Ending a nurse practitioner-patient relationship: uncovering patients' perceptions.

DATA SOURCES: Seventy-nine patients assigned to the care of a nurse practitioner (NP) were interviewed to explore reactions to ending a yearlong therapeutic relationship at the conclusion of a clinical trial. Three researchers identified, reviewed and CONCLUSIONS: Of the total 79 patients, 22 (28%) spontaneously discussed perceptions and feelings about the termination of their relationship with the NP, Qualitative analysis of their statements identified future concerns about continuity of care and emotional themes ranging from gratitude, regret, and anxiety to grief. IMPLICATIONS FOR PRACTICE: Changes in health care coverage often result in abrupt termination of patient-provider relationships. The involuntary termination of a patient-provider relationship may have significant negative consequences on patients with substantial influence on physical and emotional health. Awareness and anticipatory counseling may be useful in stemming these effects.

Differences in breast cancer screening rates: an issue of ethnicity or socioeconomics?

Previous reports suggest that use of preventive measures, such as screening mammography (SM), differs by ethnicity. It is unclear, however, if this is determined directly by ethnicity or indirectly by related socioeconomic factors. We studied self-reported data from 18,245 women aged 40-49 who participated in the Behavioral Risk Factor Surveillance System telephone survey in 1992 and 1993. Of these, 11,509 (63%) reported having obtained mammography within the preceding 2 years for screening purposes only. Using reports of other preventive healthcare behaviors, education level, socioeconomic status, and healthcare access problems as independent variables, bivariate associations were assessed, and a logistic regression model was developed. Models for each ethnic group were developed, with consistent results. Women who engaged in other preventive health measures, such as Pap smear (odds ratio [OR] 8.99, 95% confidence interval [CI] = 7.6-10.7), cholesterol measurement (OR 2.64, 95% CI = 2.3-3.0), and seatbelt use, were more likely to obtain SM. Women with healthcare access or insurance problems (OR 0. 59, 95% CI = 0.5-0.7) and current smokers (OR 0.71, CI = 0.6-0.8) had a lower likelihood of obtaining SM. Ethnicity, alcohol use, marital status, and education level were not significantly associated with women's reports of SM. Although ethnicity apparently does not influence a woman's likelihood of obtaining SM, access to healthcare and insurance and engaging in other healthy behaviors do. Health policy planners should consider the importance of these related factors when developing preventive health programs for women.

Framing procedural risks to patients: is 99% safe the same as a risk of 1 in 100?

PURPOSE: A patient's willingness to consent to a procedure may be influenced by various factors, including the patient's rapport with the physician, nonverbal cues he or she receives during the discussion of risks, and other elements of the discussion of risks. Previous reports address these influences, but the effect of the actual wording used to describe risks is unclear. The purpose of this study was to better understand how framing the risk involved in a procedure affects a patient's likelihood to consent to the procedure. METHOD: In a 1997 study at the Cleveland Clinic Foundation, the authors randomly assigned 116 patients to view one of two short videos describing angioplasty and its associated risks. Sixty-three participants viewed the first video, which framed the procedure as 99% safe, and 53 viewed the second, which framed the likelihood of complication as 1 in 100. Participants were then asked to rate their consent to two hypothetical treatment scenarios on a four-point Likert-type scale (1 = definitely, 4 = definitely not). RESULTS: When asked to consent to a treatment scenario that would relieve chest pain but offer no survival benefit, respondents who viewed the first video were more likely to consent than were those who viewed the second (p<.001). There was no significant difference in the two groups' likelihoods to consent when the potential health benefit was to reduce the risk of future heart attack. CONCLUSION: This study's finding provides evidence that how a physician describes a procedure's risks when obtaining a patient's informed consent significantly influences the likelihood of consent. This fact should be considered when teaching communication skills, including interviewing and patient education skills, so that patients will be more likely to make health care decisions that are consistent with their own values and beliefs.

Surviving the prospective payment system: potential problems and solutions to ensure quality of care.

In response to diagnosis-related group payment systems and changing social structures, many hospital systems have created alternative discharge sites, thus shifting care to subacute units offering comprehensive inpatient programs of cost-effective restorative care. The growth in expenditures for these postacute services led to the implementation of the prospective payment system (PPS). This article discusses factors involved in calculating reimbursement and solutions to such problems as inadequate reimbursement, quality of care, and documentation requirements. For subacute care to succeed clinically and financially, a basis for collaboration between hospital-based referring physicians and subacute unit directors must be established; patient satisfaction and quality of care must be monitored closely; and a well-trained nursing staff with frequent in-service training in patient care should be employed. The reorganization tactics suggested in this article may help a subacute facility function in an efficient way at acceptable costs while maintaining high quality patient care.

Controlling varicella in the healthcare setting: barriers to varicella vaccination among healthcare workers.

