Assessing outcomes in advanced practice nursing practice: the use of quality indicators and evidence-based practice

Advanced practice nurses (APNs) impact both patient care and healthcare systems on a daily basis. Tracking and documenting the outcomes of APN practice have become essential, due partly to the emphasis on outcomes that has become a component of the majority of healthcare initiatives. This article outlines important aspects related to assessing outcomes and discusses the use of quality indicators to demonstrate outcomes of APN practice. Examples from clinical practice are provided in order to demonstrate that assessing the outcomes of APN practice can be incorporated into daily practice as part of ongoing initiatives. In delineating the outcomes of APN care, the value of APNs can be formally acknowledged.     

Global considerations in measuring effectiveness of advanced practice nurses

Documentation of advanced practice nurses' (APNs) effectiveness globally is essential in developing educational programs and standards, regulations, titling, prescribing privileges, and scope and standards of practice. Based on the body of research on APN effectiveness to date, two major factors have emerged in developing future studies, (1) careful, deliberate choice of outcomes and (2) dose effects. The purpose of this paper is to review these measurement issues. Careful selection in choice of patient outcomes important to regional and national health care challenges is essential in developing studies to document APN effects on outcomes important to the country and region. It is equally important to consider the concept of dose effects of the APNs. Dose effects consist of 3 components: dose (number of APNs at the clinical practice site, region or country and amount of APN care in minutes or contacts); APN (education, expertise, and experience); and host and host response (organizational, governmental or patient and/or family receptiveness to APNs and to APN practice). Considering each component of the concept is essential in developing studies to examine APN effectiveness internationally.     

The Cardiac Surgery Advanced Practice Group: A Case Study of APN and PA Collaborative Practice

In the United States, more than 600,000 surgeries for cardiac disease are performed annually, accounting for millions of dollars in health care expenses. The rise in patient acuity levels from comorbid factors is contributing to these costs. In a health care reform environment, the challenges to the health care system are to maintain quality of care and provide advanced therapies while decreasing the costs associated with that care. Advanced practice nurses (APNs) and physician assistants (PAs) are able to work with multidisciplinary groups to provide comprehensive care and decrease costs. The purpose of this article is to explore the evolution of the role of the APN and PA in an acute care setting. The origins and benefits of this role and future for this model are addressed.     

The impact of reducing dose frequency on health outcomes

BACKGROUND: Dosing schedules may be one important factor determining whether patients take their prescribed medication. Schedules may influence whether a patient stays on the prescribed therapy and, if so, the degree to which the regimen is followed. Both factors are important determinants of health outcomes and health care costs. OBJECTIVE: The goal of this study was to investigate the impact of reducing dose frequency on health outcomes and health care costs. METHODS: Articles from peer-reviewed journals were identified from the medical literature databases MEDLINE, International Pharmaceutical Abstracts, and HealthSTAR for the years 1985 through 2002. The search included all references that reported on the impact of a change of dose frequency on chronic disease. Search terms used were combinations of dose frequency, dose schedule, and dosing and efficacy, safety, clinical effectiveness, preferences, adherence, compliance, persistence, health-related quality of life, patient satisfaction, resource use, and costs. RESULTS: Reducing the number of daily doses through extended-release formulations or newer drugs has frequently been shown to provide the patient with better symptom control in a number of disease states. Overall improvements were seen in adherence, patient quality of life, patient satisfaction, and costs. However, results of some studies indicate that not all patients, medications, or diseases may be candidates for reduced dosing due to the potential effects on symptom control, incidence of adverse events, and overcompensation for missed doses. CONCLUSION: Where feasible, reducing dose frequency may offer benefits for the patient in terms of health outcomes and for the health care budget holder in terms of costs.     

Effects of New Zealand's health reengineering on nursing and patient outcomes

BACKGROUND: In 1993, New Zealand (NZ) implemented policies aimed at controlling costs in the country's public health care system through market competition, generic management, and managerialism. The cost control focus was similar to reengineering efforts implemented by other countries struggling with escalating health care costs, particularly the United States. OBJECTIVE: The study's purpose was to examine the effects hospital reengineering may have on adverse patient outcomes and the nursing workforce. RESEARCH DESIGN: The study was a retrospective, longitudinal analysis of administrative data. Relationships between adverse outcome rates and nursing workforce characteristics were examined using autoregression analysis. SUBJECTS: All medical and surgical discharges from NZ's public hospitals (n = 3.3 million inpatient discharges) from 1989 through 2000 and survey data from the corresponding nursing workforce (n = 65,221 nurse responses) from 1993 through 2000 were examined. MEASURES: Measures included the frequency of 11 nurse sensitive patient outcomes, average length of stay, and mortality along with the number of nursing full time equivalents (FTEs), hours worked, and skill mix. RESULTS: After 1993, nursing FTEs and hours decreased 36% and skill mix increased 18%. Average length of stay decreased approximately 20%. Adverse clinical outcome rates increased substantially. Mortality decreased among medical patients and remained stable among surgical patients. The relationship between changes in nursing and adverse outcomes rates over time were consistently statistically significant. CONCLUSIONS: In the chaotic environment created in NZ by reengineering policy, patient care quality declined as nursing FTEs and hours decreased. The study provides insight into the role organizational change plays in patient outcomes, the unintended consequences of health care reengineering and market approaches in health care, and nursing's unique contribution to quality of care.     

