The Role of Stigma in Access to Health Care for the Poor

Context

The Affordable Care Act provides new Medicaid coverage to an estimated 12 million low-income adults. Barriers to access or quality could hamper the program''s success. One of these barriers might be the stigma associated with Medicaid or poverty.

Methods

Our mixed-methods study involved 574 low-income adults and included data from an in-person survey and follow-up interviews. Our analysis of the interviews showed that many participants who were on Medicaid or uninsured described a perception or fear of being treated poorly in the health care setting. We defined this experience as stigma and merged our qualitative interviews coded for stigma with our quantitative survey data to see whether stigma was related to other sociodemographic characteristics. We also examined whether stigma was associated with access to care, quality of care, and self-reported health.

Findings

We were unable to identify other sociodemographic characteristics associated with stigma in this low-income sample. The qualitative interviews suggested that stigma was most often the result of a provider-patient interaction that felt demeaning, rather than an internalized sense of shame related to receiving public insurance or charity care. An experience of stigma was associated with unmet health needs, poorer perceptions of quality of care, and worse health across several self-reported measures.

Conclusions

Because a stigmatizing experience in the health system might interfere with the delivery of high-quality care to new Medicaid enrollees, further research and policy interventions that target stigma are warranted.     

Rising Charges and Costs for Pediatric Catheter Ablation

Pediatric Ablation Charges and Costs Are Rising. Introduction: Catheter ablation has been shown to be effective for pediatric tachyarrhythmias, but the associated charges and costs have not been described in the recent era. Understanding such contemporary trends may identify ways to keep an effective therapy affordable while optimizing clinical outcomes. Methods: We used the 1997–2009 Kids’ Inpatient Databases to examine trends in charges and costs for pediatric catheter ablation and identify determinants of temporal changes. Results: There were 7,130 discharges for catheter ablation in the sample. Mean age at ablation was 12.1 ± 0.2 years. Patients with congenital heart disease (CHD) made up 10% of the sample. Complications occurred in 8% of discharges. Mean total charges rose 219% above inflation (from $23,798 ± 1,072 in 1997 to $75,831 ± 2,065 in 2009). From 2003 to 2009, costs rose 25% (from $20,459 ± 780 in 2003 to $25,628 ± 992 in 2009). Charges for ablation increased markedly relative to surgical procedures, but with a similar slope to other catheter‐based interventions. Multivariable analysis revealed that year (P < 0.0001), payer (P = 0.0002), CHD (P < 0.0001), valvular heart disease (P = 0.0004), cardiomyopathy (P = 0.0009), hospital region (P < 0.0001), length of stay (P < 0.0001), and complications (P < 0.0001) predicted increased charges. The same factors also predicted increased costs. Charges and costs varied considerably by region, particularly for high‐volume centers (P < 0.0001). Conclusions: Charges and costs for pediatric catheter ablation increased relative to other procedures and significantly outstripped inflation. Further study of complications, length of stay, and regional differences may help control rising costs while maintaining quality of care. (J Cardiovasc Electrophysiol, Vol. 24, pp. 162‐169, February 2013)     

The state of the science of emotional intelligence related to nursing leadership: an integrative review

akerjordet k. & severinsson e. (2010) Journal of Nursing Management 18, 363–382
The state of the science of emotional intelligence related to nursing leadership: an integrative review Aim To explore the state of the science of emotional intelligence (EI) related to nursing leadership and its critiques. Background The phenomenon of EI has emerged as a potential new construct of importance for nursing leadership that enhances educational, organizational, staff and patient outcomes. Nevertheless, important questions and critical reflections related to exaggerated claims, conceptualizations and measurements exist. Method A literature search was conducted using international databases covering the period January 1999 to December 2009. A manual search of relevant journals and significant references increased the data. Results Critical reflection seems to be associated with the unsubstantiated predictive validity of EI in the area of nursing leadership. In addition, important moral issues are called into question. Conclusions It is important to possess in-depth knowledge of EI and its scientific critique when integrating the concept into nursing research, education and practical settings. More attention to the nature of emotion in EI is necessary. Implications for nursing leadership The dynamics of EI should be explored in the context of both the surrounding environment and individual differences, as the latter can be adaptive in some settings but harmful in others.     

Molecular characterization of CTX‐M‐15‐producing clinical isolates of Escherichia coli reveals the spread of multidrug‐resistant ST131 (O25:H4) and ST964 (O102:H6) strains in Norway

