Understanding APRN Distribution in the United States Using NPI Data

This study examined the 2010 Centers for Medicare and Medicaid Services National Plan and Provider Enumeration System's National Provider Identifier (NPI) data to ascertain their usefulness to determine the distribution of advanced practice registered nurses (APRNs) in rural and urban areas of the United States. This study showed that certified registered nurse anesthetists were more likely to practice in rural areas in states with greater practice autonomy. For nurse practitioners, the findings were similar but were of borderline statistical significance. These findings imply that practice autonomy should be considered as a state-level strategy to encourage rural practice by APRNs.     

Emergency medical services management of ST-segment elevation myocardial infarction in the United States—a report from the American Heart Association Mission: Lifeline Program

Objective

ST-segment elevation myocardial infarction (STEMI) is a major cause of morbidity and mortality in the United States. Emergency medical services (EMS) agencies play a critical role in its initial identification and treatment. We conducted this study to assess EMS management of STEMI care in the United States.

Methods

A structured questionnaire was administered to leaders of EMS agencies to define the elements of STEMI care related to 4 core measures: (1) electrocardiogram (ECG) capability at the scene, (2) destination protocols, (3) catheterization laboratory activation before hospital arrival, and (4) 12-lead ECG quality review. Geographic areas were grouped into large metropolitan, small metropolitan, micropolitan, and noncore (or rural) by using Urban Influence Codes, with a stratified analysis.

Results

Data were included based on responses from 5296 EMS agencies (36% of those in the United States) serving 91% of the US population, with at least 1 valid response from each of the 50 states and the District of Columbia. Approximately 63% of agencies obtained ECGs at the scene using providers trained in ECG acquisition and interpretation. A total of 46% of EMS systems used protocols to determine hospital destination, cardiac catheterization laboratory activation, and communications with the receiving hospital. More than 75% of EMS systems used their own agency funds to purchase equipment, train personnel, and provide administrative oversight. A total of 49% of agencies have quality review programs in place. In general, EMS systems covering higher population densities had easier access to resources needed to maintain STEMI systems of care. Emergency medical services systems that have adopted all 4 core elements cover 14% of the US population.

Conclusions

There are large differences in EMS systems of STEMI care in the United States. Most EMS agencies have implemented at least 1 of the 4 core elements of STEMI care, with many having implemented multiple elements.     

Distribution of Emergency Departments According to Annual Visit Volume and Urban–Rural Status: Implications for Access and Staffing

Objectives: Ongoing efforts to improve access to emergency care and emergency department (ED) staffing would benefit from a better understanding of the distribution of EDs in the United States by size and location. This article describes the distribution of U.S. ED visit volumes according to ED urban versus rural status. Methods: The authors used the 2007 National Emergency Department Inventories (NEDI)‐USA database to identify all nonfederal U.S. hospitals with EDs and their annual ED visit volumes. One of twelve 2003 Urban Influence Codes was applied to each ED location based on its county. These categories were collapsed into urban counties and three types of rural counties: adjacent to urban, large nonadjacent, and small nonadjacent. The number of emergency physicians (EPs) needed to staff the higher‐volume rural EDs was estimated. Results: Of the 4,874 U.S. EDs in 2007, 58% were in urban counties and 42% in rural counties. Among the 2,038 rural EDs, 56% were adjacent to urban, 15% were large nonadjacent, and 29% were small nonadjacent. Of the 1,503 lower‐volume (< 10,000 visit) EDs, 21% were in urban counties. Of the 3,371 higher‐volume (≥ 10,000 visit) EDs, 25% were in rural counties. Of the 857 higher‐volume rural EDs, 66% were adjacent to urban, 22% were large nonadjacent, and 12% were small nonadjacent. The authors estimate that approximately 5,600 EPs are needed to staff these higher‐volume rural EDs. Conclusions: There are many lower‐volume EDs in urban areas and higher‐volume EDs in rural areas. Most higher‐volume rural EDs are in rural areas adjacent to urban counties. These data challenge popular assumptions regarding ED visit volumes, locations, and staffing needs. ACADEMIC EMERGENCY MEDICINE 2010; 17:1390–1397 © 2010 by the Society for Academic Emergency Medicine     

