Vacancy, stability, and turnover of registered nurses in hospitals

The purpose of this study was to determine if organizational, administrative, and practice factors differentiate among hospitals and patient care units as to registered nurse vacancy, stability, and turnover rates. Data from 90 patient care units in 15 hospitals are reported. Results from stepwise multiple regression indicate that 52% of the variability in vacancy, 56% of the variance in registered nurse stability, and 42% of the variance in relative turnover rates were explained by seven variables. Important predictors included nursing workload, characteristics of nurse staffing and practice, as well as job satisfaction. These findings indicate that a combination of organizational attributes and staff attitudes are important for understanding nurse staffing.     

Trends in the perceived complexity of primary health care: a secondary analysis

Rationale If the complexity of the patient's medical problems increases or the complexity of the interactions between the doctor and the patient, the staff or the health care system increase, then complexity of patient care will increase. This study examined trends in patient complexity, and identified doctor, practice and improvement strategy characteristics associated with perceived complexity. Methods This secondary analysis used data from three Community Tracking Surveys with 22 134 primary care doctors completing surveys about themselves, their practice setting, practice improvement strategies and complexity of care in three consecutive 2‐year time periods (1996–1997, 1998–1999, 2000–2001). Data were analysed using hierarchical logistic regression. Results The proportion of primary care doctors who perceived that complexity of care had increased over the past 2 years rose from 31.5% to 35.9%. Perceived complexity of patient care was consistently related to being in solo practice and the belief that they could not frequently obtain high‐quality services and referrals for patients. As availability of services increased, complexity decreased whereas as use of practice improvement strategies increased, complexity also increased. Conclusions Understanding that we cannot determine whether respondents understood care as ‘complicated’ or ‘complex’, potential consequences of this increase in complexity include an increase in medical errors and referral rates along with decreased quality of patient care and career satisfaction.     

Family doctors and psychologists working together: doctors' and patients' perspectives

Background Strategies to improve primary care in the Canadian Primary Care Reform include integrating different professionals to the medical team. Objective This demonstration project explores the perceived impact on doctors and patients, of having family doctors and psychologists work together. Setting Two family practices of Eastern Ontario, Canada Methods Two board certified psychologists (one per practice) were integrated in the practices for 12 months. Psychologists conducted assessments, consultations and short‐term treatments, as well as knowledge‐transfer sessions for doctors. Outcome measures included referral patterns, patient outcomes, patient and provider satisfaction as well as doctors' billing. Results Three hundred and seventy‐six participants received psychological care; most were women (68%) and between the ages of 25–64 (67%). Anxiety and depression were the most prevalent diagnoses. Reasons for referral included: psychological treatment (70%); emotional support and counselling (35%); clarification of diagnosis and case conceptualization (25%). Referrals could be for more than one reason. After intervention, 60% of patients had improvement on the outcome questionnaire‐45 (OQ‐45). Quality of life as measured by the EuroQol‐5D also improved (P < 0.001). Over 77% of patients reported increased confidence in handling their problems after treatment. Compared with their family doctor, patients felt the psychologist had more time and was better trained (75%) Doctors felt mental health problems were diagnosed more rapidly, patient care improved as well as their own knowledge of psychological management and treatment. Doctors felt it freed up their time and improved working conditions. Audit of the doctors' billing showed reduction in doctors' mental health billing. Conclusions Having an on‐site psychologist was highly satisfactory for patients and providers, resulting in improved patient care and outcomes.     

Sharing specialist skills for diabetes in an inner city: a comparison of two primary care organisations over 4 years

OBJECTIVE: To evaluate the effects of organizational change and sharing of specialist skills and information technology for diabetes in two primary care groups (PCGs) over 4 years. METHODS: In PCG-A, an intervention comprised dedicated specialist sessions in primary care, clinical guidelines, educational meetings for professionals and a shared diabetes electronic patient record (EPR). Comparison was made with the neighbouring PCG-B as control. In intervention and control PCGs, practice development work was undertaken for a new contract for family doctors. Data were collected for clinical measures, practice organizational characteristics and professional and patient views. RESULTS: Data were analysed for 26 general practices including 17 in PCG-A and nine in PCG-B. The median practice-specific proportions of patients with HbA1c recorded annually increased in both areas: PCG-A from median 65% to 77%, while PCG-B from 53% to 84%. For cholesterol recording, PCG-A increased from 50% to 76%, and PCG-B from 56% to 80%. Organizational changes in both PCGs included the establishment of recall systems, dedicated clinics and educational sessions for patients. In both PCGs, practices performing poorly at baseline showed the greatest improvements in organization and clinical practice. Primary care professionals' satisfaction with access and communication with diabetes specialist doctors and nurses increased, more so in the intervention PCG. Only 16% of primary care professional respondents used the diabetes EPR at least monthly. Patient satisfaction and knowledge did not change. CONCLUSIONS: Improvements in practices' organizational arrangements were associated with improvements in clinical care in both PCGs. Sharing specialist skills in one PCG was associated with increased professional satisfaction but no net improvement in clinical measures. A shared diabetes EPR is unlikely to be used, unless integrated with practice information systems.     

