Variation in inpatient resource use in the treatment of HIV: do the privately insured receive more care?

OBJECTIVE: To estimate the impact of insurance status on inpatient resource use after adjusting for health upon admission and site of care. DESIGN: Detailed patient information linked to billing records from the AIDS Cost and Service Utilization Survey (ACSUS), a longitudinal analysis of inpatient and outpatient care between March 1991 and August 1992. SETTING: Hospitalizations of human immunodeficiency virus (HIV) patients from 10 US cities with high incidence of AIDS. PATIENTS: One thousand, nine hundred and forty nine adolescents and adults at various stages of HIV. MAIN OUTCOME MEASURES: We estimate inpatient charges, payments and length of stay as a function of patient, and provider and reimbursement characteristics for more than 1,500 hospitalizations to HIV patients. We control for patient characteristics and underlying risk factors including disease stage, CD4 percentage, mode of transmission, discharge status, type of admission, and region. We use hospital-fixed effects to control for unmeasured differences across facilities. RESULTS: Unadjusted means indicate that uninsured patients or patients covered by public insurance have significantly lower charges and payments than privately insured patients with similar medical conditions. We find that those differences are substantially reduced after controlling for the hospital in which care is received. Further, we find little evidence that "underinsured" patients are discharged sooner on average. CONCLUSIONS: Inpatient resource use is affected by both the hospital in which care is received and the type of patient admitted. Failure to control for unmeasured differences across hospitals is likely to overstate the impact of insurance substantially.     

How do patients view the role of the primary care physician in inpatient care?

As hospitalized patients are increasingly cared for by physicians who are not their primary care physicians, discontinuity of care occurs when patients are sickest. We sought to determine hospitalized patients' knowledge, preferences, and satisfaction regarding the involvement of their primary care physician in their inpatient care. We conducted a cross-sectional questionnaire of 73 patients cared for by inpatient physicians and 12 relatives of such patients on an inpatient general medical service in a teaching hospital. Eligible patients were those admitted to the care of an inpatient physician other than their primary care provider (PCP), who stayed in the hospital for >1 day. If these patients were too sick to be interviewed or did not speak English, a relative knowledgeable about their medical care was interviewed. In all, 87% of patients had a primary care physician. Of these, 33% had some contact with their PCP while in the hospital. A total of 66% of respondents were satisfied with the contact they or their relative had with the PCP. Some 61% of respondents knew that communication had occurred between the inpatient and PCP. Respondents generally had positive opinions of their hospital care. However, most agreed that patients receive better care from and have more trust in physicians they have known for a long time, compared with those they have just met. About 50% of respondents believed that a PCP (rather than a separate hospital physician) should inform a patient of a serious diagnosis or discuss choices between medical and surgical management. Patients under the care of an inpatient physician want contact with their PCP and want good communication between the PCP and hospital doctors. Systems should be established to facilitate communication between in patient and primary care physicians, and between PCPs and patients.     

Domestic violence and anger: what can primary care nurses do?

Patients with anger problems can cause difficulties for themselves, their families and society. Though psychological treatments are available, they are not always accessible. In order to help the victims of domestic violence, we focus here on working with perpetrators of violence. This article offers some statistics about the extent of the problem. It discusses difficulties in motivating patients for therapy and describes the cognitive model of anger. A number of intervention strategies based on this model are then discussed. The purpose is to assist clinicians with less experience of this patient group to help their patients minimize the frequency and severity of the anger incidents. Pointers for good practice are outlined.     

Outcomes among orthopedic patients in skilled nursing facilities: does managed care make a difference?

The use of rehabilitative care has increased greatly. This study evaluates whether managed care affects health outcomes among Medicare orthopedic patients receiving rehabilitative treatments. Managed care versus fee-for-service patients had better outcomes at four months following discharge from skilled nursing facilities. It is important to address predictive factors, such as age, length of hospital stay, debilitation and social living arrangements, which can also influence health outcomes when planning rehabilitative treatment for older patients.     

The concepts of expectation and satisfaction: do they capture the way patients evaluate their care?