The influences of postdischarge management by nurse practitioners on hospital readmission for heart failure

PURPOSE: The primary purpose of this literature review is to examine advanced practice nurse (APN)-directed versus registered nurse (RN)-directed telemanagement programs for heart failure patients. DATA SOURCES: Research articles identified through CINAHL and OVID databases. CONCLUSIONS: Implementing a telemanagement program directed by an APN after hospital discharge decreases the costs and frequent rehospitalizations associated with heart failure and improves the patient's quality of life. While APNs are more costly than RNs, it is important to understand that this level of provider has a more significant impact on the outcomes of patients who use the services provided in the comprehensive discharge programs. IMPLICATIONS FOR PRACTICE: An APN-directed heart failure telemanagement program can reduce the rising healthcare costs that result from frequent readmissions. These programs can improve the quality of care given to heart failure patients while reducing the cost to the institution, the patient, and the healthcare system. When considering the number of older adults hospitalized each year with heart failure, the potential patient benefits and savings to the healthcare system resulting from APN-directed telemanagement are substantial.     

The U.S. presidential election and health care workforce policy

The candidates for the 2008 presidential election have offered a range of proposals that could bring significant changes in health care. Although few are aimed directly at the nurse and physician workforce, nearly all of the proposals have the potential to affect the health care workforce. Furthermore, the success of the proposed initiatives is dependent on a robust nurse and physician workforce. The purpose of this article is to outline the current needs and challenges for the nurse and physician workforce and highlight how candidates' proposals intersect with the adequacy of the health care workforce. Three general themes are highlighted for their implications on the physician and nurse workforce supply, including (a) expansion of health care coverage, (b) workforce investment, and (c) cost control and quality improvement.     

The social bases of discrepancies in health/illness perceptions

Health care professionals generally assume that their perceptions and assessments of their patients' health status are accurate and are congruent with those of the patient and other health care providers. However, despite the patient education process, there is evidence that discrepancies in perceptions persist. These discrepancies are of particular concern to nurses because they may interfere with the provision of quality patient care. Poor communication, non-compliance with the treatment regimen, inadequate or unnecessary treatment, and ethical problems could be outcomes of discrepancies in perceptions. In this paper, the literature pertaining to discrepancies in health/illness perceptions is reviewed. As well, several social factors that may affect perceptions are described. These include cultural background, gender, socioeconomic status, experience and role. The effect of occupational role on health/illness perceptions has not been examined systematically. Regarding differences in perceptions of physicians, nurses and patients, further research is required to clarify and explain the nature of discrepancies in health/illness perceptions.     

Process and outcome measures using nursing sensitive indicators

Measuring the impact of high quality nursing care has become an imperative driven by several issues during the past several years. Current challenges surrounding the nursing shortage and the decreasing nursing workforce projected for the next decade alone have raised serious questions about the effect fewer registered nurses (RNs) will have on the quality of health care. In addition, heightened public attention to patient safety and adverse outcomes has prompted national organizations, such as the Joint Commission for Accreditation of Healthcare Organizations, the American Nurses Credentialing Center, and the National Quality Forum, to consider and implement recommendations for establishing and monitoring nursing quality indicators that focus on nursing-sensitive patient outcomes. These issues, now more than ever, have provided us with a burning platform to examine exactly what nurses do and their impact on patient health outcomes.     

Advanced practice nursing for congestive heart failure

Congestive heart failure (CHF) is an enormous burden on society and the health care system. The role of the advanced practice nurse (APN) in CHF is multifaceted and combines inpatient, outpatient, and community patient care skills. Case management and quality management have been traditional focuses, with a high level of practice impact on patient care. Outcomes management in the APN role for CHF care is the future for measurable outcomes and maximum impact on organizational values. Because outcomes management is an evolving field for the APN, focus on a chronic disease such as CHF is a very valuable tool for implementation.     