Trauma system development and future directions

Traumatic injury, both unintentional and intentional, is a serious public health problem. Trauma care systems play a significant role in reducing mortality, morbidity, and disability due to injuries. However, barriers to the provision of prompt and appropriate emergency medical services still exist in many areas of the United States. Title XII of the Public Health Service Act provides for programs in support of trauma care planning and system development by states and localities. This legislation includes provisions for: 1) grants to state agencies to modify the trauma care component of the state Emergency Medical Services (EMS) plan; 2) grants to improve the quality and availability of trauma care in rural areas; 3) development of a Model Trauma Care System Plan for states to use as a guide in trauma system development; and 4) the establishment of a National Advisory Council on Trauma Care Systems.     

Pale, poor, and 'pretubercular' children: a history of pediatric antituberculosis efforts in France, Germany, and the United States, 1899-1929

An international consensus emerged in the years between 1900 and 1910 regarding the need to refocus antituberculosis efforts away from treating tuberculosis in adults and toward preventing active disease in children. This paper uses social history as a framework to explore pediatric health experiments in France (foster placement of city children with rural farm families), Germany (open-air schools), and the United States (preventorium) for children considered 'pretubercular'. The scientific, social, and political variables that reshaped prevailing ideas and practice with regard to TB prevention during those years are described. The creation of the first preventorium in the United States is explained and the way in which French and German pediatric prevention strategies were adapted to address a specific population considered at high risk in the United States, indigent immigrants, is detailed. For each of these three nations, nurses were central actors. Their efforts provide a unique vantage point to study the cultural dimensions of risk and prevention embedded in nursing care and the interplay between science, culture, nurses, and the state.     

Smokeless tobacco use among adults in the Southeast

Tobacco use is associated with numerous illnesses and contributes to as many as 400,000 deaths in the United States each year. Most tobacco use in the United States is in the form of cigarette smoking, but smokeless tobacco use is particularly high in certain areas and within certain subpopulations. Among US adults, smokeless tobacco use is associated with low socioeconomic status, male sex, Native American race, and southern or rural residence. We review six studies among adults (> or = 18 years) describing the epidemiology of smokeless tobacco use in the southeastern United States. These studies indicate that the Southeast, with its strong ties to tobacco production, is an area that requires intensive tobacco cessation strategies targeting the use of smokeless tobacco as well as cigarettes.     

Nurses' agricultural education in the southeastern United States

The number of nurses across the United States with expertise in agricultural health nursing is unknown, yet as many as 8,000 are needed. This article describes agricultural health content in nursing programs in the southeastern United States. Agriculture is primarily family based but ranks among the top three most hazardous industries in America. Nurses in the southeastern United States serve more than 541,000 farm families, more than a quarter of the nation's agricultural population. A 15-item survey was mailed to 185 nursing schools located within 13 southeastern states. Information was requested about undergraduate and graduate curricula that included information about agricultural health and safety. Surveys were returned from 113 programs (61.1%). Schools with larger percentages of rural students were more likely to include mention of agricultural health; however, scant attention was given to any rurally focused content. In 27.4% of the schools, no mention of agricultural health issues was made, and 54.0% of nursing faculty who completed the survey were not aware of the need for nurses with agricultural health expertise. Results suggested that, when agricultural health topics were presented in class, student interest in the topic increased. Given the occupational hazards faced in agriculture and the region's economic dependence on agriculture, increased attention should be focused on agricultural health content within nursing programs.     

Critical access hospitals: rural nursing issues.

Critical Access Hospitals (CAHs) are a recent federal initiative to address the fiscal concerns of small rural hospitals and improve access to healthcare for rural residents. A national effort exists to examine the outcomes of this federal initiative, but there is a paucity of information about nursing in CAHs. This pilot study, using survey techniques, examined rural nurses' perceptions of CAH conversion. The authors discuss the authorizing legislation, Medicare Rural Hospital Flexibility Program (MRHFP), and highlight survey findings on nurses' perceptions about hospitals that converted to CAH status. The information can be used by nursing administrators and educators to prepare nurses to work in CAHs that are located in more remote areas of the United States.     

