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PubMedDate not supplied

Hypopituitarism in childhood.

BACKGROUND: Childhood hypopituitarism may be present at birth or may be acquired. Early diagnosis and treatment promote the best possible outcomes. METHODS: The anatomy, etiologies, clinical presentation, diagnostic testing strategies, and current treatments relevant to childhood hypopituitarism are reviewed. RESULTS: Children with congenital hypopituitarism may present with life-threatening hypoglycemia, abnormal serum sodium concentrations, shock, microphallus in males, and, only later, growth failure. Causes of congenital hypopituitarism include septo-optic dysplasia, other midline syndromes, and mutations of transcription factors involved in pituitary gland development. Children with acquired hypopituitarism typically present with growth failure and may have other complaints depending on the etiology and the extent of missing pituitary hormones. Acquired hypopituitarism may result from tumors (most commonly craniopharyngioma), radiation, infection, hydrocephalus, vascular anomalies, and trauma. CONCLUSIONS: An MRI of the head is critical in determining the etiology. Testing for pituitary hormone deficiencies is undertaken along with appropriate hormonal replacement and, in some cases, direct treatment of the cause of the hypopituitarism. All children with hypopituitarism require coordination of medical care by a pediatric endocrinologist and, when older, transition to the care of an internist endocrinologist. Referrals to a reproductive endocrinologist may be required as fertility issues arise.

Age of Onset↗

PubMed2004

Transition of young people with respiratory diseases to adult health care.

As many more young people with chronic health conditions survive well into adulthood, transition of affected young people from paediatric to adult health care is increasingly becoming the expected standard of care. Despite this, there is still little objective or long-term evidence to guide the development or deployment of developmentally appropriate transition processes or to define the precise manner in which the transfer of care should take place. Nevertheless, certain principles of transition have now received nearly universal endorsement. In this paper, the rationale for transition is discussed, practical strategies for transition are described, the existing evidence base supporting transition is reviewed and limitations in our knowledge are outlined. Ultimately, a carefully planned transition to adult health care should improve self-reliance, enhance autonomy and independence and support young people in attaining their maximum potential and meaningful adult lives.

Adolescent↗

PubMedDate not supplied

The impact of primary and modular nursing delivery systems on perceptions of caring behavior.

PURPOSE/OBJECTIVES: To determine if differences existed in patients' and family members' perceptions of caring behaviors after the transition from a primary to a modular care delivery system. DESIGN: Descriptive, comparative, and correlational. SETTING: Urban, inpatient, acute-care hospital. SAMPLE: A convenience sample of 42 patients with cancer hospitalized for chemotherapy administration or complications arising from their diagnoses and 27 of their family members. Ninety-four data sets were collected--62 from the patients and 32 from the family members. METHODS: Subjects were asked to evaluate their nurse's caring attributes using the Caring Perception index. Caring scores of patients receiving primary nursing care were compared to caring scores of patients receiving modular nursing care. MAIN RESEARCH VARIABLE: Patients' and family members' perception of caring. FINDINGS: Mean caring scores did not differ significantly between patients receiving primary care (mean = 35.9, SD = 5.4) and patients receiving modular care (mean = 36.2, SD = 5.3). Patient and nursing delivery characteristics were used to predict and explain variance in the dependent variable care. Number of days hospitalized accounted for 14% of the variance, with those patients hospitalized longer rating nurses as more caring. CONCLUSIONS: The longer a patient stays in the hospital, the greater the likelihood the patient and family members will feel nurses exceeded exceptions for caring. The findings support other studies that have compared quality care indicators across different types of delivery systems. IMPLICATIONS FOR NURSING PRACTICE: Measures to evaluate quality care should be used when transitioning to new delivery models. Nurses need to recognize that not all patients value the same nurse qualities equally. When receiving care over an extended period of time from same nurse, patients and family members are more likely to rate the nurse as exceeding expectations.

Adult↗

PubMed2004

System to decrease length of stay for vascular surgery.

