HRSA-funded Health Centers Are an Important Source of Care and Reduce Unmet Needs in Primary Care Services.

BACKGROUND: Evidence indicates the unmet need for primary care services including medical, mental health, and dental care is greater among uninsured and Medicaid beneficiaries than privately insured individuals, many of whom use Health Resources and Services Administration-funded health centers (HRSA HCs). OBJECTIVE: We examined differences in rates of unmet need between low-income uninsured and Medicaid patients of HRSA HCs and safety-net clinics in general or private physicians. RESEARCH DESIGN: We used logistic regression models to compare the predicted probabilities of unmet need for uninsured and Medicaid individuals whose usual source of care is HRSA HCs versus clinics in general or private physicians. SAMPLE: We used a nationally representative survey of low income, adult patients who identified HRSA HCs as their usual source of care. We used the National Health Interview Survey to independently identify low-income individuals whose usual source of care was clinics (National Health Interview Survey clinics) or physicians (National Health Interview Survey physicians) in the general population. MEASURES: Dependent variables were unmet need and delay in medical care, and unmet need for prescription medications, mental health, and dental care. The primary independent variable of interest was the usual source of care. We controlled for potential confounders. RESULTS: We found the probability of unmet need for medical and dental care to be lower among HRSA HC patients than individuals whose usual source of care were not HRSA HCs. CONCLUSIONS: HRSA HC patients have lower probabilities of unmet need for medical and dental care. This is likely because HRSA HCs provide accessible, affordable, and comprehensive primary care services. Expanding capacity of these organizations will help reduce unmet need and its consequences.

A prospective, randomized, single-blind study evaluating the effectiveness, tolerability, and cost of colonoscopy bowel preparations.

Colorectal cancer, the third most common cancer in U.S. adults, can be detected early through colonoscopy. Thorough bowel preparation facilitates successful colonoscopy. Effectiveness, tolerability, and costs of 3 bowel preparations were compared in patients undergoing outpatient screening colonoscopy. In this prospective, randomized, single-blind study, comparing three preparation protocols, 209 of 276 consented subjects completed (Protocol [N = 67] = HalfLytely© 1 L × 2 doses and bisacodyl 5 mg delayed release tablets × 2 tablets; Protocol 2 [N = 74] = MiraLAX® 5 tablespoons × 2 doses and bisacodyl 5 mg tablets × 2 tablets; and Protocol 3 [N = 68] = MoviPrep 1 L × 2 doses). Patients completed symptom diaries and a gastroenterologist rated effectiveness. Most subjects were White females, aged 59 years (mean). Protocol 1 was the most effective regimen, but Protocol 2 was the most tolerable and cost-effective. While the three bowel protocol differences were not statistically significant for all outcomes measured, there were clinically meaningful differences. As Protocol 1 was most effective, HalfLytely© and bisacodyl is recommended for patients prior to colonoscopy. For patients who cannot tolerate HalfLytely© or MoviPrep, or with financial concerns, Protocol 2 (MiraLAX® & bisacodyl) is alternatively recommended.

Effect of preoperative incentive spirometry patient education on patient outcomes in the knee and hip joint replacement population.

PURPOSE: This study examined the effects of preoperative incentive spirometry (IS) education (POISE) on postoperative outcomes for knee and hip total joint replacement patients. DESIGN: In this prospective study, 140 patients were randomized to Group 1 (POISE intervention = 50 completing) or Group 2 (no intervention = 56 completing) (34 dropped). METHODS: The Group 1 intervention consisted of formal instruction preoperatively for IS home use, postoperative use, and IS volumes documentation. Group 2 patients received no intervention. Patients recorded postoperative IS volumes, which were used to determine return to baseline volume. FINDINGS: One hundred six patients completed the study. Most were Caucasian females averaging 64 years. Although IS return to baseline volume time was not significantly different between groups, POISE patients had fewer postoperative complications, hospital days, and charges. POISE patients ranked the intervention as helpful. CONCLUSIONS: Although IS volumes were not significantly different between groups, POISE patients had better outcomes and ranked the intervention as helpful.

Evaluation of fall risk assessment tools for psychiatric patient fall prevention: a comparative study.

