Current interventions to promote safe and appropriate pain management.

PURPOSE: Describe patient-, clinician-, system-, and community-level interventions for pain management developed and employed by 9 healthcare systems across the United States and report on lessons learned from the implementation of these interventions. SUMMARY: The high cost associated with pain coupled with the frequent use of opioid analgesics as primary treatment options has made novel pain management strategies a necessity. Interventions that target multiple levels within healthcare are needed to help combat the opioid epidemic and improve strategies to manage chronic pain. Patient-level interventions implemented ranged from traditional paper-based educational tools to videos, digital applications, and peer networks. Clinician-level interventions focused on providing education, ensuring proper follow-up care, and establishing multidisciplinary teams that included prescribers, pharmacists, nurses, and other healthcare professionals. System- and community-level interventions included metric tracking and analytics, electronic health record tools, lockbox distribution for safe storage, medication return bins for removal of opioids, risk assessment tool utilization, and improved access to reversal agents. CONCLUSION: Strategies to better manage pain can be implemented within health systems at multiple levels and on many fronts; however, these changes are most effective when accepted and widely used by the population for which they are targeted.

The quality, safety and governance of telephone triage and advice services - an overview of evidence from systematic reviews.

BACKGROUND: Telephone triage and advice services (TTAS) are increasingly being implemented around the world. These services allow people to speak to a nurse or general practitioner over the telephone and receive assessment and healthcare advice. There is an existing body of research on the topic of TTAS, however the diffuseness of the evidence base makes it difficult to identify key lessons that are consistent across the literature. Systematic reviews represent the highest level of evidence synthesis. We aimed to undertake an overview of such reviews to determine the scope, consistency and generalisability of findings in relation to the governance, safety and quality of TTAS. METHODS: We searched PubMed, MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library for English language systematic reviews focused on key governance, quality and safety findings related to telephone based triage and advice services, published since 1990. The search was undertaken by three researchers who reached consensus on all included systematic reviews. An appraisal of the methodological quality of the systematic reviews was independently undertaken by two researchers using A Measurement Tool to Assess Systematic Reviews. RESULTS: Ten systematic reviews from a potential 291 results were selected for inclusion. TTAS was examined either alone, or as part of a primary care service model or intervention designed to improve primary care. Evidence of TTAS performance was reported across nine key indicators - access, appropriateness, compliance, patient satisfaction, cost, safety, health service utilisation, physician workload and clinical outcomes. Patient satisfaction with TTAS was generally high and there is some consistency of evidence of the ability of TTAS to reduce clinical workload. Measures of the safety of TTAS tended to show that there is no major difference between TTAS and traditional care. CONCLUSIONS: Taken as a whole, current evidence does not provide definitive answers to questions about the quality of care provided, access and equity of the service, its costs and outcomes. The available evidence also suggests that there are many interactional factors (e.g., relationship with other health service providers) which can impact on measures of performance, and also affect the external validity of the research findings.

Compliance with telephone triage advice among adults aged 45 years and older: an Australian data linkage study.

BACKGROUND: Middle-aged and older patients are prominent users of telephone triage services for timely access to health information and appropriate referrals. Non-compliance with advice to seek appropriate care could potentially lead to poorer health outcomes among those patients. It is imperative to assess the extent to which middle-aged and older patients follow triage advice and how this varies according to their socio-demographic, lifestyle and health characteristics as well as features of the call. METHODS: Records of calls to the Australian healthdirect helpline (July 2008-December 2011) were linked to baseline questionnaire data from the 45 and Up Study (participants age ≥ 45 years), records of emergency department (ED) presentations, hospital admissions, and medical consultation claims. Outcomes of the call included compliance with the advice "Attend ED immediately"; "See a doctor (immediately, within 4 hours, or within 24 hours)"; "Self-care"; and self-referral to ED or hospital within 24 h when given a self-care or low-urgency care advice. Multivariable logistic regression was used to investigate associations between call outcomes and patient and call characteristics. RESULTS: This study included 8406 adults (age ≥ 45 years) who were subjects of 11,088 calls to the healthdirect helpline. Rates of compliance with the advices "Attend ED immediately", "See a doctor" and "Self-care" were 68.6%, 64.6% and 77.5% respectively, while self-referral to ED within 24 h followed 7.0% of calls. Compliance with the advice "Attend ED immediately" was higher among patients who had three or more positive lifestyle behaviours, called after-hours, or stated that their original intention was to attend ED, while it was lower among those who lived in rural and remote areas or reported high or very high levels of psychological distress. Compliance with the advice "See a doctor" was higher in patients who were aged ≥65 years, worked full-time, or lived in socio-economically advantaged areas, when another person made the call on the patient's behalf, and when the original intention was to seek care from an ED or a doctor. It was lower among patients in rural and remote areas and those taking five medications or more. Patients aged ≥65 years were less likely to comply with the advice "Self-care". The rates of self-referral to ED within 24 h were greater in patients from disadvantaged areas, among calls made after-hours or by another person, and when the original intention was to attend ED. Patients who were given a self-care or low-urgency care advice, whose calls concerned bleeding, cardiac, gastrointestinal, head and facial injury symptoms, were more likely to self-refer to ED. CONCLUSIONS: Compliance with telephone triage advice among middle-age and older patients varied substantially according to both patient- and call-related factors. Knowledge about the patients who are less likely to comply with telephone triage advice, and about characteristics of calls that may influence compliance, will assist in refining patient triage protocols and referral pathways, training staff and tailoring service design and delivery to achieve optimal patient compliance.