OBJECTIVES: Reduction of length of stay (LOS) is critical for optimal use of hospital resources. We developed and evaluated a system to aggressively reduce LOS for vascular surgery. METHOD: Key to this system, which we introduced on January 1, 2001, was appointment of a LOS officer, who communicated daily during hospitalization with patients and families about discharge planning, organized outpatient services for wound care and rehabilitation to transition patients quickly to nonhospital care, and had biweekly meetings with relevant paramedical services. LOS for 509 patients operated on in 2000 (standard group) was compared with LOS for 474 operated on in 2001 and 595 patients operated on in 2002 (LOS reduction groups). Data for all patients with aortic aneurysm, carotid artery stenosis, lower extremity critical ischemia or amputation, and foot debridement were included. RESULTS: LOS in 2000 averaged 8.5 days, compared with 5.9 days in 2001 and 5.6 days in 2002. All decreases in LOS for each diagnostic category in 2001 and 2002 were statistically significant (P = <.001-.03). There was no significant increase in readmission rate (2.2% vs 1.9% and 2.0%, respectively), mortality rate (0.8% vs 0.6% and 0.7%, respectively), or percent of patients who received endovascular treatment (18% vs 16% and 14%, respectively). These decreases in LOS saved the hospital more than US dollars 616200 in 2001, and US dollars 847550 in 2002 (US dollars 500/patient-day). CONCLUSIONS: A committed LOS officer with major specific daily responsibilities for decreasing LOS and discharging patients resulted in a 31% to 33% decrease in LOS, with important cost savings to the hospital and no negative effect on patient care.

Aged↗

PubMedDate not supplied

PNP roles and interventions with children with special needs and their families.

Pediatric nurse practitioners (PNPs) can create excellent professional roles caring for children with special health care needs (CSHCN) and their families. Children with chronic conditions represent an estimated 31% of the US population younger than 18 years (approximately 20 million children in 1988). Five percent of all children who have multiple special needs account for approximately 40% of all pediatric health care expenditures. Skill building is needed for PNPs who have traditionally focused on wellness and common acute illnesses in primary care settings. Role theory and research can guide PNPs in creating roles and interventions to improve the health, safety, and developmental outcomes for CSHCN and their families. Two roles are described, with examples of specific nursing interventions. Assisting child care centers to serve children and families with special needs is an ideal role for PNPs who have knowledge of health and regulatory issues. Another important PNP role is working with adolescents with special health care needs as they transition from pediatric to adult care. Many resources (such as those from the Maternal and Child Health Bureau) are available to assist PNPs to create new roles and interventions for CSHCN and their families.

Adolescent↗

PubMed2000

Medicaid managed care and provider consolidation.

In the thrust toward constructing economic value, health care provider firms have been consolidating at a marked rate. Medicaid managed care programs have been rapidly emerging with the objectives of containing health care costs and improving services for beneficiaries. However, there are concerns that the trend toward achieving market efficiency through merger is largely incongruent with the economic and health value objectives of Medicaid managed care programs in the states. Discordance among value objectives arises primarily because of inefficient and market concentrating horizontal merger strategies employed by firms and disruptions in quality of care that occur during the transition to integrated health care systems. By promoting vertical integration strategies and filling in the quality gaps created by an active merger environment, Medicaid offices advance state objectives of cost containment and quality while recognizing that providers operate in a complex and competitive environment that necessitates consolidation for organizational survival.

Cost Control↗

PubMed2002

Reforms of health care system in Romania.

AIM: To describe health care reforms and analyze the transition of the health care system in Romania in the 1989-2001 period. METHOD: We analyzed policy documents, political intentions and objectives of health care reform, described new legislation, and presented changes in financial resources of the health care system. RESULTS: The reforms of the health care system in Romania have been realized in a rather difficult context of scarcity of financial and human resources. The Gross Domestic Product spent on health care in 2000 was 4% and the number of physicians in 1999 was 42,975. The main changes due to the legislative reforms have been the introduction of a new social health insurance and strengthening of the position of family physicians. Negative effects of the reforms have been the decrease in health care accessibility and growing inequity in utilization of health care services. Health care users still pay physicians under-the-table, and have more out-of-pocket health care expenses. CONCLUSION: Future reforms in Romania should encourage the positive effects of current reforms: free choice of physician, autonomy of the primary health care system, and increasing financial resources for the health care system.

Delivery of Health Care↗

PubMed2005

Evolutionary pathways in shorebird breeding systems: sexual conflict, parental care, and chick development.

Sexual selection, mating opportunities, and parental behavior are interrelated, although the specific nature of these relationships is controversial. Two major hypotheses have been suggested. The parental investment hypothesis states that the relative parental investment of the sexes drives the operation of sexual selection. Thus, the sex that invests less in offspring care competes more intensely and monopolizes access to mates. The sexual conflict hypothesis proposes that sexual selection (the competition among both males and females for mates), mating opportunities, and parental behavior are interrelated and predicts a feedback loop between mating systems and parental care. Here we test both hypotheses using a comprehensive dataset of shorebirds, a maximum-likelihood statistical technique, and a recent supertree of extant shorebirds and allies. Shorebirds are an excellent group for these analyses because they display unique variation in parental care and social mating system. First, we show that chick development constrains the evolution of both parental care and mate competition, because transitions toward more precocial offspring preceded transitions toward reduced parental care and social polygamy. Second, changes in care and mating systems respond to one another, most likely because both influenced and are influenced by mating opportunities. Taken together, our results are more consistent with the sexual conflict hypothesis than the parental investment hypothesis.