The Hendrich II Fall Risk Model™ (Hendrich II) is used to determine patient fall risks. However, the WilsonSims Fall Risk Assessment Tool (WSFRAT) is more specific to psychiatric patients. The current study tested the Hendrich II and WSFRAT simultaneously to determine which tool was the most predictive for patient falls in a psychiatric population. Fall risk assessments using the Hendrich II and WSFRAT tools were completed through discharge. Fall risk assessment scores, medications, and falls data were documented. Fifty patients who met eligibility criteria generated 319 observations; of the 50 patients, two (4%) experienced falls. Sensitivity was 100% for the Hendrich II and WSFRAT, with all patients properly categorized as high risk for falling. Both assessments had similar specificity (Hendrich II = 67.8%; WSFRAT = 63.1%). Both tools have similar specificity; thus, additional research is warranted.

Exploring how nurses and managers perceive shared governance.

BACKGROUND: Nurse managers have a pivotal role in the success of unit-based councils, which include direct care nurses. These councils establish shared governance to provide innovative, quality-based, and cost-effective nursing care. PURPOSE: This study explored differences between direct care nurses' and nurse managers' perceptions of factors affecting direct care nurses' participation in unit-based and general shared governance activities and nurse engagement. METHODS: In a survey research study, 425 direct care RNs and nurse managers were asked to complete a 26-item research survey addressing 16 shared governance factors; 144 participated (response rate = 33.8%). RESULTS: Most nurse participants provided direct care (N = 129, 89.6%; nurse managers = 15, 10.4%), were older than 35 (75.6%), had more than 5 years of experience (76.4%), and worked more than 35 hours per week (72.9%). Direct care nurses' and managers' perceptions showed a few significant differences. Factors ranked as very important by direct care nurses and managers included direct care nurses perceiving support from unit manager to participate in shared governance activities (84.0%); unit nurses working as a team (79.0%); direct care nurses participating in shared governance activities won't disrupt patient care (76.9%); and direct care nurses will be paid for participating beyond scheduled shifts (71.3%). Overall, 79.2% had some level of engagement in shared governance activities. Managers reported more engagement than direct care nurses. CONCLUSIONS: Nurse managers and unit-based councils should evaluate nurses' perceptions of manager support, teamwork, lack of disruption to patient care, and payment for participation in shared governance-related activities. These research findings can be used to evaluate hospital practices for direct care nurse participation in unit-based shared governance activities.

What causes near-misses and how are they mitigated?

OBJECTIVES: The objectives of this study were to determine the reasons hospital RNs attribute to near-misses and the techniques they used to mitigate these near-misses to prevent serious reportable events. BACKGROUND: Our health system developed this definition for the study: A near-miss is a variation in a normal process that, if continued, could have a negative impact on patients. METHODS: Study participants were RNs who completed a survey about a self-reported near-miss or another RN's near-miss they'd witnessed. Data collected included participant demographics, near-miss occurrence by day of week and time, near-miss type, and attributed causes. RESULTS: A total of 144 near-miss types were self-reported or witnessed by 123 respondents; of these, 43 (35%) self-reported a near-miss event and 80 (65%) witnessed a near-miss event. The respondents identified medication administration (19%) and transcription errors (10%) as the most frequent types of near-misses (N = 144). Selecting from 412 factors related to near-misses, more RNs attributed near-misses to personal factors than institutional factors. Top personal factors were not following policy and inappropriate decision making or critical assumptions. Top institutional factors were work-related interruptions and distractions, and poor communication about a patient. A total of 400 techniques were used to mitigate the near-misses, nearly one per causative factor identified. Top techniques used were stop, think, act, review (STAR) and verification of proper procedures or actions. CONCLUSIONS: Hospital administrators should consider both personal and institutional factors when evaluating patient-safety programs. Education about mitigating techniques for near-misses is imperative for RNs.

Knowledge and perceptions of prostate cancer among Nigerian male immigrants.

Studies focusing on prostate cancer in the Nigerian population, especially Nigerian male immigrants residing in the United States, are limited. Nigerian immigrants are one of the fastest growing populations of Africans currently residing in the United States. According to a report from Migration Policy Institute in Washington DC, 1.4 million African immigrants live in the United States, of which 13.1% or 185,787 are Nigerian-born individuals (Terrazas, 2009). A great number of these African immigrants (159,928/11.3%) currently reside in the Washington metropolitan area. Similar to African American males in the United States, Nigerian men are at high risk for developing prostate cancer. In Nigeria, prostate cancer constitutes 11% of all male cancers making it the #1 ranking cancer among Nigerian men.