District health manager and mid-level provider perceptions of practice environments in acute obstetric settings in Tanzania: a mixed-method study.

BACKGROUND: In sub-Saharan Africa, the capacity of human resources for health (HRH) managers to create positive practice environments that enable motivated, productive, and high-performing HRH is weak. We implemented a unique approach to examining HRH management practices by comparing perspectives offered by mid-level providers (MLPs) of emergency obstetric care (EmOC) in Tanzania to those presented by local health authorities, known as council health management teams (CHMTs). METHODS: This study was guided by the basic strategic human resources management (SHRM) component model. A convergent mixed-method design was utilized to assess qualitative and quantitative data from the Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers project. Survey data was obtained from 837 mid-level providers, 83 of whom participated in a critical incident interview whose aim was to elicit negative events in the practice environment that induced intention to leave their job. HRH management practices were assessed quantitatively in 48 districts with 37 members of CHMTs participating in semi-structured interviews. RESULTS: The eight human resources management practices enumerated in the basic SHRM component model were implemented unevenly. On the one hand, members of CHMTs and mid-level providers agreed that there were severe shortages of health workers, deficient salaries, and an overwhelming workload. On the other hand, members of CHMTs and mid-level providers differed in their perspectives on rewards and allocation of opportunities for in-service training. Although written standards of performance and supervision requirements were available in most districts, they did not reflect actual duties. Members of CHMTs reported high levels of autonomy in key HRH management practices, but mid-level providers disputed the degree to which the real situation on the ground was factored into job-related decision-making by CHMTs. CONCLUSIONS: The incongruence in perspectives offered by members of CHMTs and mid-level providers points to deficient HRH management practices, which contribute to poor practice environments in acute obstetric settings in Tanzania. Our findings indicate that members of CHMTs require additional support to adequately fulfill their HRH management role. Further research conducted in low-income countries is necessary to determine the appropriate package of interventions required to strengthen the capacity of members of CHMTs.

Recidivism after release from a prison nursery program.

OBJECTIVE: To analyze 3-year recidivism after release from a prison nursery, a secure unit that allows imprisoned women to care for their infants. DESIGN AND SAMPLE: Descriptive study of 139 women who co-resided with their infants between 2001 and 2007 in a New York State prison nursery. MEASURES: Administrative criminal justice data were analyzed along with prospective study data on demographic, mental health, and prison nursery policy-related factors. RESULTS: Results reflect a sample of young women of color with histories of clinically significant depressive symptoms and substance dependence, who were convicted of nonviolent crimes and had multiple prior arrests. Three years after release 86.3% remained in the community. Only 4% of women returned to prison for new crimes. Survival modeling indicated that women who had previously violated parole had a significantly shorter mean return to prison time than those who were in the nursery for a new crime. CONCLUSION: Women released from a prison nursery have a low likelihood of recidivism. Innovative interventions are needed to address incarceration's public health effects. Nurses can partner with criminal justice organizations to develop, implement, and evaluate programs to ensure the health needs of criminal justice involved people and their families are met.

Translating policy into practice: a case study in the secondary prevention of coronary heart disease.

