rate is dropping as more families do not choose breastfeeding. Doctor Hua suggests: first, we should make a good use of the 3-level maternal and childcare network covering the whole city, strengthen primary care, and pay particular attention to the women of 1st pregnancy at middle age and the unhealthy pregnant women; 2nd, health and medical sectors should put some funds on improving maternal facilities and equipments, increase maternity staff, and raise the income of maternity workers; lastly, all hospitals should keep the mother and baby in the same ward, and greatest efforts should be made to raise the breastfeeding rate.

Asia↗
PubMed1991

General theory of paradigms in health.

In Costa Rica, three sequential health paradigms have been identified over the last 50 years. The first began to develop during the 40's and has been called that of the deficiency diseases, since with a diachronic approach it placed excessive emphasis on malnutrition. The second began in 1970 and it is known as that of the infectious diseases, since through a holistic or synchronic approach, it underlined the importance of infections in high rates of morbidity and mortality. The third and last is the paradigm of the chronic diseases, it appeared in the 80's and is presently in process, doing battle with the chronic ailments, life styles, and environment, and it also utilizes a holistic approach. The recognition of these three paradigms has permitted Costa Rica a rapid advance in improving the health of its population, to the point that with a per capita outlay of $130 (US dollars), it has indices similar to those of the industrialized nations. This particular experience could be useful for other less-developed countries that are still applying the paradigm of the deficiency diseases.

Adult↗
PubMed1978

Depression in primary care: changes in pattern of patient visits and complaints during a developing depression.

The purpose of this study was to characterize changes in patient behavior associated with a developing depression. The records of 154 depressed patients from a solo family practice were examined for type and number of complaints, number of visits, and amount of hospitalization during two periods of time. In addition, 154 patients were used as controls and matched to the depressive patients by age, sex, and season of year seen. Two similar time periods were examined in the controls. The depressed group in comparisons both with itself and with the control group showed, in the seven months prior to the diagnosis of depression, these changes: (1) increase in number of patient-initiated office and home visits; (2) increased incidence of hospitalization; and (3) increased number of presenting complaints of three types: ill-defined "functional" complaints; pain of undetermined etiology in a wide variety of sites: head, chest, abdomen, and extremities; and "nervous" complaints, mainly increased tension and feelings of anxiety. The study results indicate that increased number of office visits and "functional" somatic complaints or anxiety-tension feelings should suggest depression.

Adolescent↗
PubMed1980

A new direction for public health care: changing cafeteria eating habits.

A "Food for Thought" game, an eight-week, media-based nutrition program designed to influence food choices in a cafeteria setting, was conducted in a National Institutes of Health employee cafeteria. Its purpose was to encourage customers to select lower-caloric food during lunch. The effects of the program on food choices and total calories of food purchased each day were measured by time series analyses. During the eight-week intervention period, skim milk purchases increased, and dessert and bread sales, as well as average number of calories purchased per day per person, declined significantly. Some evidence for a maintenance effect over a ten-week follow-up period was obtained. The "Food for Thought" game delivered nutrition education in an upbeat but unobtrusive way. Although people patronize cafeterias to eat, socialize, and relax and not to be educated, this program had only minimal requirements for participation. The result was a high level of interest and involvement. People can "learn while they eat," if careful attention is paid to customer needs and principles of effective communication.

Diet↗
PubMed1995

Medicare reimbursement for preventive care. Changes in performance of services, quality of life, and health care costs.

A randomized, controlled trial was conducted to assess the effects of a financial and office systems intervention to increase preventive care in physicians' offices for patients aged 65 years or older. A total of 1,914 patients from 10 primary-care medical practices in central North Carolina were randomized within practices to an intervention and a usual-care control group. The intervention consisted of full Medicare reimbursement to physicians for preventive care and health promotion packages (thus making these services free for patients), regular prompting of physicians to routinely schedule preventive care visits, a new office system in which nurses carried out many preventive procedures, and a form for charting preventive care. The performance of screening tests dramatically increased in the intervention group relative to control (P < 0.001), but there was evidence of lack of follow-up of abnormal findings by physicians. At the 2-year follow-up, there were minimal differences between intervention and control groups in health-related quality-of-life indicators. Relative to the $294 per patient 3-year cost to Medicare for waivered services, the intervention was reimbursed-cost neutral or slightly cost reducing ($190 over 3 years) for Medicare. It is concluded that adding reimbursement for preventive services to Medicare--even with the office systems changes made in this study--will not by itself lead to effective implementation of preventive services in community medical practices. To enhance patient benefit from preventive services, greater attention needs to be focused on an organized approach to patient follow-up.

Aged↗