What causes near-misses and how are they mitigated?

OBJECTIVES: The objectives of this study were to determine the reasons hospital RNs attribute to near-misses and the techniques they used to mitigate these near-misses to prevent serious reportable events. BACKGROUND: Our health system developed this definition for the study: A near-miss is a variation in a normal process that, if continued, could have a negative impact on patients. METHODS: Study participants were RNs who completed a survey about a self-reported near-miss or another RN's near-miss they'd witnessed. Data collected included participant demographics, near-miss occurrence by day of week and time, near-miss type, and attributed causes. RESULTS: A total of 144 near-miss types were self-reported or witnessed by 123 respondents; of these, 43 (35%) self-reported a near-miss event and 80 (65%) witnessed a near-miss event. The respondents identified medication administration (19%) and transcription errors (10%) as the most frequent types of near-misses (N = 144). Selecting from 412 factors related to near-misses, more RNs attributed near-misses to personal factors than institutional factors. Top personal factors were not following policy and inappropriate decision making or critical assumptions. Top institutional factors were work-related interruptions and distractions, and poor communication about a patient. A total of 400 techniques were used to mitigate the near-misses, nearly one per causative factor identified. Top techniques used were stop, think, act, review (STAR) and verification of proper procedures or actions. CONCLUSIONS: Hospital administrators should consider both personal and institutional factors when evaluating patient-safety programs. Education about mitigating techniques for near-misses is imperative for RNs.

Off-label prescribing patterns of antidepressants in children and adolescents.

PURPOSE: To understand the extent of off-label prescribing among pediatrics, the study assesses the prescribing patterns of antidepressants in ambulatory settings. METHODS: A cross-sectional analysis was conducted using the National Ambulatory Medical Care Survey from 2000 to 2006. The prevalence of off-label prescribing of antidepressants was estimated, and predictive factors were evaluated. PARTICIPANTS: Children and adolescents aged 6-18 years to private physicians' offices. MAIN OUTCOME MEASURES: Prevalence of antidepressant prescriptions including FDA and non-FDA-approved indications, types of antidepressants prescribed, and factors associated with off-label prescribing. RESULTS: Our study population made 18 646 visits to private physicians' offices, representing about 667 million weighted visits during the study period. The mean age of the patients was 12.2 years (SD = 3.7), and majority of the visits were made by White people (73.1%). Of all visits, 3.7% (95%CI: 3.2%-4.2%) were associated with antidepressants. The most prevalent form of antidepressants prescribed were selective serotonin reuptake inhibitors (63.7%). Only 9.2% of the visits were associated with FDA-approved indications. Visits made to pediatricians (adjusted OR = 2.4; 95%CI: 1.1-5.1), family physicians, and other offices (adjusted OR = 1.9; 95%CI: 1.2-3.1) were more likely to be associated with off-label prescribing as compared with visits to a psychiatrist's office. CONCLUSIONS: The study observed a very high prevalence of off-label antidepressant prescribing patterns among children and adolescents in US ambulatory care settings. Coordinated efforts should be placed to evaluate the potential reasons and ramifications of antidepressant off-label prescribing to guard patients' safety.

Patients' perceptions of patient care providers with tattoos and/or body piercings.

OBJECTIVE: This study evaluated patients' perceptions of patient care providers with visible tattoos and/or body piercings. BACKGROUND: As tattooing and body piercing are increasingly popular, research that informs nursing administrators regarding policies on patient care providers having visible tattoos and body piercings is warranted. METHODS: A total of 150 hospitalized adult patients compared pictures of male and female patient care providers in uniform with and without tattoos and/or nonearlobe body piercings. RESULTS: Patient care providers with visible tattoos and/or body piercings were not perceived by patients in this study as more caring, confident, reliable, attentive, cooperative, professional, efficient, or approachable than nontattooed or nonpierced providers. Tattooed female providers were perceived as less professional than male providers with similar tattoos. Female providers with piercings were perceived as less confident, professional, efficient, and approachable than nonpierced female providers. CONCLUSIONS: Nursing administrators should develop and/or evaluate policies regarding patient care providers with visible tattoos and/or body piercings.