BACKGROUND: This paper focuses on the relationships between health 'policy' as it is embodied in official documentation, and health 'practice' as reported and reflected on in the talk of policy-makers, health professionals and patients. The specific context for the study involves a comparison of policies relating to the secondary prevention of coronary heart disease (CHD) in the two jurisdictions of Ireland - involving as they do a predominantly state funded (National Health Service) system in the north and a mixed health-care economy in the south. The key question is to determine how the detail of health policy as contained in policy documents connects to and gets translated into practice and action. METHODS: The data sources for the study include relevant health-care policy documents (N=5) and progress reports (N=6) in the two Irish jurisdictions, and semi-structured interviews with a range of policy-makers (N=28), practice nurses (14), general practitioners (12) and patients (13) to explore their awareness of the documents' contents and how they saw the impact of 'policy' on primary care practice. RESULTS: The findings suggest that although strategic policy documents can be useful for highlighting and channelling attention to health issues that require concerted action, they have little impact on what either professionals or lay people do. CONCLUSION: To influence the latter and to encourage a systematic approach to the delivery of health care it seems likely that contractual arrangements - specifying tasks to be undertaken and methods for monitoring and reporting on activity - are required.

Feasibility and pilot study of the Pediatric Anesthesia NeuroDevelopment Assessment (PANDA) project.

BACKGROUND: Animal studies have documented that exposure of the developing brain to commonly used anesthetic agents induces neurotoxicity and late abnormal neurobehavioral functions as adults. Results from clinical studies have all been analyzed using existing data sets, and these studies produced inconsistent results. To provide more definitive evidence to address the clinical relevance of anesthetic neurotoxicity in children, an interdisciplinary team of investigators designed and developed the Pediatric Anesthesia NeuroDevelopment Assessment (PANDA) project. We present pilot study results in 28 sibling pairs recruited and tested at the Columbia University Medical Center (CUMC) and Children's Hospital of Boston (CHB) for the PANDA project. METHODS: The PANDA project uses an ambidirectional cohort design. We performed prospective neuropsychological assessment in 28 exposed-unexposed sibling pairs from 6 to 11 years of age. The exposed siblings were ASA 1 or 2 and had received a single episode of anesthesia for inguinal hernia repair before the age of 36 months and the unexposed siblings had no anesthesia before the age of 36 months. All the sibling pairs were English speaking and were 36 weeks of gestational age or older. Each sibling pair underwent a direct testing using the Wechsler Abbreviated Scale of Intelligence (WASI) and the NEuroPSYchological Assessment, second edition (NEPSY II), and the parents completed questionnaires related to behavior using CBCL and Conners rating. Data are presented as means±SD. We conducted descriptive analyses of the demographic data. We compared both the exposed and the unexposed sibling groups on WASI and NEPSY II, and total and T scores from CBCL and Conners rating were analyzed as continuous data using the paired t test between the two groups. A P<0.05 was considered significant. RESULTS: After the Institutional Review Board approval for the study at both CUMC and CHB, the full PANDA study protocol was implemented to perform a pilot feasibility study. Our success rate was 96.7% in obtaining detailed medical and anesthesia records in our historical cohort. The scores for verbal IQ (exposed=106.1±16.3, unexposed=109.2±17.9), performance IQ (exposed=109.1±16.0, unexposed=113.9±15.9), and full IQ (exposed=108.2±14.0, unexposed=112.8±16.8) were comparable between the siblings. There were no differences between the two groups in T scores for any of the NEPSY II subdomains, CBCL, or Conners rating. An abstraction protocol with web-based electronic data capture forms also was developed in conjunction with the International Center for Health Outcomes and Innovation Research (InCHOIR). CONCLUSIONS: The pilot study provided useful information for feasibility to recruit the sample size and to obtain relevant clinical data. For the final study protocol, both the neuropsychological battery and the age range for testing were revised. Our results confirmed the feasibility of our study approach and yielded pilot data from neuropsychological testing.

Relative cost effectiveness of the SPHERE intervention in selected patient subgroups with existing coronary heart disease.

Heterogeneity exists within the patient population with coronary heart disease and the cost effectiveness of treatment may vary across subgroups within the overall population. This study compares the cost effectiveness of a secondary prevention intervention for a combined patient population relative to three selected subgroups: patients aged over 70 years; patients with a diagnosis other than angina only (that is, patients with a history of myocardial infarction, coronary artery bypass graft and/or percutaneous transluminal coronary angioplasty); and patients with diabetes. The results for the general population have been published elsewhere, but ongoing budget constraints require consideration of the appropriateness of targeting resources to patient subgroups. We adopt a probabilistic model to combine within trial and beyond trial impacts of treatment to estimate the lifetime health care costs and quality-adjusted life years of two primary care-based secondary prevention strategies: SPHERE Intervention--tailored practice and patient care plans and Control--standardised usual care. In all cases, the intervention was associated with mean cost savings and mean QALYs gains, when compared to the control, though statistical significance was never achieved. However, the probability of the intervention being cost effective was higher than 85% in all analyses across a range of potential cost-effectiveness threshold values. There is no compelling statistical evidence to support the targeting of specific subgroups across the general population. However, if affordability constraints are binding, the results do allow a tentative ranking of priorities based on the probabilistic subgroup analysis.