We surveyed healthcare workers to determine factors that may influence acceptance of varicella-zoster virus vaccine. Of 2,801 workers tested, 90 were susceptible to varicella; of workers offered vaccination, 68% accepted. Workers providing direct patient care were 3.7-fold more likely than other workers to accept VZV vaccination (P=.04).

Developing better critical paths in healthcare: combining 'best practice' and the quantitative approach.

Critical paths are tools to manage healthcare delivery and ensure favorable patient outcomes. Unfortunately, many of these paths are not evaluated or revised after their initial development. One potential problem faced by nursing managers is that critical paths may lose relevance in a rapidly changing healthcare environment. The authors suggest one strategy to strengthen existing critical paths in a way that is responsive to these changes.

Injury prevention education in United States medical school curricula.

BACKGROUND: In 1993, representatives from the Centers for Disease Control and Prevention recommended that a national injury control training plan be developed that would encourage education about injuries and injury prevention in the required curricula of medical schools. METHODS: A mail survey of curriculum officers was conducted to identify the availability of, characteristics of, and support for educational opportunities in injury prevention at medical schools in the United States. RESULTS: Eighty-seven medical schools (70.2%) responded. Forty-one (47.1%) covered injury prevention in their required curricula. Twenty-six (29.9%) offered nonclinical elective opportunities on injury prevention subjects. In medical schools associated with trauma centers, injury prevention information was almost four times more likely to be included in the required curricula. CONCLUSION: Educational opportunities for medical students in injury prevention are limited. Trauma centers appear to support these efforts at their medical school affiliates.

The impact of drug therapy on quality of life in headache and migraine.

Although headache is among the most common and costly disorders in primary care, our understanding of its direct impact on the quality of life of affected individuals is incomplete. While studies evaluating the role of headache on health-related quality of life and healthcare economics are starting to appear in the medical literature, the effect of pharmacotherapy in improving quality of life is only beginning to be studied. At present, studies evaluating health-related quality of life in patients with migraine who are undergoing treatment are limited to 3 agents: sumatriptan, flurbiprofen and diclofenac. Several studies have consistently indicated that these drugs benefit patients by improving key dimensions of health-related quality of life or patients' sense of well-being to a significant extent. Given the magnitude of functional and emotional impairment associated with chronic headache disorders, assessing patients' perceptions of their quality of life makes a useful contribution to the evaluation of therapeutic interventions and should supplement traditional clinical endpoints in determining the effectiveness of new drugs.

Using pretreatment quality of life perceptions to predict response to sumatriptan in migraineurs.

Quality of life perceptions vary for individuals with similar medical conditions and reflect disease impact. When correlated with subsequent response to treatment, such data may contribute useful insights in understanding the determinants of therapeutic effectiveness in selected medical conditions. Two hundred thirty-five migraine patients never previously treated with injectable sumatriptan completed a Short Form-36 questionnaire before receiving a supervised test dose and a prescription for the medication. Medical records were examined to determine the number of comorbid conditions, headache characteristics (age at onset, headache frequency, duration of disease, aura, association with menses, unilaterality, and emesis), and documentation of sumatriptan's effect in relieving migraine during 12 months of follow-up. Logistic regression was used to identify patient- and disease-specific features most closely associated with the dependent variable, clinical response. One hundred eighty-four patients (78%) reported both relief of symptoms and continued usage of sumatriptan. Patients who experienced emesis with headaches (OR = 2.05 [1.07, 3.91]) and those with higher pretreatment Physical Functioning scores (OR = 3.27 [1.28, 8.37]) were more likely to respond to sumatriptan. Response to sumatriptan therapy was associated with specific pretreatment quality of life domains and headache features. These results may be useful in improving the efficiency of disease management strategies for patients with migraine.

Impact of sumatriptan on clinic utilization and costs of care in migraineurs.

BACKGROUND: Although migraine headaches affect a large segment of the population, no objective measure of therapeutic success is currently available. Comparing visit frequency and associated costs of care before and after introduction of a new therapy represents an important surrogate measure of success. METHODS: One hundred four patients regularly attending a headache clinic for migraines at a tertiary care hospital were instructed in the use of a new abortive migraine therapy. Medical appointment and financial systems were searched retrospectively for visit frequency and associated patient care and institutional costs. The number of visits and mean costs 18 months before and after initiation of therapy were compared using the signed rank test and paired t-test, respectively. RESULTS: The median number of visits made by study subjects to the headache clinic fell significantly following sumatriptan test dosing (P < 0.001). Prior to the new treatment, mean total patient care and institutional costs were $228.59 and $112.81 per person, respectively, and fell to $135.93 and $78.16 (P < 0.001) after therapy began. CONCLUSIONS: These data suggest that many patients with migraine benefit from sumatriptan, seek medical attention in a headache clinic less often, and incur fewer costs following initiation of treatment with this drug.