Animals↗

PubMedDate not supplied

Peripheral blood progenitor cells: enabling outpatient transplantation.

Peripheral blood progenitor cells (PBPCs) are becoming the stem cell source of choice for rescuing patients from marrow aplasia after high-dose chemotherapy. Their advantages over bone marrow include avoidance of general anesthesia and more rapid hematologic recovery after transplantation. More rapid engraftment can reduce the risks associated with transplantation and shorten the hospital stay or, under certain circumstances, eliminate it. The cost reductions associated with a shorter stay have made PBPC transplantation cost-competitive with more conventional therapy. The move to outpatient transplantation requires increased patient and family involvement with posttransplantation care, as well as increased patient education and a multidisciplinary care team for the safe transition of patients between care sites. Improvements in outpatient transplantation may incorporate a cooperative care model with the intent of reducing readmission rates and extending this modality to most patients who undergo autologous transplantation.

Ambulatory Care↗

PubMed2003

Case finding and referral model for emergency department elders: a randomized clinical trial.

STUDY OBJECTIVE: Elderly emergency department patients have complex medical needs and limited social support. A transitional model of care adapted from hospitals was tested for its effectiveness in the ED in reducing subsequent service use. METHODS: A randomized clinical trial was conducted at 2 urban, academically affiliated hospitals. Participants were 650 community-residing individuals 65 years or older who were discharged home after an ED visit. Main outcomes were service use rates, defined as repeat ED visits, hospitalizations, or nursing home admissions, and health care costs at 30 and 120 days. Intervention consisted of comprehensive geriatric assessment in the ED by an advanced practice nurse and subsequent referral to a community or social agency, primary care provider, and/or geriatric clinic for unmet health, social, and medical needs. Control group participants received usual and customary ED care. RESULTS: The intervention had no effect on overall service use rates at 30 or 120 days. However, the intervention was effective in lowering nursing home admissions at 30 days (0.7% versus 3%; odds ratio 0.21; 95% confidence interval [CI] 0.05 to 0.99) and in increasing patient satisfaction with ED discharge care (3.41 versus 3.03; mean difference 0.37; 95% CI 0.13 to 0.62). The intervention was more effective for high-risk than low-risk elders. CONCLUSION: An ED-based transitional model of care reduced subsequent nursing home admissions but did not decrease overall service use for older ED patients. Further studies are needed to determine the best models of care for this setting and for at-risk patients.

Activities of Daily Living↗

PubMedDate not supplied

Facilitating the transition of adolescents with chronic conditions from pediatric to adult health care and community settings.

This article provides an overview of the health care issues and concerns of adolescents with special health care needs and disabilities who are in transition from pediatric to adult health care settings. Adolescents and their families face numerous challenges in accessing adult health care providers who can give adequate primary and specialized health care services to this growing population of youth. Navigating the myriad new and unfamiliar adult services available can be overwhelming for adolescents, their families, and pediatric providers. Assessment and intervention strategies are described that can be used by the pediatric nurse to facilitate successful transitions to adult health care and community-based services.

Adolescent↗

PubMedDate not supplied

Quality management in home care: models for today's practice.

In less than a decade, home care providers have been a part of two major transitions in health care delivery. First, because of the advent of managed care and a shift from inpatient to community-based services, home care service delivery systems have experienced tremendous growth. Second, the principles and practices of total quality management and continuous quality improvement have permeated the organization, administration, and practice of home health care. Based on the work of Deming, Juran, and Crosby, the basic tenets of the new quality management philosophy involve a focus on the following five key areas: (1) systems and processes rather than individual performance; (2) involvement, collaboration, and empowerment; (3) internal and external "customers"; (4) data and measurement; and (5) standards, guidelines, and outcomes of care. Home care providers are among those in the forefront who are developing and implementing programs that integrate these foci into the delivery of quality home care services. This article provides a summary of current home care programs that address these five key areas of quality management philosophy and provide models for innovative quality management practice in home care. For further information about each program, readers are referred to the original reports in the home care and quality management journal literature, as cited herein.

Community Health Nursing↗

PubMedDate not supplied

Breaking the "bad" news to patients and families: preparing to have the conversation about end-of-life and hospice care.