The effect of menstruation on psychiatric hospitalization.

This study evaluated the effect of menstruation on psychiatric hospitalization. We conducted a retrospective chart review of the medical records of 177 women who met the eligibility criteria. Data collected included demographic details, primary and secondary diagnoses, date of last menstrual period (LMP), medication adherence, psychiatric hospitalization length of stay, previous psychiatric admissions (including those related to menstruation), discharge referrals, and readmissions. The majority of women were admitted for major depression, were single, Caucasian, and had a mean age of 34. A disproportionate percentage (37%) of women had their LMP within 5 days of psychiatric hospitalization (p = 0.0006). The overall average length of stay was 4.37 days, and 48.3% had a previous psychiatric admission. Medication adherence was routinely not documented (77.4%). Psychiatric hospitalizations for women are significantly greater within 5 days of their LMP. Nursing education and improved documentation are warranted to decrease the potential for readmission.

Pilot study to assess HIV knowledge, spirituality, and risk behaviors among older African Americans.

A pilot study was conducted in anticipation of implementation of a larger project to assess human immunodeficiency virus (HIV) risk behaviors among older African Americans. A cross-sectional methodology was employed, including 33 African Americans aged more than 50 years in the metropolitan Washington, DC, area. The average age of the participants was 66 years old, with an age range from 51 to 86 years. Data were collected utilizing previously validated instruments that were administered using an audio computer-assisted survey instrument. There was relatively high knowledge regarding HIV, with female participants scoring significantly higher compared to male participants (p=.003). Another specific finding of the preliminary study was the association between higher levels of spirituality and lower levels of HIV sexual risk behaviors (Spearman's correlation=-0.369, p=.035). Results of this pilot study suggest that older African American females may be more knowledgeable regarding HIV than older African American males. This may suggest that educational and behavioral interventions developedfor this group may need to be structured based upon the targeted gender of the audience. The association between increased spirituality and decreased risk behaviors may suggest that spiritually-based interventions may provide some benefit regarding reduction of HIV risk behaviors in this population. However, the small sample size in this study warrants caution in the conclusions and highlights the need for further research in this population.

Comparative effectiveness of standard endotracheal tubes vs. endotracheal tubes with continuous subglottic suctioning on ventilator-associated pneumonia rates.

Ventilator-associated pneumonia (VAP) accounts for the majority of nosocomial pneumonias, which may increase intensive care and prolonged hospital stays. Endotracheal tubes allowing continuous subglottic suctioning may reduce VAP; however, they are more expensive than standard endotracheal tubes not allowing continuous suctioning. he objective of this study was to measure the comparative costs associated with continuous subglottic suctioning endotracheal tubes (CSS-ETT) versus standard endotracheal tubes (S-ETT) among intubated patients and whether cost differential is offset by the occurrence of VAP in patients receiving either type of intubation. A retrospective chart review was conducted for 154 intubated adult patients (77 = S-ETT; 77 = CSS-ETT). The S-ETT group had one case of VAP; the CSS-ETT group had none. The mean total hospital charges were higher for the S-ETT group ($103,600; CSS-ETT= $88,500) (p = 0.3). Although the average number of intubation days and ICU days were greater for the CSS-ETT group, there were no cases of VAP compared to the S-ETT group. ased upon the one S-ETT VAP case and the VAP attributable costs, it is cost effective to use the CSS-ETT.

A comparison of the quality of blood specimens drawn in the field by EMS versus specimens obtained in the emergency department.

