Identifying measures for evaluating new models of nursing care: a survey of NSW nurse practitioners

Health-care reforms in Australia and worldwide have seen the creation of the position of nurse practitioner (NP). To date, no protocol has been developed in Australia to guide the evaluation of this new role. All NSW authorized NPs were invited to participate in a self-administered questionnaire. Generic process and outcome measures of NP services were taken from a review of the literature. NPs were asked to determine how 'essential' each of these measures would be to describe their clinical practice. Of the 36 eligible authorized NPs in NSW, 30 returned completed questionnaires (83% response rate). The following measures were rated 'essential' by all (100%) NPs: presenting issue as stated by patient; current medications; patient satisfaction with education, quality of care received, and provider knowledge and skill. Our results provide a unique set of indicators with which to evaluate process and outcome measures of NP services. Standard outcome measures will enable NPs to evaluate their service efficiently and to benchmark against other NPs.     

State of the science of postacute rehabilitation: setting a research agenda and developing an evidence base for practice and public policy. An introduction.

The Rehabilitation Research and Training Center on Measuring Rehabilitation Outcomes and Effectiveness, along with academic, professional, provider, accreditor, and other organizations, sponsored a 2-day symposium on the state of the science of postacute rehabilitation in February 2007. The aim of this symposium was to serve as a catalyst for expanded research on postacute care (PAC) rehabilitation so that health policy could be founded on a solid evidence base. The goals were to (1) describe the state of our knowledge regarding utilization, organization, and outcomes of postacute rehabilitation settings, (2) identify methodologic and measurement challenges to conducting research, (3) foster the exchange of ideas among researchers, policymakers, industry representatives, funding agency staff, consumers, and advocacy groups, and (4) identify critical issues related to setting, delivery, payment, and effectiveness of rehabilitation services. Plenary presentation and state-of-the-science summaries were organized around four themes: (1) the need for improved measurement of key rehabilitation variables and methods to collect and analyze this information, (2) factors that influence access to postacute rehabilitation care, (3) similarities and differences in quality and quantity of services across PAC settings, and (4) effectiveness ofpostacute rehabilitation services. The full set of symposium articles, including recommendations for future research,     

Outcomes-based trial of an inpatient nurse practitioner service for general medical patients

Although teaching hospitals are increasingly using nurse practitioners (NPs) to provide inpatient care, few studies have compared care delivered by NPs and housestaff or the ability of NPs to admit and manage unselected general medical patients. In a Midwest academic teaching hospital 381 patients were randomized to general medical wards staffed either by NPs and a medical director or medical housestaff. Data were obtained from medical records, interviews and hospital databases. Outcomes were compared on both an intention to treat (i.e. wards to which patients were randomized) and actual treatment (i.e. wards to which patients were admitted) basis. At admission, patients assigned randomly to NP-based care (n = 193) and housestaff care (n= 188) were similar with respect to demographics, comorbidity, severity of illness and functional parameters. Outcomes at discharge and at 6 weeks after discharge were similar (P>0.10) in the two groups, including: length of stay; charges; costs; consultations; complications; transfers to intensive care; 30-day mortality; patient assessments of care; and changes in activities of daily living, SF-36 scores and symptom severity. However, after randomization, 90 of 193 patients (47%) assigned to the NP ward were actually admitted to housestaff wards, largely because of attending physicians and NP requests. None the less, outcomes of patients admitted to NP and housestaff wards were similar (P>0.1). NP-based care can be implemented successfully in teaching hospitals and, compared to housestaff care, may be associated with similar costs and clinical and functional outcomes. However, there may be important obstacles to increasing the number of patients cared for by NPs, including physician concerns about NPs' capabilities and NPs' limited flexibility in managing varying numbers of patients and accepting off-hours admissions.     

Publishing outcome data: is it an effective approach?

RATIONALE, AIMS AND OBJECTIVES: The publication of health outcome data--rather than merely the measurement and collection--is being given increasing consideration. Publication reflects society's increasing emphasis on a general 'right to know', as well as being a means of informing consumer choice. In theory, publication may help to promote public trust, support patient choice, and stimulate action to improve the quality of care whilst controlling costs. METHODS: Drawing on a literature review, this paper overviews the strategies employed in the UK and US to publish outcome data. The focus is on outcomes, and certain related process measures, that measure the performance of hospitals or surgeons. RESULTS AND CONCLUSIONS: Presenting the limited evidence that exists, we review the potential beneficial and harmful effects of publishing hospital outcome data. We also consider the risks of making incorrect inferences based on these data and the potential for dysfunctional consequences. Recognizing that the public largely mistrusts currently published health outcome data, we offer some recommendations for the future direction of strategies for publication.     