Nationwide, CTX‐M‐producing clinical Escherichia coli isolates from the Norwegian ESBL study in 2003 (n=45) were characterized on strain and plasmid levels. Bla_CTX‐M allele typing, characterization of the genetic environment, phylogenetic groups, pulsed field gel electrophoresis (PFGE), serotyping and multilocus sequence typing were performed. Plasmid analysis included S1‐nuclease‐PFGE, polymerase chain reaction‐based replicon typing, plasmid transfer and multidrug resistance profiling. Bla_CTX‐M‐15 (n=23; 51%) and bla_CTX‐M‐14 (n=11; 24%) were the major alleles of which 18 (78%) and 6 (55%), respectively, were linked to ISEcp1. Thirty‐two isolates were of phylogenetic groups B2 and D. Isolates were of 29 different XbaI‐PFGE‐types including six regional clusters. Twenty‐three different O:H serotypes were found, dominated by O25:H4 (n=9, 20%) and O102:H6 (n=9, 20%). Nineteen different STs were identified, where ST131 (n=9, 20%) and ST964 (n=7, 16%) were dominant. Bla_CTX‐M was found on ≥100 kb plasmids (39/45) of 10 different replicons dominated by IncFII (n=39, 87%), FIB (n=20, 44%) and FIA (n=19, 42%). Thirty‐nine isolates (87%) displayed co‐resistance to other classes of antibiotics. A transferable CTX‐M phenotype was observed in 9/14 isolates. This study reveals that the majority of CTX‐M‐15‐expressing strains in Norway are part of the global spread of multidrug‐resistant ST131 and ST‐complex 405, associated with ISEcp1 on transferrable IncFII plasmids.     

Quality of recovery from two types of general anesthesia for ambulatory dental surgery in children: a double-blind, randomized trial

Background:  Pediatric dental procedures are increasingly performed under general anesthesia because of the inability to cooperate, situational anxiety, or other behavioral problems. Volatile anesthetics have been associated with emergence delirium in children, whereas the use of propofol for anesthetic maintenance has been shown to reduce the incidence of emergence delirium after other types of surgeries. The aim of this study is to compare a sevoflurane-based anesthetic with a propofol-based technique as it relates to the incidence of emergence delirium and the quality of recovery after pediatric dental surgery, in patients who present with risk factors for perioperative behavioral issues.
Methods:  We prospectively collected data of 179 pediatric patients scheduled for ambulatory dental surgery using a double-blind and randomized trial design. Subjects were anesthetized following standardized protocols for either a sevoflurane- or a propofol-based technique. The incidence of emergency delirium, as measured by the Pediatric Anesthesia Emergence Delirium score, was the primary outcome. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), number of nursing interventions in the recovery room, time to discharge readiness, and parental satisfaction.
Results:  We found no difference in the incidence of emergence delirium after both types of anesthesia. However, use of sevoflurane significantly increased both the risk of PONV and the number of postoperative nursing interventions. Discharge criteria were met about 10 min earlier in patients anesthetized with sevoflurane. Parental satisfaction was equally high with both anesthesia regimens.
Conclusions:  A propofol-based anesthetic technique did not lead to a lower incidence of emergence delirium after dental surgery in children but did result in significantly less PONV and fewer postoperative nursing interventions.     

An Integrated Dual Sensor System Automatically Optimized by Target Rate Histogram

The use of combined sensors and advanced algorithms using different principles can improve rate performance over a single sensor system. Combinations of sensors and more sophisticated algorithms, however, invariably increase the complexity of pacemaker programming. An automatically optimized combined minute ventilation and activity DDDR pacemaker was developed to minimize repeated sensor adjustment. The device used subthreshold (below cardiac stimulation threshold) lead impedance to detect lead configuration at implantation automatically, followed by "implant management," including setting of lead polarity and initiation of DDDR pacing. Automatic sensor adaptation was achieved by programming a "target rate histogram" based on the patient's activity level and frequency of exertion, and the rate profile optimization process matched the recorded integrated sensor response to the target rate histogram profile. In nine patients implanted with the DX2 pacemakers, the implant management gave 100% accuracy in the detection of lead polarity. Rate profile optinuzation automatically increased the pacing rate during exercise between discharge and 3-month follow-up (hall walk: 78 ± 3 vs 98 ± 3 beats/min, and maximal treadmill exercise: 89 ± 6 vs 115 ± 5 beats/min, P < 0.001) with a significant increase in exercise duration during maximal exercise (7.18 ± 1 min vs 9.56 ± 2 min, P = 0.05). The accuracy of rate profile optimization versus manual programming was assessed at 1 month, and there was no significant difference between pacing rate kinetics and maximal pacing rate between the two methods of programming. In conclusion, pacemaker automaticity can be initiated at implantation and the self-optimized rate adaptive response appeared to be comparable to that derived from a manual programming procedure, which may reduce the need to perform time consuming sensor programming.     

Inhibition of Interleukin-10 During Pregnancy Results in Neonatal Growth Retardation

PROBLEM: Interleukin 10 is considered to be important in the survival of the fetus in murine pregnancies that are known to be at risk for fetal wastage. The function of IL-10 in a normal pregnancy is not known. METHODS: In this report, we attempted to neutralize Interleukin 10 by administering anti IL-10 monoclonal antibodies (mAb) to pregnant mice that have a low background risk for fetal resorptions. The first group of mice was sacrificed on gestation day 18 to study the fetal effects of anti IL-10 administration. The second group of mice was allowed to deliver to study the effects on the neonatal outcome. RESULTS: Administration of anti IL-10 mAb did not affect the duration of gestation or the fetal outcome. Neonates exposed to anti IL-10 mAb in utero showed signs of transient growth deficiency starting at 4 weeks of age that spontaneously corrected by 6 weeks of age. CONCLUSIONS: Administration of anti IL-10 mAb does not alter the duration of gestation or the fetal outcome in normal murine pregnancies; however, it appears to be associated with transient neonatal growth problems.