INTRODUCTION: Emergency Department (ED) acceptance of blood specimens drawn by Emergency Medical Services (EMS) staff is not a consistent standard of practice across hospitals. The literature does not address acceptance of pre-hospital phlebotomy specimens drawn by EMS staff. The purpose of this study was to compare specimen redraw rates and ED throughput times for specimens drawn by EMS versus ED staff. METHODS: Data was collected on 400 patients regarding phlebotomist type, intravenous (i.v.) site, i.v. angiocatheter size, number of i.v. attempts producing blood specimens, redraw reason, undue blood exposure to phlebotomist, diagnosis, and length of stay. RESULTS: In this study of 400 patients (EMS=200; ED=200), the redraw rate was higher for the ED group (11.5%) than the EMS group (9.5%). The primary reason for redraw in the EMS group was insufficient quantity (52.6%; ED=8.7%, p<.05). The primary reason for redraw in the ED group was hemolysis (52.2%; EMS=31.6%). Median ED throughput time was 17 minutes less for the EMS group (163 minutes) than for ED group (180 minutes). There were no incidences of undue blood exposure in either group. DISCUSSION: Based on no statistically significant differences between the two study groups in redraw rates, a decreased ED patient throughput time, and no undue blood exposure incidences, pre-hospital phlebotomy by EMS in the field and subsequent ED acceptance of samples is a standard of practice that can be implemented.

Improving Outcomes of Care for HRSA-Funded Health Center Patients Who Have Mental Health Conditions and Substance Use Disorders.

The rising prevalence of mental health conditions and substance use disorders (MH/SUD) underscores the important role of health centers (HCs) in caring for low-income and uninsured MH/SUD patients. This study used the 2014 Health Center Patient Survey and 2014 Uniform Data System to determine the independent association between delivery of MH/SUD integration and related interventions to patients that reported a MH/SUD condition (n=2714) with the number of HC visits, emergency department (ED) visits, and hospitalizations last year. Results showed that health education was associated with fewer predicted ED visits (1.8 vs. 2.3) and lower likelihood of hospitalizations (16% vs. 24%) among MH patients. Medical enabling services was associated with lower rates of ED visits (0.3 vs.1.9) and hospitalizations (< 1% vs. 13%) among SUD patients. The results indicate the utility of integration and related intervention services in primary care settings to improve service use and reduce ED and hospitalization among MH/SUD patients.

Racial/ethnic variations in weight management among patients with overweight and obesity status who are served by health centres.

This study sought to examine racial/ethnic variations in receipt of provider recommendations on weight loss, patient adherence, perception of weight, attempts at weight loss and actual weight loss among patients with overweight/obesity status at Health Resources and Services Administration-funded health centres (HC). We used a 2014 nationally representative survey of adult HC patients with overweight/obesity status (PwOW/OB) last year and reported the HC was their usual source of care (n = 3517). We used logistic regression models to assess the interaction of race/ethnicity and having obesity in (1) provider recommendations of diet or (2) exercise, (3) patient adherence to diet or (4) exercise, (5) perceptions of weight and (6) weight loss attempts. We used a multinomial regression model to examine (7) weight loss or gain vs no change and a linear regression model to evaluate (8) percent weight change. We found Black PwOW/OB (OR = 1.65) experienced greater odds of receiving diet recommendations than Whites. We found limited racial/ethnic disparities in adherence. Black (OR = 0.41), Hispanic/Latino (OR = 0.45), and American Indian/Alaska Native (OR = 0.41) PwOW/OB had lower odds of perceiving themselves as overweight. Black (OR = 1.68) and Hispanic (OR = 1.98) PwOW/OB had a greater odds of reporting weight gain, and Asian PwOW/OB (OR = 0.42) had lower odds of reporting weight loss than Whites. Disparities in provider diet recommendations among Blacks and Hispanics indicated the importance of personalized weight management recommendations. Understanding underlying reasons for discordance between self-perception and observed weight among different groups is needed. Overall increase in weight, despite current interventions, should be addressed through targeted racially/ethnically appropriate approaches.

Impact of oral health service expansion funding at health centers in the United States.