The ability to compassionately communicate difficult or "bad news" to a patient and family is essential to the provision of quality care at the end-of-life. Preparing to have these conversations requires a deliberate multilevel approach that includes: 1) becoming comfortable with end-of-life issues; 2) understanding the scope of the experiences from the patient's and family's perspectives; 3) understanding the full range of choices and options you can offer patients and families regarding their care (including hospice care); 4) developing a "can do" approach toward your involvement with end-of-life care; and 5) learning to effectively share and receive information in a compassionate manner. The following article explores this multilevel approach in an effort to assist physicians and other health care professions in supporting patients and families in their transition from curative care to hospice and palliative care.

Attitude to Death↗

PubMed1995

Managed care on the march: will physicians meet the challenge?

The health care delivery system in the United States is in transition. Increasingly managed care plans are gaining in predominance. The proliferation of managed care systems will have an impact on the demand and requirements for physicians. This paper attempts to project and estimate requirements for physicians in 2000 and 2020, assuming that the health care system will continue to be dominated by managed care. The projections are then compared to forecasts of physician supply under two separate physician production scenarios. The authors discuss the adequacy of the future physician workforce to provide services required by a health care system dominated by managed care.

Forecasting↗

PubMed2003

System flexibility in the rehabilitation process of mentally disabled persons in a hostel that bridges between the hospital and the community.

BACKGROUND: Deinstitutionalization and community mental health services have become the focus of mental health care in the United States, Italy and England, and now in Israel. METHODS: Tirat Carmel MHC developed an intervention model of organizational change implemented in a rehabilitation hostel. It is an interim service based on graduated transition from maintenance care to a transitional Half-way House, followed by a Transitional Living Skills Center oriented for independent community living. RESULTS: Of 205 rehabilitees who resided in the hostel since the beginning of the project, 138 were discharged to community residential settings: 67 patients were discharged to reinforced community hostels; 27 to sheltered housing and 23 to independent residential quarters; 7 patients were discharged to comprehensive hostels, 3 to old-age homes and 11 returned home to their families. In terms of employment, 79 were placed in sheltered employment facilities, 24 work in the open market and 3 returned to school; 22 work in therapeutic occupational settings and 10 patients discharged to comprehensive hostels and old-age homes are engaged in sheltered employment programs in those settings. CONCLUSION: The system flexibility model and the rehabilitation processes anchored in normalization supported the relocation of hospitalized psychiatric patients to community-based settings and enabled the rehabilitees to cope with readjustment to community life.

Community Mental Health Services↗

PubMed1997

A breast cancer care report card. An assessment of performance and a pursuit of value.

The transition to managed care raises concerns about the resulting quality of care. The report card, a publicly released, standardized report on quality, has received widespread acceptance as a method to evaluate physician performance. Current report cards provide insufficient information to allow purchasers of health care to assess accurately the performance of professionals who provide breast care. To overcome these limitations, we propose an expanded report card on breast cancer care. Mammographers and general surgeons would assess an independent series of at least 100 consecutive cases of newly diagnosed breast cancer. Mammographers would determine the percentage of invasive cancers < 15 mm detected on screening mammograms in asymptomatic women aged 50 to 74 years. Surgeons would determine the percentage of combined stages 0 and 1 breast cancers detected and the percentage of patients receiving breast-conserving surgical therapy. Performance targets are set at 60% for invasive cancers < 15 mm detected on screening mammography, 60% for combined stage 0 and 1 breast cancers, and 50% for patients receiving breast-conserving therapy.

Aged↗

PubMed2006

'Would you like to talk about your future treatment options'? Discussing the transition from curative cancer treatment to palliative care.

Palliative care focuses on improving quality of life for patients with life-threatening illness and their families. There comes a time when actively pursuing aggressive curative treatment may do more harm than good. The cessation of curative treatment is often viewed as a distinct event; however, current practice guidelines suggest that a palliative approach should be gradually adopted as the disease progresses. The challenge is how to facilitate a sensitive transition from curative to palliative care. On the basis of an extensive literature review, recommended steps for facilitating this transition have been outlined. The recommendations cover: the timing of the discussion; preparing for this discussion; the environment and circumstances of the consultation; initiating the discussion; identifying the information to be provided; responding to the person's emotional reaction; introducing palliative care services; continuity of care; family concerns; cultural and linguistic diversity; concluding the discussion. These steps were based on the best available evidence. However, as there is a paucity of research in this area, only three relevant systematic reviews of randomized controlled trials were identified and only one of these reviews related directly to palliative care. The majority of the relevant research was descriptive evidence. There is a need for more high quality research in this area.

Advance Care Planning↗

PubMedDate not supplied

The transition from hospital to long-term institutional care.

The focus of this article is user and carer involvement in the transition of older people from acute hospital to continuing institutional long-term care. The policy context and research of relevant studies are reviewed. Findings from an action research project currently in progress further elucidate the concerns of older users and carers.

Aged↗