Frequent emergency department utilization and behavioral health diagnoses.

BACKGROUND: There are 12 million emergency department (ED) visits each year related to behavioral health diagnoses. Frequent ED utilization among subpopulations, such as those with behavioral health diagnoses, flags the need for more accessible and effective healthcare delivery systems. Reducing frequent ED use is essential to controlling healthcare cost and poor outcomes of ED overcrowding. OBJECTIVES: The purpose of this study is to stratify individuals by overall health complexity and examine the relationship of behavioral health diagnoses (psychiatric and substance abuse) as well as frequent treat-and-release ED utilization in a cohort of Medicaid recipients. METHODS: This study was a retrospective analysis of 2009 Medicaid claims from two Western New York State counties. The claims represented 56,491 individuals (18-64 years old). Individuals were stratified into four separate cohorts for analysis based on underlying disease complexity. Data were analyzed using logistic regression models. RESULTS: The following factors significantly increased the odds of frequent treat-and-release ED use in all the four complexity cohorts: psychiatric diagnosis (ORs = 1.4-2.3), substance abuse (ORs = 2.4-3.8), and smoking (ORs = 1.7-4.0). Medicaid patients with behavioral health diagnoses show high risk of frequent treat-and-release ED use. DISCUSSION: The results of this study show that psychiatric diagnosis, substance abuse, and smoking are associated with increased odds of frequent treat-and-release ED utilization for Medicaid recipients in all categories of underlying disease complexity. Our findings support associations reported in the literature.

Multi-level model of missed nursing care in the context of hospital merger.

The aim of this study was to delineate the multi-level relationships of individual registered nurse (RN) and nursing unit factors on missed nursing care. This was a quantitative model-building study using a descriptive, cross-sectional design. Surveys (N = 553) and administrative unit records from nurses in one hospital system undergoing merger were included. The results showed that 36% of the variation in missed nursing care is due to the unit context, with a corresponding 64% due to individual nurse differences. At the unit level, workload, skill mix, and critical unit type affected the amount of missed nursing care. At the individual nurse level, more experience, supplies problems, communication problems, and involvement in errors of commission all increased the perception of the amount of missed nursing care. Education level was not related to the amount of missed nursing care. The findings highlight the importance of unit- and individual-level interventions to redesign hospital nursing care.

Electrocardiogram-based predictors of clinical outcomes: a meta-analysis of the prognostic value of ventricular repolarization.

OBJECTIVES: To estimate age- and sex-specific prognostic values of eight electrocardiographic repolarization descriptors to predict various mortality endpoints. BACKGROUND: Using electrocardiographic markers for risk stratification is well studied; however, the prognostic value of many markers is controversial, and their clinical utility remains debatable. No meta-analyses exist that address the prognostic value of ECG markers. METHODS: Data were synthesized from 106 primary studies using a random-effect variance model. Age and sex subgroups were analyzed using sensitivity analysis. RESULTS: Four classic (i.e., duration, amplitude, inversion, and ST-T changes) and four novel (i.e., axis, loop, wavefront direction, and waveform complexity) repolarization descriptors were studied. These novel descriptors were particularly useful in predicting sudden death. Abnormal repolarization duration, vectors, and loops have greater impact on negative cardiovascular outcomes in women compared to men; additionally, ischemic repolarization changes have greater impact on negative cardiovascular outcomes in younger versus older adults. CONCLUSIONS: Assessing repolarization abnormalities is particularly helpful in women and younger adults. Researchers need to further explore the clinical utility of these abnormalities in management algorithms.

Depression, anxiety, and suicidal ideation among Chinese Americans: a study of immigration-related factors.

The aim of this study was to identify anxiety, depression, and suicidal ideation disparities among Chinese Americans and how immigration-related factors affected the outcomes. We tried to explain the differences as a function of the Chinese culture. Data were derived from the National Latino and Asian American Study, the first national epidemiological survey of these populations in the United States. We used only the Chinese sample (N = 600) and focused on depressive disorder, anxiety disorder, and suicidal ideation. The United States-born Chinese and those Chinese who immigrated to the United States at 18 years or younger were at higher risk for lifetime depressive or anxiety disorders or suicidal ideation than were their China-born counterparts who arrived in the country at or after 18 years of age. For Chinese Americans, immigration-related factors were associated with depression and anxiety disorders and suicidal ideation. The higher prevalence of these disorders might be attributed to the psychological strains experienced by those who are at higher risk of cultural conflicts.

Influence of demographic factors, knowledge, and beliefs on Jordanian women's intention to undergo mammography screening.