The Center for Research on Chronic Health Conditions: a strategy for enhancing rural nursing research

Conducting nursing research with rural populations is influenced by the multidimensional characteristics of rural dwellers, the rural environment, the paucity of nurse scientists prepared and supported to conduct rural research, and institutional constraints common to academic institutions serving rural communities. Collaboration across rural academic settings is therefore integral to the success of rural nursing science. The purpose of this article is to discuss the role of the Center for Research on Chronic Health Conditions in Rural Dwellers as a strategy for overcoming the challenges of conducting rural nursing research in the rural western mountain region of the United States.     

Distribution of US anesthesia providers and services

This study describes the correlation between anesthesia providers by type (Certified Registered Nurse Anesthetist [CRNA] or anesthesiologist) and their respective rural or urban distributions across America. Analyses are based on county level data contained in several distinct databases with a given assumption that most providers practice and reside in the same rural or urban designation category. Data reveal that 91.6% (28,569) of active practicing anesthesiologists reside in metropolitan counties and that 8.4% (2,625) reside in nonmetropolitan counties. Of the 26,658 active practicing CRNAs, 81.4% (21,701), reside in metropolitan counties as opposed to 18.6% (4,957) in nonmetropolitan counties. Overall, analyses indicate that out of a total of 3,140 counties, there are 843 counties in the United States where neither anesthesiologists nor CRNAs reside. Ninety-seven percent (816) of these counties are nonmetropolitan.     

Variation in Pediatric Traumatic Brain Injury Outcomes in the United States

Objective

To ascertain the degree of variation, by state of hospitalization, in outcomes associated with traumatic brain injury (TBI) in a pediatric population.

Design

A retrospective cohort study of pediatric patients admitted to a hospital with a TBI.

Setting

Hospitals from states in the United States that voluntarily participate in the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.

Participants

Pediatric (age ≤19y) patients hospitalized for TBI (N=71,476) in the United States during 2001, 2004, 2007, and 2010.

Interventions

None.

Main Outcome Measures

Primary outcome was proportion of patients discharged to rehabilitation after an acute care hospitalization among alive discharges. The secondary outcome was inpatient mortality.

Results

The relative risk of discharge to inpatient rehabilitation varied by as much as 3-fold among the states, and the relative risk of inpatient mortality varied by as much as nearly 2-fold. In the United States, approximately 1981 patients could be discharged to inpatient rehabilitation care if the observed variation in outcomes was eliminated.

Conclusions

There was significant variation between states in both rehabilitation discharge and inpatient mortality after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the cause of this state-to-state variation, its relationship to patient outcome, and standardizing treatment across the United States.     

Integrating international medical graduates into the physician-scientist pool: solution to the problem of decreasing physician-scientists in the United States.

There is an increasing shortage of physician-scientists in the United States, threatening future medical research. There are several factors that dissuade US medical graduates from entering into physician scientists careers. This article proposes that international medical graduates (IMGs) who have contributed to the physician work force in the under serviced rural health system could also be a great source to meet the increasing physician-scientist demand. Mechanisms to allow IMGs to enter into the physician-scientist career track in the United States are suggested.     

Narrowing performance gap between rural and urban hospitals for acute myocardial infarction care

BackgroundRural communities experience significant barriers to quality healthcare, including disparities in medical care following acute myocardial infarctions (AMI). This study sought to determine if the population density of the county where Medicare patients were hospitalized following AMI predicted short-term outcomes and to quantify longitudinal changes in hospital performance on quality of care metrics.MethodsHospital-level data was queried from the 2012 and 2018 Centers for Medicare & Medicaid Services archives. Each hospital was classified based on residing county using the National Center for Health Statistics Rural-Urban Continuum Codes (RUCC). Variations and longitudinal changes in risk-adjusted outcomes and quality of care metrics were stratified by RUCC classification and analyzed.ResultsAmong the 4798 hospitals identified, rural hospitals had significantly higher risk-adjusted 30-day mortality (r_s = 0.095, p < 0.001) and decreased statin prescribed at discharge (r_s = −0.066, p = 0.004). Only aspirin (R² = 0.003, p = 0.024) and statin (R² = 0.006, p = 0.001) prescribed at discharge were correlated with improved 30-day mortality. Despite these differences, from 2012 to 2018 the performance gap between rural and urban hospitals narrowed for all but one quality of care metric, with concurrent 1.83% [95% CI 1.76–1.90] and 3.37% [95% CI 3.30–3.44] reductions in mortality and hospital readmissions, respectively.ConclusionsIn the United States, only modest variations currently exist between rural and urban hospitals in the medical care of AMI. Although the performance gap has narrowed, new strategies to improve timely and effective care are necessary to alleviate residual cardiovascular healthcare disparities in rural communities.     