Validity of the de Morton Mobility Index (DEMMI) for measuring the mobility of patients with hip fracture during rehabilitation

Purpose: Many patients suffer long term loss of mobility after hip fracture but there is no gold standard method for measuring mobility in this group. We aimed to validate a new mobility outcome measure, the de Morton Mobility Index (DEMMI) in a hip fracture population during inpatient rehabilitation. Method: The DEMMI was compared with the existing measures of activity limitation: 6 minute walk test, 6 metre walk test and Barthel Index on 109 consecutive patients admitted to rehabilitation after surgery for hip fracture. Patients were assessed by a physiotherapist at admission and discharge. Scale width, validity, minimal clinically important difference (MCID), responsiveness, and unidimensionality were investigated. Results: Evidence of convergent, discriminant and known groups validity were obtained for the DEMMI. Responsiveness was similar across instruments and the MCIDs were consistent with previous reports. A floor effect was identified for the 6 metre walk test and 6 minute walk test at hospital admission. Rasch analysis identified that the DEMMI maintains its unidimensional properties in this population. Conclusions: The DEMMI has a broader scale width than existing measures of activity limitation and provides a unidimensional measure of mobility for hip fracture patients during inpatient rehabilitation.

Implications for Rehabilitation

• Loss of mobility is a common and significant problem following hip fracture.

• The de Morton Mobilitiy Index (DEMMI) is an effective instrument for measuring mobility in patients with hip fracture during rehabilitation

• The DEMMI is unidimensional, has a broader scale width than existing measures and offers an interval scale for measurement of mobility in hip fracture during rehabilitation

     

All Kinds of Love Experiencing Hospice. By Carolyn Jaffe and Carol H. Ehrlich

On April 6, 2005, the Directors of the Office of New Drugs and the Office of Pharmacoepidemiology and Statistical Science at the U.S. Food and Drug Administration posted the following information on the FDA website pertaining to analysis and recommendations for FDA action regarding nonsteroidal anti-inflammatory drugs and cardiovascular risk.     

An evaluation of antimicrobial prophylaxis in paediatric surgery and its financial implication

OBJECTIVE: To assess the appropriateness of use of antimicrobial prophylaxis in paediatric surgery in Singapore. METHODS: A prospective evaluation of the use of antimicrobial prophylaxis in paediatric patients undergoing surgery in KK Hospital, Singapore was carried out from September and December 2001. Process measures for the study included adherence to local or international guidelines, choice and dose of antimicrobial agent and timing and duration of prophylaxis. Outcome measures included surgical site and other related infections. A cost analysis was also performed to look at the extra expenditure due to any excessive use of antimicrobials. RESULTS: A total of 171 patients with a mean age of 5.7 years (SD=4.5) were included in the study. Among the 117 (68.4%) elective and 54 (31.6%) emergency procedures, 22 cases (12.8%) were fully compliant with the guidelines. The most frequently encountered non-compliance types were unnecessary prolongation of prophylaxis (54.4%), inappropriate choice of antibiotics (42.7%) and overdose of antibiotics (26.3%). The estimated extra cost to patients for the study period was Sing$13,879.41 (US 8164.36). CONCLUSION: The results showed a significantly high level of inappropriate use of antimicrobial prophylaxis in paediatric surgery in Singapore. However, when the individual factors such as appropriate choice of antibiotics, appropriate timing and duration were considered, the situation was very similar to the results obtained from overseas studies.     

Using Patient Care Quality Measures to Assess Educational Outcomes

Objectives To report the results of a project designed to develop and implement a prototype methodology for identifying candidate patient care quality measures for potential use in assessing the outcomes and effectiveness of graduate medical education in emergency medicine. Methods A workgroup composed of experts in emergency medicine residency education and patient care quality measurement was convened. Workgroup members performed a modified Delphi process that included iterative review of potential measures; individual expert rating of the measures on four dimensions, including measures quality of care and educational effectiveness; development of consensus on measures to be retained; external stakeholder rating of measures followed by a final workgroup review; and a post hoc stratification of measures. The workgroup completed a structured exercise to examine the linkage of patient care process and outcome measures to educational effectiveness. Results The workgroup selected 62 measures for inclusion in its final set, including 43 measures for 21 clinical conditions, eight medication measures, seven measures for procedures, and four measures for department efficiency. Twenty‐six measures met the more stringent criteria applied post hoc to further stratify and prioritize measures for development. Nineteen of these measures received high ratings from 75% of the workgroup and external stakeholder raters on importance for care in the ED, measures quality of care, and measures educational effectiveness; the majority of the raters considered these indicators feasible to measure. The workgroup utilized a simple framework for exploring the relationship of residency program educational activities, competencies from the six Accreditation Council for Graduate Medical Education general competency domains, patient care quality measures, and external factors that could intervene to affect care quality. Conclusions Numerous patient care quality measures have potential for use in assessing the educational effectiveness and performance of graduate medical education programs in emergency medicine. The measures identified in this report can be used as a starter set for further development, implementation, and study. Implementation of the measures, especially for high‐stakes use, will require resolution of significant measurement issues.     