Pediatric Use of Emergency Medical Services: The Role of Chronic Illnesses and Behavioral Health Problems

Objective: The increasing use of prehospital emergency medical services (EMS) and its contribution to rising emergency department use and healthcare costs point to the need for better understanding factors associated with EMS use to inform preventive interventions. Understanding patient factors associated with pediatric use of EMS will inform pediatric-specific intervention. We examined pediatric patient demographic and health factors associated with one-time and repeat use of EMS. Methods: We reviewed data from Baltimore City Fire Department EMS patient records over a 23-month period (2008–10) for patients under 21 years of age (n = 24,760). Repeat use was defined as involvement in more than one EMS incident during the observation period. Analyses compared demographics of EMS users to the city population and demographics and health problems of repeat and one-time EMS users. Health comparisons were conducted at the patient and incident levels of analysis. Results: Repeat users (n = 1,931) accounted for 9.0% of pediatric users and 20.8% of pediatric incidents, and were over-represented among the 18–20 year age group and among females. While trauma accounted for approximately one-quarter of incidents, repeat versus one-time users had a lower proportion of trauma-related incidents (7.2% vs. 26.7%) and higher proportion of medical-related incidents (92.6% vs. 71.4%), including higher proportions of incidents related to asthma, seizures, and obstetric/gynecologic issues. In patient-level analysis, based on provider or patient reports, greater proportions of repeat compared to one-time users had asthma, behavioral health problems (mental, conduct and substance use problems), seizures, and diabetes. Conclusions: Chronic somatic conditions and behavioral health problems appear to contribute to a large proportion of the repeat pediatric use of this EMS system. Interventions may be needed to engage repeat users in primary care and behavioral health services, to train EMS providers on the recognition and management of behavioral health emergencies, and to improve family care and self-management of pediatric asthma and other chronic conditions.     

Organizational determinants of high-quality routine diabetes care

Abstract

Objective. Randomized trials showed that changes in healthcare organization improved diabetes care. This study aimed to identify which organizational determinants were associated with patient outcomes in routine diabetes care. Design. Observational study, in which multilevel regression analyses were applied to examine the impact of 12 organizational determinants on diabetes care as separate measures and as a composite score. Setting. Primary care practices in the Netherlands. Subjects. 11,751 patients with diabetes in 354 practices. Main outcome measures. Patients’ recorded glycated hemoglobin (HbA1c), systolic blood pressure, and serum cholesterol levels. Results. A higher score on the composite measure of organizational determinants was associated with better control of systolic blood pressure (p = 0.017). No effects on HbA1C or cholesterol levels were found. Exploration of specific organizational factors found significant impact of use of an electronic patient registry on HbA1c (OR = 1.80, 95% CI 1.12–2.88), availability of patient leaflets on systolic blood pressure control (OR = 2.59, 95% CI 1.06–6.35), and number of hours’ nurse education on cholesterol control (OR = 2.51, 95% CI 1.02–6.15). Conclusion. In routine primary care, it was found that favorable healthcare organization was associated with a number of intermediate outcomes in diabetes care. This finding lends support to the findings of trials on organizational changes in diabetes care. Notably, the composite measure of organizational determinants had most impact.     

Caring for uninsured patients with diabetes: designing and evaluating a novel chronic care model for diabetes care