Predictors of post-release research retention and subsequent reenrollment for women recruited while incarcerated.

Correctional facilities are prime targets for nursing interventions to decrease health disparities, but challenges to post-release follow-up limit use of the longitudinal research designs needed to fully examine intervention effects. Using an adapted version of the Behavioral Model for Vulnerable Populations, we determined predictors of 1-year post-release study retention and subsequent reenrollment an average of 3 years later in 88 mother and child dyads recruited from a state prison nursery. Predisposing characteristics and enabling factors emerged as strong predictors of loss to follow-up. Female research participants can be successfully retained years after release from a correctional facility. Understanding the barriers and facilitators to post-release follow-up supports the creation of theoretically informed strategies to retain formerly incarcerated populations.

Attachment organization in a sample of incarcerated mothers: distribution of classifications and associations with substance abuse history, depressive symptoms, perceptions of parenting competency and social support.

We report attachment classifications in a sample of pregnant women incarcerated in a state prison with a nursery program. Analyses were based on 69 women serving sentences for felony crimes who were followed from the birth of their child to completion of the prison nursery co-residence. They completed the Adult Attachment Interview shortly after entering the program and scales measuring depression, perceived parenting competency, and social support at study entry (Time 1) and program completion (Time 2). Incarcerated mothers had higher rates of insecure attachment than previous low-risk community samples. Compared with dismissing and secure mothers, preoccupied mothers reported higher levels of depressive symptoms, lower parenting competency, and lower satisfaction with social support at the conclusion of the nursery program. Higher scores on unresolved loss and derogation were associated with a history of substance abuse; higher scores on unresolved trauma were associated with depressive symptoms at program completion.

The cost-effectiveness of the SPHERE intervention for the secondary prevention of coronary heart disease.

OBJECTIVES: The Secondary Prevention of Heart disEase in geneRal practicE (SPHERE) trial has recently reported. This study examines the cost-effectiveness of the SPHERE intervention in both healthcare systems on the island of Ireland. METHODS: Incremental cost-effectiveness analysis. A probabilistic model was developed to combine within-trial and beyond-trial impacts of treatment to estimate the lifetime costs and benefits of two secondary prevention strategies: Intervention - tailored practice and patient care plans; and Control - standardized usual care. RESULTS: The intervention strategy resulted in mean cost savings per patient of euro512.77 (95 percent confidence interval [CI], -1086.46-91.98) and an increase in mean quality-adjusted life-years (QALYs) per patient of 0.0051 (95 percent CI, -0.0101-0.0200), when compared with the control strategy. The probability of the intervention being cost-effective was 94 percent if decision makers are willing to pay euro45,000 per additional QALY. CONCLUSIONS: Decision makers in both settings must determine whether the level of evidence presented is sufficient to justify the adoption of the SPHERE intervention in clinical practice.

A retrospective cohort study of the association of anesthesia and hernia repair surgery with behavioral and developmental disorders in young children.

Recent animal studies have shown that commonly used anesthetic agents may have serious neurotoxic effects on the developing brain. The purpose of this study was to assess the association between surgery for hernia repair and the risk of behavioral and developmental disorders in young children. We performed a retrospective cohort analysis of children who were enrollees of the New York State Medicaid program. Our analysis involved following a birth cohort of 383 children who underwent inguinal hernia repair during the first 3 years of life, and a sample of 5050 children frequency-matched on age with no history of hernia-repair before age 3. After controlling for age, sex, and complicating birth-related conditions such as low birth weight, children who underwent hernia repair under 3 years of age were more than twice as likely as children in the comparison group to be subsequently diagnosed with a developmental or behavioral disorder (adjusted hazard ratio 2.3, 95% confidence interval 1.3, 4.1). Our findings add to recent evidence of the potential association of surgery and its concurrent exposure to anesthetic agents with neurotoxicity and underscore the need for more rigorous clinical research on the long-term effects of surgery and anesthesia in children.

Biopsychosocial approach to treating self-injurious behaviors: an adolescent case study.