Long-term persistence of quality improvements for an intensive care unit communication initiative using the VALUE strategy

Purpose

Communication in the intensive care unit (ICU) is an important component of quality ICU care. In this report, we evaluate the long-term effects of a quality improvement (QI) initiative, based on the VALUE communication strategy, designed to improve communication with family members of critically ill patients.

Materials and Methods

We implemented a multifaceted intervention to improve communication in the ICU and measured processes of care. Quality improvement components included posted VALUE placards, templated progress note inclusive of communication documentation, and a daily rounding checklist prompt. We evaluated care for all patients cared for by the intensivists during three separate 3 week periods, pre, post, and 3 years following the initial intervention.

Results

Care delivery was assessed in 38 patients and their families in the pre-intervention sample, 27 in the post-intervention period, and 41 in follow-up. Process measures of communication showed improvement across the evaluation periods, for example, daily updates increased from pre 62% to post 76% to current 84% of opportunities.

Conclusions

Our evaluation of this quality improvement project suggests persistence and continued improvements in the delivery of measured aspects of ICU family communication. Maintenance with point-of-care-tools may account for some of the persistence and continued improvements.     

Utility of the Community Integration Questionnaire in a sample of adults with neurological and neuropsychiatric disorders receiving prevocational training

Purpose: To investigate utility of the Community Integration Questionnaire (CIQ) in a mixed sample of adults with neurological and neuropsychiatric disorders. Method: Cross-sectional, interview-based study. Participants were community-dwelling adults with disabilities resulting from neurological and neuropsychiatric disorders (N?=?54), who participated in a pre-vocational readiness and social skills training program. Psychometric properties of the Community Integration Questionnaire (CIQ) were assessed and validated against Mayo-Portland Adaptability Inventory (MPAI) and The Problem Checklist from the New York University Head Injury Family Interview (PCL). Results: Based on the revised scoring procedures, psychometric properties of the CIQ Home Competency scale were excellent, followed by the Total score and Social Integration scale. Productive Activity scale had low content validity and a weak association with the total score. Convergent and discriminant validity of the CIQ were demonstrated by correlation patterns with MPAI scales in the expected direction. Significant relationship was found with PCL Physical/Dependency scale. Significant associations were found with sex, living status, and record of subsequent employment. Conclusions: The results provide support for the use of the CIQ as a measure of participation in individuals with neurological and neuropsychiatric diagnoses and resulting disabilities.

• Implications for Rehabilitation

• An important goal of rehabilitation and training programs for individuals with dysfunction of the central nervous system is to promote their participation in social, vocational, and domestic activities.

• The Community Integration Questionnaire (CIQ) is a brief and efficient instrument for measuring these participation domains.

• This study demonstrated good psychometric properties and high utility of the CIQ in a sample of 54 individuals participating in a prevocational training program.

     

The state-of-the-science: challenges in designing postacute care payment policy

Chan L. The state-of-the-science: challenges in designing postacute care payment policy.This report describes Medicare’s postacute care (PAC) payment systems and their incentives, as well as global changes in capacity, quality, and utilization over time. It assesses the payment systems’ impact on PAC services, referencing relevant works in progress. Suggestions are made for future research.     

State-of-the-science on postacute rehabilitation: measurement and methodologies for assessing quality and establishing policy for postacute care

Duncan PW, Velozo CA. State-of-the-science on postacute rehabilitation: measurement and methodologies for assessing quality and establishing policy for postacute care.We present an overview of commonly used postacute outcome measures and review new methodologies for postacute assessment. We question the impact that current measurement has had on improvement of quality of postacute care (PAC) and its utility in informing health policy. We suggest that Donabedian’s model of health care quality should be endorsed for measurement. Specifically, measurement of outcomes and process should be used jointly in assessment of PAC.