Background Safety net urban hospitals are being overwhelmed by an increasing number of patients with diabetes, who frequently only access the health system through visits to emergency departments and urgent care clinics. It is uncertain whether the chronic care model advocated for diabetes care would be feasible and effective for managing diabetes in an acute care setting. Objective Determine if redesigning the system of care for treating diabetic patients who do not have primary care doctors is feasible, acceptable to patients and effectively lowers patients' haemoglobin A1c, blood pressure and cholesterol levels. Design Prospective single cohort study. Patients A total of 1098 consecutive diabetic patients presenting to an urgent care clinic at an urban safety net public hospital in Chicago between October 2004 and April 2006 who had a haemoglobin A1c measured at baseline. Intervention Adapt the chronic care model for managing diabetes to the acute care setting of an urgent care clinic to manage uninsured patients with diabetes who do not have primary care. Results Among the 1098 patients, 833 (76%) had a repeat A1c during the 2‐ to 12‐month follow‐up period. On average, A1c values decreased by 1.5 percentage points; systolic blood pressure decreased by 9 mmHg; low‐density lipoprotein cholesterol decreased 11 points; and weight decreased 2.3 pounds (all: P < 0.001). The percentage using angiotensin‐converting enzyme inhibitor drugs increased from 45% to 83%; aspirin use increased from 38% to 83%; and statin use increased from 34% to 76%. Conclusions This novel chronic care model for diabetes care of uninsured patients without primary care doctors was feasible, acceptable and effective in increasing the quality of diabetes care and decreasing haemoglobin A1c, blood pressure, cholesterol and weight.     

An overview of patients' preference for, and satisfaction with, care provided by general practitioners and nurse practitioners

Aim and objectives. To assess patients’ views on the care provided by nurse practitioners compared with that provided by general practitioners and to determine factors influencing these views. Background. Many countries have sought to shift aspects of primary care provision from doctors to nurses. It is unclear how patients view these skill mix changes. Design. Cross‐sectional survey. Method. Patients (n = 235) who received care from both nurse and doctor were sent a self‐administered questionnaire. The main outcome measures were patient preferences, satisfaction with the nurses and doctors and factors influencing patients’ preference and satisfaction. Results. Patients preferred the doctor for medical aspects of care, whereas for educational and routine aspects of care half of the patients preferred the nurse or had no preference for either the nurse or doctor. Patients were generally very satisfied with both nurse and doctor. Patients were significantly more satisfied with the nurse for those aspects of care related to the support provided to patients and families and to the time made available to patients. However, variations in preference and satisfaction were mostly attributable to variation in individual patient characteristics, not doctor, nurse or practice characteristics. Conclusion. Patient preference for nurse or doctor and patient satisfaction both vary with the type of care required and reflect usual work demarcations between nurses and doctors. In general, patients are very satisfied with the care they receive. Relevance to clinical practice. In many countries, different aspects of primary care provision have shifted from doctors to nurses. Our study suggests that these skill mix changes meet the needs of patients and that patients are very satisfied with the care they receive. However, to implement skill mix change in general practice it is important to consider usual work demarcations between nurses and doctors.     

Concordance of provider recommendations with American Diabetes Association's Guidelines

PURPOSE: To determine if selected client characteristics were factors influencing the provision of provider advice for diet, exercise, smoking cessation, alcohol cessation, eye and foot care, and influenza and pneumonia vaccine for those told by a provider that they had diabetes. DATA SOURCES: Data from the 2001 National Health Interview Survey were used in a secondary analysis to answer the research question. This study used a subsample who self-reported having provider-diagnosed diabetes; the subsample comprised 2287 unweighted subjects that, when weighted, represent 6.38% of the civilian noninstitutionalized individuals with diabetes in the United States. CONCLUSIONS: This study suggests that many patients are not receiving all the eight processes of care studied, particularly those with new onset diabetes, elders, black people, and Hispanics. IMPLICATIONS FOR PRACTICE: This study suggests that the present paradigm is not early prevention but treatment of established disease. Changes in entrenched thinking about clinical care need to be addressed. Patients with diabetes need to have an awareness that there is a standard of optimal care, and they should be encouraged to seek those who provide this care. Further, system changes may be required to address changes that are not easily made at the provider level.     

Physician process and patient outcome measures for diabetes care: relationships to organizational characteristics

BACKGROUND: Optimal diabetes management relies on providers adhering to evidence-based practice guidelines in the processes of care delivery and patients adhering to self-management recommendations to maximize patient outcomes. PURPOSE: To explore: (1) the degree to which providers adhere to the guidelines; (2) the extent of glycemic, lipid, and blood pressure control in patients with diabetes; and (3) the roles of organizational and patient population characteristics in affecting both provider adherence and patient outcome measures for diabetes. DESIGN: Secondary data analysis of provider adherence and patient outcome measures from chart reviews, along with surveys of facility quality managers. SAMPLE: We sampled 109 Veterans Affairs medical centers (VAMCs). RESULTS: Analyses indicated that provider adherence to diabetes guidelines (ie, hemoglobin A1c, foot, eye, renal, and lipid screens) and patient outcome measures (ie, glycemic, lipid, and hypertension control plus nonsmoking status) are comparable or better in VAMCs than reported elsewhere. VAMCs with higher levels of provider adherence to diabetes guidelines had distinguishing organizational characteristics, including more frequent feedback on diabetes quality of care, designation of a guideline champion, timely implementation of quality-of-care changes, and greater acceptance of guideline applicability. VAMCs with better patient outcome measures for diabetes had more effective communication between physicians and nurses, used educational programs and Grand Rounds presentations to implement the diabetes guidelines, and had an overall patient population that was older and with a smaller percentage of black patients. CONCLUSIONS: Healthcare organizations can adopt many of the identified organizational characteristics to enhance the delivery of care in their settings.     