TOPIC: Self-injurious behaviors (SIBs) are a common coping mechanism in the adolescent population. A marked increase in SIB has been seen in recent years, yet effective treatment remains elusive. PURPOSE: This study aims to review current theoretical perspectives and treatment options that reflect a biopsychosocial framework. SOURCES: Selected multidisciplinary literature related to SIB. CONCLUSIONS: A 6-month multidisciplinary approach targeting the unique physical, emotional, and social needs of a 14-year-old girl in residential treatment led to the complete cessation of SIB.

The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411].

BACKGROUND: The aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland. CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines. METHODS: SPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions. The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires. The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

Conducting research as a visiting scientist in a women's prison.

Incarcerated populations have disparities in health risks and illness conditions meriting study, but the history of prison research is marred by unethical conduct. Ethical participation strategies are discussed in the context of studies implemented by the author in a state prison system. This study used ethnographic approaches, observed adherence to federal and institutional review board regulations and corrections department directives, and maintained continuous communication with vested interests to provide entry and long-term access for studies on female prisoners and their civilian infants. A culture clash between the punitive restrictive environment that serves the custody-control-care mission of corrections systems and the open inquiry environment needed for conduct of health research exists. Federal regulations protect prisoners as human subjects but additional vigilance and communication by researchers are required. Gaining and maintaining access to prison inmates for nursing research are leadership challenges that can be met within the caring and collaborative paradigm of nursing.

Delayed and forgone care for children with special health care needs in New York State.

OBJECTIVE: To identify characteristics associated with delayed/forgone care for children with special health care needs (CSHCN) in New York State (NYS) as reported by their parents. METHODS: Data come from NYS participants in the 2000-2002 National Survey of Children with Special Health Care Needs. Data were analyzed using weighted bivariate and multivariate regression models. The dependent variable was report of delayed/forgone routine health care. Independent variables included illness characteristics, potential and actual access to care, and provider care characteristics. RESULTS: In NYS, 8.4% reported delayed/forgone health care for their child. Parents of children with delayed/forgone care were more likely to report that their child was uninsured (adjusted odds ratio [aOR] 3.8, 95% confidence interval [CI] 1.3-11.8), had experienced interrupted health insurance (aOR 3.9, 95% CI 1.5-9.7), or their child's insurance was not adequate for CSHCN (aOR 3.6, 95% CI 1.4-9.1). Further, these parents were more likely to report that providers never spend adequate time (aOR 6.3, 95% CI 1.2-34.4), provide sufficient information (aOR 8.0, 95% CI 2.5-25.0), act as partners in care (aOR 6.7, 95% CI 2.3-19.7), or display cultural sensitivity (aOR 5.4, 95% CI 1.2-24.3). CONCLUSIONS: An estimated 40,771 NYS CSHCN experience delayed/forgone routine health care. Their families report two noteworthy barriers: inadequate or discontinuous insurance coverage and poor communication with health-care providers. Access to care for CSHCN can be improved by increasing consistent comprehensive insurance coverage and increasing sensitivity in relationships between health care providers and families of CSHCN.

A mentored experience (KO1) in maternal-infant research.

Funding mechanisms that require a mentor provide a unique opportunity to implement the research mentoring that is recognized as increasingly important in nursing. Little has been written about how to create and sustain the roles of mentor and principal investigator within a funded arrangement. This article analyzes one research mentoring relationship focused on maternal-infant interaction research and implemented through the Federal KO1 (Mentored Research Scientist Development Award) grant mechanism. Methods used are personal reflections on the 4-year mentorship experience and literature review using the National Library of Medicine database from 1990 to 2001. The mentoring relationship within the National Institutes of Health KO1 award is characterized by the personal commitment, common interests, and long-term professional development that are essential qualities of traditional mentoring but differs in that it is structured by the aims, activities, and length of each award. Effective participation requires organization, focus, and self-direction on the part of the mentored principal investigator and expertise, altruism, and generativity on the part of the mentor. A grant-based mentoring relationship can provide mutual benefits to the researcher and mentor but both must attend to sustaining and enriching the relationship.

Reliability of transportable instruments for assessment of infant length.

Transportable instruments for use in home and field settings have been used for decades on the basis of assumed reliability. This article describes a study that compares two portable devices for measuring length, the tape measure and the Measure Mat, against a clinical standard stadiometer with two convenience samples of Hispanic and African-American infants in an urban general pediatrics practice setting. Mean net difference between the stadiometer and the tape measure was 1.68 inches in the first sample and 0.92 inches in the second; the difference between the stadiometer and the Measure Mat was 0.92 inches. The least variability and random error (SD = 0.57 inch) was shown in the paired measurements using the stadiometer and the Measure Mat. Bland-Altman plots showed positive bias for both portable devices across the range of measurements.