The effect of lack of insurance, poverty and paediatrician supply on immunization rates among children 19-35 months of age in the United States

Rational, aims and objectives Previous studies found that the increasing number of paediatricians in the United States was associated with improved childhood immunization coverage, while the increasing poverty level and the lack of health insurance reduced access to health care. We evaluated whether changes in the number of paediatricians, poverty level and health insurance affected national childhood immunization coverage in the state levels of the United States. Methods Data were collected primarily from the US National Immunization Surveys, series 4:3:1:3:3 from years 1995 and 2003. Ordinal logistic regression analysis was used to analyse the relationships among variables. Results Over 8 years studied, immunization coverage increased for children aged 19–35 months from 52.3% to 79.8% in the 50 states. The average number of paediatricians per 1000 births increased 28.7% while the percentage of children without health insurance declined 15.6%, and the percentage of children who lived in poverty level declined 17.3%. In 1995, the states with higher immunization coverage were associated with higher numbers of paediatricians [odds ratio (OR), 32.73; 95% confidence interval (CI), 5.96–179.77]. In 2003, the higher numbers of paediatricians still played a role in the increased immunization coverage (OR, 4.69; 95% CI, 1.01–21.78); however, the higher rate of uninsured children in 2003 had an even greater effect upon immunization coverage. Compared with states with lower rates of uninsured children, states with intermediate and higher rates of uninsured children had sixfold (OR, 0.16; 95% CI, 0.03–0.81) and 16‐fold (OR, 0.06; 95% CI, 0.01–0.40) decreased childhood immunization coverage, respectively. Conclusion Between 1995 and 2003 in the United States, the lack of health insurance became more prominent than the supply of paediatricians in affecting immunization coverage for children aged 19–35 months. Future improvements in insurance coverage for children will likely lead to greater immunization coverage.     

The Chiropractic Scope of Practice in the United States: A Cross-Sectional Survey

Objective

The purpose of this study was to assess the current status of chiropractic practice laws in the United States. This survey is an update and expansion of 3 original surveys conducted in 1987, 1992, and 1998.

Methods

A cross-sectional survey of licensure officials from the Federation of Chiropractic Licensing Boards e-mail list was conducted in 2011 requesting information about chiropractic practice laws and 97 diagnostic, evaluation, and management procedures. To evaluate content validity, the survey was distributed in draft form at the fall 2010 Federation of Chiropractic Licensing Boards regional meeting to regulatory board members and feedback was requested. Comments were reviewed and incorporated into the final survey. A duplicate question was imbedded in the survey to test reliability.

Results

Partial or complete responses were received from 96% (n = 51) of the jurisdictions in the United States. The states with the highest number of services that could be performed were Missouri (n = 92), New Mexico (n = 91), Kansas (n = 89), Utah (n = 89), Oklahoma (n = 88), Illinois (n = 87), and Alabama (n = 86). The states with the highest number of services that cannot be performed are New Hampshire (n = 49), Hawaii (n = 47), Michigan (n = 42), New Jersey (n = 39), Mississippi (n = 39), and Texas (n = 30).

Conclusion

The scope of chiropractic practice in the United States has a high degree of variability. Scope of practice is dynamic, and gray areas are subject to interpretation by ever-changing board members. Although statutes may not address specific procedures, upon challenge, there may be a possibility of sanctions depending on interpretation.     

Increasing nursing faculty in rural Texas through online education

To increase RN production, there must be a cadre of qualified faculty. Faculty shortages abound across the United States and are particularly acute in rural areas. Our innovation provides one answer to increasing rural faculty resources through online education.     