OBJECTIVES: This study aims to assess the impact of Health Resources and Services Administration (HRSA) investment in oral health through the HRSA FY16 Oral Health Service Expansion (OHSE) funding on workforce, access, and quality in health centers (HCs) from 2015 to 2017. METHODS: Analyses were conducted using data from the Uniform Data System from 2015 and 2017, and the 2015 Area Health Resource File. Change in indicators of oral health workforce, access, and quality of care by the receipt of OHSE funding received by HCs in 2016 were examined. Regression models for 1,345 HCs were developed to conduct a difference-in-difference analyses of the comparative change from 2015 to 2017 in the dependent variables among OHSE and non-OHSE awardees while controlling for confounders. RESULTS: OHSE awardees showed a significant difference in the oral health workforce with a higher mean number increase by 0.6 full time equivalent (FTE) dentists, 0.4 dental hygienists, 1.1 dental assistants, and 2.3 for other dental staff compared to non-OHSE awardees. Compared to non-OHSE awardees, OHSE awardees showed a mean increase of 712 dental patients served who received 1,402 dental visits, representing a 9-percentage point increase in the percentage of HCs that had an oral health program and a 3-percentage point increase in the ratio of dental patients to total patients. CONCLUSIONS: Funding dedicated to oral health service expansion in HCs may result in outcomes ranging from increasing workforce to reduction in access and financial barriers. Retrospective analysis demonstrated improved capacity for oral healthcare delivery attributable to HRSA support to HCs.

Examining trends in substance use disorder capacity and service delivery by Health Resources and Services Administration-funded health centers: A time series regression analysis.

BACKGROUND: The opioid epidemic and subsequent mortality is a national concern in the U.S. The burden of this problem is disproportionately high among low-income and uninsured populations who are more likely to experience unmet need for substance use services. We assessed the impact of two Health Resources and Services Administration (HRSA) substance use disorder (SUD) service capacity grants on SUD staffing and service use in HRSA -funded health centers (HCs). METHODS AND FINDINGS: We conducted cross-sectional analyses of the Uniform Data System (UDS) from 2010 to 2017 to assess HC (n = 1,341) trends in capacity measured by supply of SUD and medication-assisted treatment (MAT) providers, utilization of SUD and MAT services, and panel size and visit ratio measured by the number of patients seen and visits delivered by SUD and MAT providers. We merged mortality and national survey data to incorporate SUD mortality and SUD treatment services availability, respectively. From 2010 to 2015, 20% of HC organizations had any SUD staff, had an average of one full-time equivalent SUD employee, and did not report an increase in SUD patients or SUD services. SUD capacity grew significantly in 2016 (43%) and 2017 (22%). MAT capacity growth was measured only in 2016 and 2017 and grew by 29% between those years. Receipt of both supplementary grants increased the probability of any SUD capacity by 35% (95% CI: 26%, 44%) and service use, but decreased the probability of SUD visit ratio by 680 visits (95% CI: -1,013, -347), compared to not receiving grants. CONCLUSIONS: The significant growth in HC specialized SUD capacity is likely due to supplemental SUD-specific HRSA grants and may vary by structure of grants. Expanding SUD capacity in HCs is an important step in increasing SUD access for low income and uninsured populations broadly and for patients of these organizations.

Assessing the Impact of Patient-Centered Medical Home Principles on Hypertension Outcomes Among Patients of HRSA-Funded Health Centers.

BACKGROUND: Millions of Americans have uncontrolled hypertension and are low-income or uninsured populations. Health Resources and Services Administration-funded health centers (HCs) are primary providers of care to these patients and a majority have adopted the patient-centered medical home (PCMH). PCMH includes principles of care coordination or integration and care management-support important to the treatment of hypertension. We examined whether the receipt of PCMH concordant care by HC patients improved hypertension outcomes. METHODS: We used a nationally representative survey of adult HC patients with hypertension (n = 2,280) conducted between October 2014 and April 2015. We included data from the 2013 and 2014 Uniform Data System to include characteristics of the HCs where these patients received their care. Our outcome measures included flu shots, number of primary care visits, normal blood pressure at last visit, emergency department (ED) visits, confidence in self-care, and compliance with provider recommendations. The primary independent variables were (i) whether the HC coordinated and referred patients to specialists; (ii) provided counseling, health education, coaching, treatment plans, and advice on hypertension control; and (iii) helped patients to obtain government benefits, medical transportation, and basic needs such as housing and food. Logistic and negative binomial multivariate regression models were performed. RESULTS: Hypertension-focused coaching was associated with normal blood pressure at last visit (odds ratio (OR) = 1.47) and fewer ED visits (incidence rate ratio = 0.81). Behavioral health counseling was associated with increased self-efficacy in self-care management (OR = 3.20). CONCLUSIONS: Our findings suggested that increased focus on these practices may lead to better hypertension outcomes among patients who are low-income and uninsured populations.