The competence of primary care doctors in the investigation of patients with elevated blood pressure: results of a cross‐sectional study using clinical vignettes

Background Specific laboratory tests are required to ensure adequate management of patients with hypertension, according to internationally accepted guidelines. There is wide variation in doctor test ordering behaviour. Many factors are known to affect this. Little is known about the interaction between doctor, patient and practice characteristics. The current study was designed to explore this. Methods A series of eight case vignettes was designed to examine test ordering behaviour among primary care doctors in Poland. The cases differed with regard to the level of blood pressure and the presence or absence of other cardiovascular risk factors, including diabetes. Doctors stated their choices of laboratory investigations needed in these cases. Their responses were compared with recommendations in the 2003 European Society of Hypertension/European Society of Cardiology hypertension guidelines. Associations between the correct responses and patient, doctor and practice characteristics were tested. Results One hundred and twenty‐five out of 192 invited doctors (65%) participated in the study. They ordered a mean of 4.9 laboratory tests per case. This represents 47.9% of the tests recommended by current guidelines. Older doctors working in smaller practices and private settings ordered fewer laboratory tests. Specialization in family medicine was associated with greater compliance with guidelines. Grade 2 hypertension and the presence of other risk factors of cardiovascular disease were associated with ordering more tests but the presence of diabetes did not improve compliance with guidelines. Conclusions Further educational efforts are needed to promote rational test ordering for hypertensive patients by Polish primary health care doctors.     

Defining and identifying common elements of and contextual influences on the roles of support workers in health and social care: a thematic analysis of the literature

Rationale, aims and objectives Support workers are the largest single group of staff involved in the delivery of health and social care in the UK; however, their roles are heterogeneous and are influenced by several contextual factors. The aim of this study was to elucidate the contribution of the elements and context of work undertaken by support workers in health and social care. Methods Thematic review of the literature 2005/2006, updated in 2008. Results A total of 134 papers were included in the review, from which we identified four domains of work and four core roles of support workers. The four domains of support worker work are direct care, indirect care, administration and facilitation. The four ‘core’ attributes of support worker roles were being a helper/enabler, a companion, a facilitator and a monitor. The more ‘technical’ components of support worker roles are then shaped by contextual factors such as staffing levels and the delegation processes. Conclusion Despite the heterogeneity of support worker roles, there are some uniting ‘generic’ features, which may form some or all of the role of these practitioners. Contextual factors influence the specific technical aspects of the support role, accounting in part for their heterogeneous role.     

Impact of health literacy and patient trust on glycemic control in an urban USA population

Diabetes, with its consequences of premature death, complications, and economic costs, is a precursor to a public health crisis that is expected to worsen over the next several decades. The improvement of diabetes outcomes, specifically glycemic control as measured by glycosylated hemoglobin concentration (HbA1c), can impact this critical situation. A quantitative study was conducted that examined health literacy and patient trust as predictors of glycemic control. The related factors of demographics, socioeconomic status, diabetes knowledge, self-care activities, and depression were also considered. Implementing a cross-sectional, predictive design, a convenience sample of 102 patients with diabetes was recruited from two urban primary care clinics in the USA. A simultaneous multiple regression was conducted. The regression analysis was significant, with patient trust and depression accounting for 28.5% of the variance in HbA1c. There was a significant positive relationship between socioeconomic status and health literacy and between diabetes knowledge and health literacy. The results support promotion of the patient–provider relationship, depression screening among individuals with diabetes, and exploration of new strategies for diabetes education. Future research is needed to advance the framework, ascertain which factors engender patient trust, and determine the role of health literacy in glycemic control.     