The use of the Soterion Rapid Triage System in children presenting to the Emergency Department

There has been a recent move toward the adoption of five-level triage systems in the United States. However, there have been no studies in this country that have critically evaluated the use of these systems in children. The purpose of this study was to evaluate the reliability and validity of a new five-level triage system, the Soterion Rapid Triage System, for stratifying acuity levels in children under the age of 13 years. The study was conducted in a 389-bed Level II mixed adult and pediatric Trauma Center that experiences approximately 12,000 patient visits/year of children under the age of 13 years. We performed a prospective evaluation of the system's reliability using the weighted kappa statistical method (n = 117) and a retrospective evaluation of the system's validity through an analysis of all patients under the age of 13 years triaged with the system over an 8-month period (n = 7077). The system's validity was measured by in-hospital admission rate, Emergency Department length of stay, hospital charges, and Current Procedural Terminology (CPT) Codes 99281-99285. The inter-rater reliability as measured by the weighted kappa was 0.90 (95% confidence interval 0.83-0.96), with 92% exact agreement between nurses in the triage level assigned. The in-hospital admission rates for patients triaged as Level 1 Immediate-Level 5 Non-Urgent were 38%, 18%, 9%, 1.5% and 0.4%, respectively (p < 0.0001). The mean total hospital charges for each of the five triage levels were $2673, $1563, $1112, $477, and $258, respectively (p < 0.0001). Similarly, there were significant differences in the means for laboratory and pharmacy charges, Emergency Department lengths of stay, and CPT Codes. This report represents the first study in this country on the effectiveness of a five-level triage system in children. We have demonstrated that the Soterion Rapid Triage System possesses high inter-rater reliability and validity when used to triage children younger than 13 years of age.     

Patient ED turnaround times: a comparative review

Patient turnaround times in emergency departments (EDs) are receiving increasing attention by patients, medical staff, hospital administrators, payers, and regulatory agencies. A retrospective study of ED turnaround times by hospitals identified by Modern Healthcare as being in the top 100 hospitals in the United States was undertaken. Five different categories of hospitals were studied. The shortest turnaround times occurred in rural hospitals with less than 250 beds and the longest times were in major academic centers with more than 400 beds.     

The drug lag: an update of new drug introductions in the United States and in the United Kingdom, 1977 through 1987

This report updates previous studies that documented the existence of a significant lag between new drug introductions in the United Kingdom and in the United States. During the 11-year period from 1977 through 1987, the United Kingdom led the United States in the number of first introductions of new drugs (114 versus 41), in average lead time for mutually available drugs (60.7 versus 28.9 months), and in the number of exclusively available drugs (70 versus 54). Analysis by therapeutic category indicated large United Kingdom leads in the introduction of respiratory (5.1 years), cardiovascular (3.2 years), central nervous system (3.2 years), and anti-cancer (2.9 years) agents, and shorter leads for anesthetic and analgesic (2.0 years), gastrointestinal (2.0 years), endocrine (1.4 years), and anti-infective (0.8 years) agents. A comparison of the 5-year period from 1983 through 1987 with the previous 5-year period (1978 through 1982) showed no change in the length of the lag time (1.9 years for each period). These results indicate that the United States continues to lag behind the United Kingdom in the availability of new drugs.     

Prevalence and antimicrobial susceptibility data for extended-spectrum beta-lactamase- and AmpC-producing Enterobacteriaceae from the MYSTIC Program in Europe and the United States (1997-2004)

This article presents prevalence and susceptibility data from the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Program in Europe (1997-2004) and the United States (1999-2004) for Enterobacteriaceae producing extended-spectrum beta-lactamase (ESBL) and/or AmpC beta-lactamases. For ESBL-producing isolates, the prevalence of Escherichia coli and Klebsiella spp. in Europe and Enterobacter spp. in the United States increased over time. For AmpC-producing isolates, the prevalence of Enterobacter spp. and Citrobacter spp. decreased over time in Europe and the United States, respectively. Compared with other antimicrobial agents, meropenem and imipenem had greatest activity against ESBL-producing E. coli and Klebsiella spp. in both Europe (96.9-100.0%) and the United States (100.0%). Such activity was also found for AmpC-producing Enterobacteriaceae in Europe (50.0-100.0%), and Enterobacter spp. and Citrobacter spp. from the United States (100.0% for both). The continued efficacy of carbapenems such as meropenem confirms that these remain first-line agents for treatment of nosocomial infections caused by Enterobacteriaceae-producing ESBL or AmpC beta-lactamases.