PURPOSE: The purpose of this study was to determine the influence of demographic characteristics, breast cancer knowledge, fatalistic beliefs, health beliefs, and subjective norms on Jordanian women's intention to participate in mammography screening. DESIGN: A cross-sectional survey was used to collect data at 14 comprehensive healthcare centers in Amman and Zarqa, Jordan. A convenience sample of 142 Jordanian women 40 years of age or older with no history of breast cancer and able to read and write in Arabic participated. METHODS: Self-report surveys included a combination of researcher-designed and existing instruments to measure the study variables. Data were analyzed using descriptive statistics, Pearson's correlation, t tests, and multiple logistic regression. FINDINGS: Jordanian women surveyed lacked knowledge about breast cancer. Social norms and self-efficacy highly influenced these women's intention to engage in mammography screening. Younger women were more willing to indicate intention to engage in mammographic screening. CONCLUSIONS: Self-efficacy and the social connectedness of Jordanian society, but not religious beliefs or perceived barriers to screening, influence Jordanian women's intention to undergo mammography. Future research should examine cultural influences, rather than religious beliefs, and investigate Jordanian women's potentially unique perspectives on barriers to actual mammography screening behavior. CLINICAL RELEVANCE: The prevalence of mammography screening may be enhanced by focusing interventions on Jordanian women's support systems and empowering women by providing knowledge and skills needed to engage in the procedure.

Effects of a 6-week walking program on Taiwanese women newly diagnosed with early-stage breast cancer.

BACKGROUND: In Western culture, evidence has shown that in women with breast cancer exercise decreases fatigue and improves quality of life. However, only 1 pilot study about the effect of exercise has been examined in the Asian breast cancer population that indicated feasibility. Therefore, it is important to further study the effect of an exercise program for Taiwanese women with breast cancer. OBJECTIVE: The purpose of this study was to test the effects of a walking program on Taiwanese women newly diagnosed with early-stage breast cancer. METHODS: This was an experimental, longitudinal study with 4-time repeated measures based on Bandura's Self-efficacy Theory, with the aim of implementing interventions to boost exercise self-efficacy and to evaluate research outcomes. SPSS 17.0 with descriptive statistics using frequency, percentage, mean, and SD as well as inferential statistics such as t test, χ test, hierarchical linear model, repeated-measures analysis of variance, and analysis of covariance was used for data analysis. RESULTS: Results of this study indicated that subjects in the exercise group had significantly better quality of life, less fatigue, less sleep disturbances, higher exercise self-efficacy, more exercise behavior, and better exercise capacity compared with those in the usual-care group after the intervention. CONCLUSIONS: This program was effective and feasible, but more research studies with experimental, longitudinal design to verify the effects of this exercise program on Taiwanese women with breast cancer will be needed. IMPLICATIONS FOR PRACTICE: Nurses, depending on skill and knowledge, can encourage physical activity, refer patients to rehabilitation programs, and prescribe and monitor exercise in breast cancer population.

Factors related to quality-of-life pattern changes in recipients of implantable defibrillators.

PURPOSE: The implantable cardioverter defibrillator (ICD) has proven life-saving, yet it is important to understand its psychological effects on recipients. This study examined longitudinal changes in patterns of quality-of-life (QOL) scores in the first 3 months after an implant, and determined what variables tested as predictors of patterns. METHODS: This longitudinal, prospective, descriptive, correlational survey study followed 80 ICD patients, with data collection at a baseline preinsertion, and 1 and 3 months after implant. RESULTS: Findings revealed eight patterns of QOL change that were recoded into 3 groups: no change (44.7%), worse (20.7%), and improved (34.2%). No significant difference was evident in groups according to age at implant, gender, education, ejection fraction, number of device discharges, and comorbidities. State anxiety was significantly higher for the worsening group. CONCLUSION: This finding supports the practice of identifying and supporting patients with anxiety, which correlates with a worsening QOL.

Measuring usability of assistive technology from a multicontextual perspective: the case of power wheelchairs.

Assistive technology (AT) devices enable people with disabilities to function in multiple contexts and activities. The usability of such devices is fundamentally indicative of the user's level of participation in multiple roles and occupations. Seventy people who used power wheelchairs were interviewed using a novel tool, the Usability Scale for Assistive Technology (USAT). The USAT uses a human factors science framework to investigate the wheelchair user's perceived independence in mobility-related activities within home, workplace, community, and outdoors in accordance with the characteristics of the wheelchair, environmental factors, and abilities and skills of the user to operate the wheelchair. Descriptive analysis of the data revealed usability issues with the use of power wheelchairs in all contexts. Users confronted far more significant issues within the community and outdoor environment compared with those at home and in the workplace. These issues have been elucidated and applied to an intervention framework with relevance to a multitude of AT stakeholders.