Diabetes and oral health: doctors' knowledge,perception and practices

Objectives To assess Jordanian doctors' knowledge of the connection between diabetes and oral health and assess their willingness to advise their diabetic patients to seek dental treatment and determine the associated factors. Methods Data were collected from 164 doctors practising in Jordan using a structured questionnaire. Chi‐squared test and regression analyses were conducted to reveal factors influencing the awareness, perception and knowledge of health care professionals regarding diabetes and oral health. Results Of the respondents, 70% had heard of the link between diabetes and oral health. The majority agreed that diabetes increased the tendency to have periodontitis but only half advised their diabetic patients to consult a dentist concerning their oral health. Only a third of doctors agreed that oral health was an issue in controlling diabetes. Books, magazines and pamphlets were the main source of information with the rate of 58%, medical journals and medical curriculum were the second and third sources, respectively. General medical practitioners were less informed than specialized doctors about the relationship between oral health and diabetes. Factors that significantly predicted doctors would advise dental visits were: (1) being a specialist (P = 0.037); (2) having positive knowledge about the association between diabetes and oral health (P = 0.02, P = 0.007 and P = 0.004, respectively). Conclusion There is limited knowledge of the relationships between oral health and diabetes. The more knowledgeable doctors are, the more likely they are to make dental referrals. Screening and referral by health professionals may benefit diabetic patients by improving access to dental care. Therefore, there is a need to educate doctors about oral health and diabetes.     

2型糖尿病病人足部护理及其影响因素调查

[目的]了解2型糖尿病病人足部护理情况及其影响因素,为针对性开展足部护理教育提供依据。[方法]选择广州市5家医院就诊的349例2型糖尿病病人,对足部护理依从性及有关糖尿病知识、健康信念和自我效能等进行问卷调查,采用线性逐步回归分析法筛选病人足部护理依从性的影响因素。[结果]病人足部护理各项措施执行情况不理想;病人足部护理依从性与其年龄、经济条件、糖尿病知识、健康信念均呈正相关(P<0.01、P<0.05);生活方式呈负相关(P<0.05),与家人同住的病人容易忽视足部护理。[结论]应强化病人对糖尿病足危害的认识,提高足部护理技能;注意对非老年病人、经济条件差的病人进行教育引导;重视对病人家庭成员教育,争取获得家庭支持,以确保病人有效执行足部护理。     

Improving Access to Health Care for Uninsured Elderly Patients

ABSTRACT The purpose of this article is to explore the barriers that the uninsured elderly population encounter when accessing health care in the United States. These barriers include, but are not limited to lack of transportation, insurance, or family support; the daunting complexity of the health care system; poverty; culture; poor patient‐health care provider communications; race/ethnicity; and lack of health care professionals such as nurses and doctors with adequate geriatric preparation, or generalists who are undereducated in geriatrics. The number of health care professionals currently available to treat elderly persons in the United States is inadequate. The Federal government should take steps to develop solutions to improve access to health care and decrease health disparities for older adults. As a nation, we should be proactive in addressing these concerns instead of waiting for new barriers to arise that further limit access to health care for elderly patients and their families. In this article, we provide an assessment of the barriers that limit access to health care in the uninsured elderly population and suggest recommendations and possible solutions to eliminate or reduce these barriers.     

Management of sore throat in Polish primary care facilities: an example from the country with rare use of microbiological testing

Objective: To describe sore throat management by primary care physicians in Poland. Methods: We sent questionnaires to all primary care doctors in Podlaskie voievodship (north‐eastern Poland) with clinical vignettes depicting patients with symptoms of sore throat. The probability of bacterial (streptococcal) infection was estimated using Centor’s scale (assessment of four items – presence of tonsillar exudates, fever, lymphadenopathy and absence of cough – scores 0 and 1 indicate low probability of streptococcal infection). The respondents were asked for the suspected diagnosis (viral or bacterial pharyngitis), choose additional tests (if required to decide on management), and finally to decide on whether an antibiotic should be prescribed. Results and discussion: Two‐hundred and twenty‐five of 610 doctors surveyed provided useable answers. In cases with a very low probability of bacterial infection and a score of ‘0’, antibiotics were prescribed by 1·8–43·7% of physicians. Only 1·8% would prescribe an antibiotic to an adult with a 1‐day history of sore throat and a ‘0’ score but as many as 43·7% when the patient consulted with the same symptoms and signs again (P < 0·05). Younger age of the patient was also significantly associated with higher rate of the antibiotic prescribing – 7·6% would prescribe an antibiotic to a 5‐year‐old child with a ‘0’ score while only 1·8% would prescribe an antibiotic for an adult with a similar score, P < 0·05. Conclusions: Primary care physicians in Poland tend to prescribe antibiotics for sore throats even for patients with a low risk of bacterial infection when influenced by factors like repeat visits of the patient or young age. Avoiding antibiotics in such low risk of bacterial infection patients is an important and achievable goal.