Nurse-sensitive outcomes of advanced practice

Advanced practice nurses (APNs) in the USA are registered nurses who hold masters or doctoral degrees in a specialized area of nursing. They provide advanced clinical care to clients, manage health care systems and influence health care decision-making through expert clinical reasoning and research and theory-based action. APN impact on health care outcomes is supported by studies using physician-focused indicators, although a few studies have identified several that are sensitive to or reflective of advanced practice nursing. A modified Delphi survey was conducted during May 1997-December 1998 to determine the outcome indicators APNs recommend for use in measuring their effect on care delivery outcomes. A convenience sample of 66 APNs attending a statewide outcomes conference identified 27 potential outcome indicators. These indicators were included in a mailed survey sent to APNs working in Tennessee. Respondents were asked to rate each indicator for validity, sensitivity, feasibility, utility and cost. In the second round of the survey, they were asked whether or not they agreed with the rank ordering of indicators, which was determined by the means calculated from responses in the first round. The 10 highest ranked indicators were satisfaction with care delivery, symptom resolution/reduction, perception of being well cared for, compliance/adherence with treatment plan, knowledge of patients and families, trust of care provider, collaboration among care providers, frequency and type of procedures ordered and quality of life. APNs identified both direct and indirect measures of effect on care delivery outcomes. Some of these are currently used as indicators of advanced practice, but many are not. Additional research is needed to determine whether the indicators proposed are valid and sensitive to advanced practice care by nurses.     

The relationship between family physician density and health related outcomes: the Canadian evidence

This paper analyzes if and to what extent the density of family physicians influences health related outcomes in Canada. The density of family physicians in a given region is assumed to serve as proxy for the access to and availability of desirable primary care services. We use self-reported general and mental health status as our overall health outcome measures. We also use several quality of care indicators reflecting whether or not an individual received influenza immunization, mammography, pap smear, and colorectal cancer screening if at high-risk. The empirical results of this study suggest that an additional family physician per 10,000 population has a statistically significant impact in the order of 2% to 4% on self-reported general health status, as well as, other quality of care outcomes. We also find important socioeconomic and demographic factors, such as income, education and immigrant status, influencing health related outcomes considered in this study. Understanding the influence of physician density and socioeconomic factors on health related outcomes are important considerations for health policy and planning.     

Relationships of rurality, home health care use, and outcomes

Rural elders have a disproportionate prevalence of illness and limited access to health services. The purpose of this study is to determine whether degree of rurality and home health care use influences home health care patient outcomes. An adaptation of the Outcomes Model for Health Care Research provided the framework for the study. A stratified random sample was selected from a database of risk-adjusted publicly reported patient outcomes from Medicare-certified home health care agencies and merged with agency factors from Medicare cost reports and U.S. Census data. Path analysis was performed to evaluate the relationships in the model. Hospitalization is the only outcome variable associated with community and agency characteristics or home health care use. Rurality does not have a direct effect on hospitalization; however, increased visits per patient and low-income community status are associated with increased hospitalization. Rurality may not have a direct effect on outcomes but instead acts through health care services.     

Health care system factors affecting end-of-life care

The field of palliative care in the United States developed in response to a public health crisis--namely, poor quality of life for patients with serious illness and their families--and most palliative care research to date has been appropriately focused on identifying patient and family needs and identifying gaps in the current health care system and in the education of our health care professionals. Research has also begun to develop and evaluate new interventions and systems to address these care gaps. Preliminary studies suggest modest benefits of an array of programs designed to deliver palliative care services. These benefits include improved pain and other symptoms, increased family satisfaction, and lower hospital costs. Unfortunately, the validity and reliability of these findings are limited by important methodological weaknesses including small sample sizes, poorly described and nongeneralizable interventions, diverse and nonstandardized outcome measures, and poor study designs (i.e., lack of appropriate control groups, nonblinded designs). Comprehensive and rigorous research is needed to evaluate the effect of well-delineated and generalizable palliative care structures and processes on important clinical and use outcomes. Large multisite studies that have adequate power to detect meaningful differences in clinical and use outcomes, and that use well-defined and generalizable structures and evidence-based care processes, well-defined uniform outcome measures, and analyses that link the outcomes of interest to individual components of the interventions, are needed to guide further development of the field.     