Development and psychometric evaluation of the instrument: attitude toward patient advocacy.

Nurses' patient advocacy can influence patient outcomes. There is a lack of reliable and valid instruments on patient advocacy. The purpose of this study was to develop an instrument to measure nurses' attitudes toward patient advocacy. Bu and Jezewski's theory of patient advocacy and Fishbein and Ajzen's definition of attitude were used to guide the development and evaluation of the scale. Seven experts evaluated scale content validity. Two samples (N = 200; N = 2,500) were randomly selected from the Oncology Nursing Society membership to allow us to examine psychometric properties of the scale. The scale possessed satisfactory psychometric properties.

Conceptualization and measurement of assistive technology usability.

UNLABELLED: The concept of product usability has been discussed in several areas of product research and development. Usability, within the realm of assistive technology (AT) devices, determines how effectively and efficiently AT users with disabilities can function in different contexts and environments. OBJECTIVE: This article conceptualizes and proposes the significance of AT usability and its measurement in entirety from a human factors perspective. Conceptual models that characterize the interaction of the AT user, the AT device, the context and the involved activity is considered to be the hallmark of measurement of AT usability. On that basis, the article highlights the methodology and the initial progress of the development of an AT outcome tool, the Usability Scale for Assistive Technology (USAT), to measure self reported degree of AT usability. METHODOLOGY: In order to identify usability indicators for measurement, a qualitative study was conducted by exploring the experiences of AT users. Ten participants who used either wheeled mobility or computer based AT devices were interviewed with questions based on the theme of a usability framework. RESULTS: The coded interview data generated more than 800 usability indicators specific to the two categories of AT devices. These indicators were mapped to a generic usability criteria list for construction of the USAT-Wheeled Mobility and the USAT-Computer Access. IMPLICATIONS: The USAT, when developed, is projected to be valid and useful for AT outcomes research as well as clinical practice. The use of the USAT will enable researchers and clinicians to comprehensively identify factors that underlie effectiveness and efficiency in AT device use and establish intervention protocols to optimize user-AT interaction.

A CNS-facilitated ICD support group: a clinical project evaluation.

PURPOSE: The purpose of this article is to describe and evaluate a clinical nurse specialist (CNS)-facilitated support group for recipients of implantable cardioverter defibrillator. Specific evaluation aims were as follows: (1) How do demographic and clinical factors differ between those who attended the support group and those who did not? (2) Is there a difference in the quality of life index (QLI) of individuals with an implantable cardioverter defibrillator who attended the CNS-facilitated support group and those who did not? (3) What demographic and clinical factors are related to QLI? DESIGN AND METHOD: Clinical project theory-based objectives were described. Implementation of the project was evaluated by retrospective survey of all implantable cardioverter defibrillator recipients during a 10-year time frame using the Ferrans and Powers' Quality of Life Index: Cardiac Version and demographic questionnaire. Attendance sheets defined who attended so comparisons could be made. EVALUATION RESULTS: One hundred and twelve surveys were returned (34% return rate). A positive relationship between CNS visit during hospitalization, number of and value of supports, years of education, and ejection fraction was noted with attendance at the support group. No between-group differences on total QLI, or on any subscales, were found. Comorbidity was the only clinical factor correlated with QLI. CONCLUSION: CNS-facilitated support groups can be offered as an additional support. Evaluation design issues limited the measuring outcomes of existing interventions. Future prospective studies are recommended to determine the affect of the support group on quality of life.

Nurses' intention to report child abuse in Taiwan: a test of the theory of planned behavior.

The purposes of this study were to identify factors associated with nurses' intention to report suspected child abuse in Taiwan, and to determine the empirical adequacy of the extended theory of planned behavior (TPB) to explain nurses' intention to report child abuse. A stratified quota sampling technique was used to select registered nurses in emergency rooms, psychiatric units, and pediatric units in Taiwan. A total of 1,362 questionnaires from 1,617 nurses were used for the analyses. Structural equation modeling demonstrated that nurses' attitudes toward reporting child abuse, perceived behavioral control, subjective norms, and knowledge of the child abuse and reporting law explained 85% to 91% of the variance in nurses' intention to report child abuse for the less severe and severe child abuse cases in vignettes, respectively. The findings support the use of the extended TPB in identifying factors associated with nurses' intention to report child abuse in Taiwan.

The impact of centering first-level predictors on individual and contextual effects in multilevel data analysis.