The measurement of patient satisfaction has become a common way to elicit patients' views of their health care. However, difficulties arising from the limited theoretical underpinning of satisfaction, the difficulty in defining expectations and satisfaction and the methodological problems associated with their measurement have cast doubt on the validity of studies. This paper reviews the methodological and theoretical difficulties in measuring these concepts and argues that a better understanding of expectations and satisfaction, which is based in patient experience, must first be achieved before theoretical modelling and valid measurement can progress. It presents the findings of a study which attempted to clarify the concepts of expectations and satisfaction by exploring the experience of cardiac patients. The findings are discussed in the context of the key issues in this area.     

Hypernatremia in the intensive care unit: an indicator of quality of care?

OBJECTIVE: To assess the frequency of hypernatremia in patients who were admitted to an intensive care unit (ICU) and to determine the correlation of hypernatremia with the clinical outcomes, durations of the patients' stays in the ICU, and other clinical variables. DESIGN: Retrospective survey. SETTING: University teaching hospital. PATIENTS: All patients (total, 389) who were admitted to the medical ICU of the department of internal medicine during 1 yr. MEASUREMENTS: The database of our hospital's mainframe computer was searched for sodium values > or = 150 mmol/L that were registered in the year 1995. These data were then matched with the registration numbers of all patients who were admitted to our medical ICU between January 1 and December 31, 1995. In this way, we identified all patients in whom hypernatremia was present at admission or those who developed hypernatremia in the course of their stay in our ICU. The prevalence and duration of hypernatremia (defined as a serum sodium concentration of > or = 150 mmol/L or more) were determined; the correlation of hypernatremia with clinical outcome, duration of ICU stay, Acute Physiology and Chronic Health Evaluation II scores, and other clinical variables were evaluated; and changes in fluid administration in response to hypernatremia and fluid regimens in the period preceding hypernatremia were examined. MAIN RESULTS: Of a total of 389 patients who were admitted in 1995, hypernatremia was present at admission in 34 patients (8.9%). The average duration of hypernatremia in these patients was 16.2 (range, 4-56) hrs. A total of 22 patients (5.7%) developed hypernatremia in the course of their stay in the ICU. The average duration of hypernatremia in this group was 34.7 (range, 4-89) hrs. Moderately elevated levels of sodium had been detected in most of these patients (n = 21) in the days before the development of severe hypernatremia; however, adjustments in fluid infusion aimed at preventing the occurrence of hypernatremia were either lacking (n = 7) or inadequate (n = 11). Hospital-acquired hypernatremia vs. hypernatremia present at admission to the ICU was associated with a higher mortality rate (32% vs. 20.3%, respectively; p < .01). CONCLUSIONS: Despite frequent measurement of sodium levels in patients in the ICU, hypernatremia is a relatively common occurrence. Initial treatment of hypernatremia is often inadequate, and sometimes treatment is delayed. The development of hypernatremia is associated with adverse outcomes for patients developing hypernatremia in the ICU. Hypernatremia could potentially be used as an indicator of quality of care in the medical ICU.     

Assessing the quality of colorectal cancer care: do we have appropriate quality measures? (A systematic review of literature)

RATIONALE, AIMS AND OBJECTIVES: The burden of illness from colorectal cancer (CRC) can be reduced by improving the quality of care. Identifying appropriate quality measures is the first step in this direction. We identified process measures currently available to assess the quality of diagnosis and management of CRC. We also evaluated the extent to which these measures are ready to be implemented in clinical practice, and identified areas for future research. METHODS: We searched MEDLINE, Cochrane Database of Systematic Reviews, and relevant grey literature. We identified 3771 abstracts and reviewed 74 articles that included quality measures for diagnosis or management of CRC. Measures from traditional quality improvement literature, and from epidemiological and other studies that included quality measures as part of their research agenda, were considered. In addition, we devised a summary rating scale (IST) to appraise the extent of a measure's importance and usability, scientific acceptability and extent of testing. RESULTS: The coverage of general process measures in CRC is extensive. Most measures are important, but need to be developed and field-tested. The best available measures relate to pathology and chemotherapy. No measures are available for assessing quality of management of stage IV rectal cancer and hepatic metastasis; chemotherapy for stage II colon cancer; and procedure notes. CONCLUSIONS: There is an urgent need to refine existing measures and to develop scientifically accurate quality measures for a comprehensive assessment of the quality of CRC care. The role of the federal government and professional societies is critical in pursuing this goal.     

The quality of nursing home care: do the opinions of family members change after implementation of emotion‐oriented care?