Economic evaluation in critical care medicine

Scarce resources are a reality in all health care systems. There is a constant challenge to maximize health benefits within the resources available. This is particularly relevant when caring for critically ill patients, given the resource-intensive technologies and medicines used and the highly specialized professionals required. Moreover, given the high acuity of illness, decision makers and health care providers in critical care units must constantly assess the value derived from therapies and resources used. Economic evaluation is the comparative analysis of alternative health care interventions in their relative costs (resource use) and effectiveness (health effects). Economic evaluations have been increasingly published in critical care journals and read by clinicians. This article illustrates how the basic principles of health economics can be applied to health care decision making through the use of economic evaluation. We demonstrate how economic evaluation can link medical outcomes, quality of life, and costs in a common index, even for therapies for different medical conditions and with different health outcomes. This article highlights the need for randomized clinical trials and economic evaluations of therapies in critical care medicine for which the effect of the therapy on health outcomes and/or costs are unknown.     

Quality measurement and accountability for substance abuse and mental health services in managed care organizations

OBJECTIVES: To analyze managed care organizations' (MCOs') use of behavioral health quality management activities using nationally representative survey data. MATERIALS AND METHODS: The primary data source is the Brandeis Survey on Alcohol, Drug Abuse, and Mental Health Services in MCOs. Using a sampling strategy designed for national estimates, we surveyed 434 MCOs in 60 market areas (response rate = 92%) regarding their commercial products' behavioral health services in 1999. Of these, 417 MCOs reported clinically oriented information for 752 products. We investigated the use of four behavioral health quality management activities: patient satisfaction surveys, clinical outcomes assessment, performance indicators, and practice guidelines. chi tests and logistic regression were used to determine effects of product type (HMO, PPO, point-of-service) and behavioral health contracting arrangement (specialty contract, comprehensive contract including general medical and behavioral health, internal provision). RESULTS: Three-quarters of products used patient satisfaction surveys (70.1%), performance indicators (72.7%), and practice guidelines (73.8%) for behavioral health. Under half (48.9%) assessed clinical outcomes. HMO products were most likely, and PPOs least likely, to conduct activities. Quality activities were significantly more common among specialty-contract products. Logistic regression showed significant negative effects on quality activity use for PPO and POS products compared with HMOs. For clinical outcomes, specialty- and comprehensive-contract arrangements had significant positive effects. There were interactions between product type and contract arrangement. CONCLUSIONS: Most commercial managed care products use patient satisfaction surveys, performance indicators, and practice guidelines for behavioral health, whereas clinical outcomes assessment is less common. Product type and contracting arrangements significantly affect use of these activities.     

Differences in physician and patient perceptions of uncomplicated UTI symptom severity: understanding the communication gap

Uncomplicated urinary tract infection (uUTI) is the most common bacterial infection encountered in clinical practice but evaluation and treatment of the illness vary considerably among physicians. The literature suggests that there is often a gap in the perception of symptom severity between physician and patient, a gap that may be a result of the different models they use to explain and manage disease, a result of misinformation or misconceptions about uUTIs, or a result of poor patient-physician communication. This gap in perceptions about uUTI may lead to poor patient care, decreased quality of life and increased antibiotic resistance. Good communication between patient and physician has been shown to result in improved health outcomes. Several approaches to improving communication during consultations have been described in the literature. Physician and patient education and their agreement about any disease, including uUTI can be expected to improve treatment compliance and reduce the incidence of recurrence of such infections. Future work should focus on improvement of communication during clinical consultations to encourage appropriate bidirectional sharing of clinical and patient information. Further research about behavioural risk factors for uUTI may allow evidence-based information to be used in educational programmes.     

Effects of registered nurse staffing on quality of care and resident outcomes in nursing homes

Few studies focus on Registered Nurse (RN) staffing and resident health outcomes in Korean nursing homes. This study aimed to investigate the effects of RN staffing on quality of care and resident outcomes in South Korean nursing homes. The study was a secondary data analysis of 5679 participants from the National Health Insurance Service. A mixed-effect linear model and multinomial logistic regression model assessed resident outcomes and quality of care, respectively. The number of RNs significantly affected patient mortality. The overall evaluation rating for quality of care in nursing homes increased as the number of RNs increased. Level of RN staffing in nursing homes influenced health management and quality of care for residents. A variety of efforts are needed to strengthen the workforce of RNs in nursing homes, including enacting a law for safe RN staffing and converting the evaluation of nursing home quality into health outcomes.     

Integrating health services research into nursing doctoral programs: the evolution of nursing research

Traditionally, nursing research has focused on the effect of an intervention on selected patients without considering the influence of the system of care and its myriad characteristics. Health services research (HSR) focuses on organization and financing of health services; access to health care; quality of care; clinical evaluation and outcomes research; informatics and clinical decision making; practitioner, patient, and consumer behavior; health professions workforce; health policy formulation and analyses; and health care model and service use. Doctoral students can benefit from HSR's broad perspective if it is included in existing nursing curricula. Ultimately, HSR could help the nursing profession achieve the capacity to develop health policy and new systems of health care for the 21st century.