BACKGROUND: Multilevel data analysis is a powerful analytical tool. Properly applying the models and correctly interpreting the findings are two interrelated general issues in using multilevel modeling (MLM). There are two specific issues when using MLM: (a) separating the individual-level effects of a predictor variable from its contextual effects and (b) centering first-level predictor variables. This can have major implications for interpreting the results at higher levels, and its impact on second-level interpretation is not always apparent. OBJECTIVES: The major purposes of this article are to show how to separate organizational-level effects from individual-level effects and to show how first-level centering decisions affect the interpretation of second-level coefficients. METHODS: The hierarchical linear models (HLM) are used to analyze a hypothetical data set with 385 patients nested within 10 hospitals, using uncentered, group-mean-centered, and grand-mean-centered versions of the predictor variable. RESULTS: Uncentered and grand-mean-centered models are equivalent, but group-mean-centered models are not equivalent to the other two. For the grand-mean-centered and uncentered models, second-level coefficients provide correct estimates of the individual effect and the contextual effect when the contextual predictor variable is included in the second-level model. The group-mean-centered model leads to a second-level coefficient where individual-level effects are confounded with contextual-level effects. DISCUSSION: There is no single best answer to the question of whether to use group-mean centering or grand-mean centering. The theory and specific questions to be answered should be the researcher's guide to selecting which centering approach to use. Understanding the implications of first-level centering is essential to interpreting second-level coefficients correctly.

The development of the School Function Assessment Chinese version for cross-cultural use in Taiwan.

The primary purpose of this research project was to translate and adapt the School Function Assessment (SFA), a standardized criterion-referenced instrument that measures school-related functional skills, for its cross-cultural use in Taiwan. The project consisted of four study phases: translation, cultural adaptation, pilot testing, and field testing for standardization. A series of rigorous procedures including the method of translation and back-translation, team consensus for cultural adaptation, and Rasch modelling techniques were used to address various dimensions of cross-cultural equivalence and psychometric properties of the translated SFA. The protocols that were developed as well as technical issues that were addressed in this project provide useful guidelines for international occupational therapists who are interested in translating and adapting instruments for cross-cultural use.

A plant food-based diet modifies the serum beta-sitosterol concentration in hyperandrogenic postmenopausal women.

Plant sterols or phytosterols are common components of plant foods, especially plant oils, seeds and nuts, cereals and legumes. The most common phytosterols are campesterol, beta-sitosterol and stigmasterol. Phytosterols have anticarcinogenic properties. Previous studies have suggested that populations with low breast cancer incidence often consume diets high in phytosterols. The present study evaluated whether consumption of a plant food-based diet, low in animal fat, may increase serum phytosterol levels in postmenopausal women. One hundred and four women volunteers were randomized to dietary intervention or control groups. The dietary intervention included intensive dietary counseling to replace animal products with plant-based foods. Subjects in the dietary intervention group participated twice a week for 18 wk in workshops about the preparation and consumption of a plant food-based diet. The absolute change in serum total phytosterol concentration was greater in the dietary intervention group than in the control group. The percent change tended to differ between groups (P = 0.06). However, only for beta-sitosterol did the absolute and percent changes within a group differ significantly between groups (P = 0.0017). The decrease in serum total cholesterol in the dietary intervention group (-14%) was greater than that in the control group (-4%; P = 0.0005). The results of this study show that circulating levels of phytosterols can be affected by dietary modification. These findings indicate that phytosterols, in particular beta-sitosterol, can be used as biomarkers of exposure in observational studies or as compliance indicators in dietary intervention studies of cancer prevention.

Is total out-of-hospital time a significant predictor of trauma patient mortality?

OBJECTIVE: To determine if there is an association between total out-of-hospital time and trauma patient mortality. METHODS: A retrospective review was performed of a convenience sample of consecutive medical records for all admitted patients transported by helicopter or ambulance from the scene of injury to the regional trauma center. Descriptive and univariate analyses were conducted to determine which variables were associated with patient mortality and total out-of-hospital time. Multiple predictors logistic regression was used to determine if total out-of-hospital time was associated with trauma patient outcome, while controlling for the variables associated with trauma patient mortality. RESULTS: Of the 2,925 patients who were transported from the scene, 1,877 met the inclusion criteria. Six percent (116) did not survive. The multiple predictors model included CUPS (critical, unstable, potentially unstable, stable) status, patient age, Injury Severity Score, Revised Trauma Score, and total out-of-hospital time as predictors of mortality. Total out-of-hospital time (odds ratio 0.987; p = 0.092) was the only variable not found to be a significant predictor of mortality. CONCLUSIONS: Provider-assigned CUPS status, patient age, Injury Severity Score, and Revised Trauma Score all were significant predictors of trauma patient mortality. Total out-of-hospital time was not associated with mortality.