OBJECTIVE: The present study focuses on opinions on the quality of nursing home care of family members of nursing home residents with dementia. Furthermore, we examined whether family members' appreciation of the care increased as a result of the implementation of emotion-oriented care. DESIGN: Randomized clinical trial. INSTRUMENT: An 18-item questionnaire was developed. The following subjects were addressed: communication activities between staff and family members; satisfaction regarding contacts with staff; the extent to which family members can participate in care; the contact that family members experience with the person with dementia, and opinions about the way in which nursing staff treat residents. RESULTS: Most family members already had a positive opinion on the nursing home care prior to the implementation of emotion-oriented care. The most positive assessment concerned the way in which nursing staff treated residents. The lowest scores concerned communication activities between ward staff and family members. Comparison of the first and end measurements showed that in general opinions on the quality of care did not change. STUDY LIMITATIONS: A large number of incomplete questionnaires made it impossible to conduct factor analysis on the classification of the questions in various sections and therefore allowed us only to make statements at the item level. CONCLUSIONS: For the most part family members had a positive opinion on the nursing home care. In general, implementation of emotion-oriented care did not lead to a more positive assessment. Despite the generally accepted notion that involving family members in care is important, family members were regularly treated as outsiders. This demonstrates that there is room for improvement in the communication by nursing home staff with family members (e.g. more frequent contacts and information about the illness).     

What type of service provision do patients with chronic pain want from primary care providers?

Purpose. The aim of this study was to explore what types of service provision patients with chronic pain wanted from their general practitioners (GP).

Method. A small scale survey measured anxiety and depression and quantified the extent to which patients wanted four different types of help from their GP (explanation and understanding, medical treatment, psychological support and information). An opportunistic sample of 155 patients (30.3% male and 69.7% female) was recruited from three general practice surgeries in the northwest region of Northern Ireland. Ninety-one participants self-reported chronic pain and there were 64 in the no pain group.

Results. Even after statistically controlling for anxiety and depression, individuals in the chronic pain group had a greater need for emotional/psychological support and explanation and understanding from their GPs. There were no significant differences between the groups with respect to the need for more information or medical treatment.

Conclusions. A biopsychosocial approach should be employed in the management of chronic pain, however as this study shows, some primary care patients are still being treated within a biomedical framework. To address the unmet needs of this patient population, there is a need for clinical guidelines in the management of chronic pain in primary care settings. Limitations of the present research, with recommendations for future study are offered.     

Does depression predict falls among home health patients? Using a clinical-research partnership to improve the quality of geriatric care

This study found that patients with depressed mood or anhedonia identified on the OASIS were nearly three times more likely to fall. The authors describe the ways these findings are being used in a fall prevention program. The clinical-research partnership used in the study was found to help agencies develop clinically driven research, analyze clinical and administrative data for quality improvement, and provide a foundation for research consultation/collaboration in applied settings.     

Illness perceptions of low back pain patients in primary care: what are they, do they change and are they associated with outcome?

We describe the illness perceptions of patients with low back pain, how they change over 6 months, and their associations with clinical outcome. Consecutive patients consulting eight general practices were eligible to take part in a prospective cohort study, providing data within 3 weeks of consultation and 6 months later. Illness perceptions were measured using the Revised Illness Perception Questionnaire (IPQ-R). Clinical outcome was defined using the Roland and Morris Disability Questionnaire (RMDQ) and patients’ global rating of change. Associations between patients, perceptions and poor outcome were analysed using unadjusted and adjusted risk ratios (RR) and 95% confidence intervals. 1591 completed questionnaires were received at baseline and 810 at 6 months. Patients had a mean age of 44 years and 59% were women. Mean (SD) RMDQ score at baseline was 8.6 (6.0) and 6.2 (6.1) at 6 months. 52% and 41% of patients had a poor clinical outcome at 6 months using RMDQ and global rating scores, respectively. There were strong, statistically significant, associations (RRs of 1.4 and over) between IPQ-R baseline consequences, timeline acute/chronic, personal control and treatment control scores and poor outcome. Patients who expected their back problem to last a long time, who perceived serious consequences, and who held weak beliefs in the controllability of their back problem were more likely to have poor clinical outcomes 6 months after they consulted their doctor. These results have implications for the management of patients, and support the need to assess and address patients’ cognitions about their back problems.     

ICF Core Set for head and neck cancer: do the categories discriminate among clinically relevant subgroups of patients?

The multidisciplinary assessment of functioning in patients with head and neck cancer (HNC) according to the ICF Core Set for Head and Neck Cancer (ICF-HNC) was developed in an international and multi-disciplinary approach. The ICF-HNC is an application of the ICF that was adopted by the World Health Organization. The objective of this study was to test whether categories of the ICF-HNC can discriminate among clinically relevant differences in patients. This was a cross-sectional multicentre study in which 267 patients with HNC from 11 different countries participated. All categories were tested within a cumulative logit model to identify which ICF-categories show differences in tumour location, staging, treatment modalities and time since treatment. In the comprehensive ICF-HNC, 84 of the tested categories (76%) reflect differences in at least one of the given parameters. In the Brief ICF Core Sets for HNC (ICF-HNC), all 19 categories (100%) reflect differences. Two categories (social relationships and economic self-sufficiency) showed significant differences among all tested criteria. Most categories of the ICF-HNC are sensitive to clinically relevant differences in the study population. Especially, the ICF component 'activities and participation' holds categories with high discriminative ability for clinically relevant differences. These aspects should be carefully included into rehabilitation plans for HNC.     

Do the self-concept and quality of life decrease in CP patients? Focussing on the predictors of self-concept and quality of life

Purpose.?To find out if the quality of life (QOL) and self-concept of the children with cerebral palsy (CP) was different from that of children without disability, to investigate predictive variables that could affect self-concept and QOL.

Methods.?A total of 40 children with CP and 46 age-matched peers were included. The baseline characteristics including sex, type of CP, the level of disability according to Gross Motor Function Classification System (GMFCS) were recorded. Education levels of both children and parents, demographic features of parents, features of living area, usage of devices and associated impairments were filled out. Self-concept was measured using Piers–Harris Self-concept (PH) Scale. Quality of life was measured by Pediatric Quality of Life Inventory 4.0 (PedsQL). The physical and psychosocial health subscale scores of PedsQL (P-PedsQL and PS-PedsQL) were recorded.

Results.?Significant differences in mean scores favouring the control group were found for PH scale, PedsQL scale (p?<?0.001). P-PedsQL and PS-PedsQL of the CP group were lower than the control group (p?<?0.001). PS-PedsQL report was significant predictor of self-concept. The presence of incontinence and GMFCS level were significant predictors of PedsQL and PPedsQL, respectively.

Conclusion.?Self-concept and QOL of the CP children were lower than the children without CP. Presence of incontinence, self-concept rating and GMFCS level were important to predict domains of QOL.     

What is the impact of advanced primary care nursing roles on patients, nurses and their colleagues? A literature review

OBJECTIVES: To review and draw together the existing research evidence to assess the impact of advanced primary care nursing roles, particularly first contact nursing roles, for patients, nurses themselves and their colleagues in order to highlight salient issues for policy, practice and research. BACKGROUND: Internationally, nurses' roles continue to expand in response to doctor shortages and policy drives to provide effective and efficient health services. A body of research exists from which to evaluate the impact of advanced nursing roles on various dimensions of healthcare delivery and organisation. DESIGN AND DATA SOURCES: Medline, CINAHL, Applied Social Sciences Index and Abstracts, British Nursing Index, Cochrane Library, EMBASE, National Research Register, and PsycINFO databases were searched, including relevant websites. Studies were included if published in English and relevant to the primary/community care setting. Of a total of 211 papers identified, 88 were of relevance and included in the review. RESULTS: Nurses working in many advanced primary care roles such as acute/minor illness, minor injury and long-term conditions provide safe and effective care, and patient satisfaction is generally high. Many factors influence patient satisfaction with, and access to, such services but are little understood. Evidence on cost-effectiveness, efficiency and impact on other health care professionals is inconclusive though research suggests the introduction of extended roles can create uncertainty and intra-/inter-professional tensions. CONCLUSIONS: Evidence is of variable quality, often ignoring potentially important effect mediators such as the experience and educational level of advanced nurses, the effect of service 'maturation', organisational characteristics and differing patient preferences. The complex range of factors that influence patient satisfaction, access and outcomes of care need further investigation. Recent UK developments in nurse prescribing and the introduction of a national post-registration competency framework may improve working relations and patient understanding and experience of advanced nursing roles in primary care.