A comparative study of PhD and DNP nurses in an integrated health care system.

BACKGROUND: A vast literature exists on doctorally-prepared RNs in academia, but little is known about those in practice settings. PURPOSE: The purpose of this study was to explore demographic, educational, and employment characteristics, as well as practice patterns and professional accomplishments of doctorally-prepared RNs in one practice setting. METHODS: Survey of approximately 100 doctorally-prepared RNs in an integrated health system were surveyed. DISCUSSION: Doctors of Nursing Practice (DNPs) outnumber PhDs three to one in the institution. Several statistically significant differences exist between them: DNPs are younger and most likely hold advanced practice nursing positions; PhDs are 10 years older and more likely hold administrative or leadership positions. Little evidence exists that neither nurses nor administrators understand the skills and knowledge that doctorally-prepared RNs bring to the organization. This is particularly true for DNPs who predominantly hold clinical positions also held by master's-prepared RNs. CONCLUSION: Advocates for continued growth of DNPs in academia and practice should partner more closely to clarify the skills and talents that doctorally-prepared nurses bring to clinical settings.

Trends in Gonorrhea and Chlamydia Testing and Infections Across the COVID-19 Pandemic in Adolescents and Young Adults in an Integrated Health System.

PURPOSE: The COVID-19 pandemic impacted testing and incidence of sexually transmitted infections (STIs), with some studies showing uneven effects across sociodemographic groups. We aim to determine whether rates of gonorrhea and chlamydia testing and infections were affected by the pandemic, overall and by subgroups, defined by sociodemographic factors and comorbidities. METHODS: We conducted a retrospective cohort study from January 1, 2016, through December 31, 2022, among adolescents and young adults ages 15-29 years within Kaiser Permanente Northern California (KPNC). We determined the rate of testing for gonorrhea/chlamydia, and the incident rates of infections before and during the COVID-19 pandemic by sociodemographic factors. We compared incidence rates of gonorrhea/chlamydia testing and infection before and during the pandemic using Poisson regression. RESULTS: Gonorrhea/chlamydia testing during the pandemic was 19% lower than prepandemic baseline. Testing among Black patients was 1.8-fold higher than White patients. Black patients had 5.5 and 3.6-fold higher rate of gonorrhea and chlamydia infections, respectively, compared with White patients. Patients living in more deprived neighborhoods also had higher rates of infection compared to those in the least deprived neighborhoods. In multivariable analyses stratified by the period before and during the COVID-19 pandemic, there were no significant differences in the incidence rate ratios of testing or infections for any specific sociodemographic factor. DISCUSSION: STI testing in adolescents and young adults dropped dramatically after the start of the pandemic and has not recovered to its prior levels. Preexisting disparities in STI testing and infections were not exacerbated by the pandemic.

Differences in healthcare costs over 10 years following discharge from military service by weight trajectory.

The prevalence of overweight and obesity among military personnel has increased substantially in the past two decades. Following military discharge many personnel can receive integrated health care from the Veterans Health Administration. Prior research related to the economic impacts of obesity has not examined health care costs following the transition into civilian life following military discharge. To address this evidence gap, this study sought to compare longitudinal costs over 10 years across weight categories among VA enrollees recently discharged from the military.

Economic costs of implementing evidence-based telemedicine outreach for posttraumatic stress disorder in VA.

Background: Telemedicine outreach for posttraumatic stress disorder (TOP) is a virtual evidence-based practice (EBP) involving telephone care management and telepsychology that engages rural patients in trauma-focused psychotherapy. This evaluation examined implementation and intervention costs attributable to deploying TOP from a health system perspective. Methods: Costs were ascertained as part of a stepped wedge cluster randomized trial at five sites within the Veterans Affairs (VA) Healthcare System. All sites initially received a standard implementation strategy, which included internal facilitation, dissemination of an internal facilitators operational guide, funded care manager, care managing training, and technical support. A subset of clinics that failed to meet performance metrics were subsequently randomized to enhanced implementation, which added external facilitation that focused on incorporating TOP clinical processes into existing clinic workflow. We measured site-level implementation activities using project records and structured activity logs tracking personnel-level time devoted to all implementation activities. We monetized time devoted to implementation activities by applying an opportunity cost approach. Intervention costs were measured as accounting-based costs for telepsychiatry/telepsychology and care manager visits, ascertained using VA administrative data. We conducted descriptive analyses of strategy-specific implementation costs across five sites. Descriptive analyses were conducted instead of population-level cost-effectiveness analysis because previous research found enhanced implementation was not more successful than the standard implementation in improving uptake of TOP. Results: Over the 40-month study period, four of five sites received enhanced implementation. Mean site-level implementation cost per month was $919 (SD = $238) during standard implementation and increased to $1,651 (SD = $460) during enhanced implementation. Mean site-level intervention cost per patient-month was $46 (SD = $28) during standard implementation and $31 (SD = $21) during enhanced implementation. Conclusions: Project findings inform the expected cost of implementing TOP, which represents one factor health systems should consider in the decision to broadly adopt this EBP. Plain Language Summary: What is already known about the topic: Trauma-focused psychotherapy delivered through telemedicine has been demonstrated as an effective approach for the treatment of post-traumatic stress disorder (PTSD). However, uptake of this evidence-based approach by integrated health systems such as the Veterans Affairs (VA) Health Care System is low. What does this paper add: This paper presents new findings on the costs of two implementation approaches designed to increase adoption telemedicine outreach for PTSD from a health system perspective. What are the implications for practice, research, and policy: Cost estimates from this paper can be used by health systems to inform the relative value of candidate implementation strategies to increase adoption of evidence-based treatments for PTSD or other mental health conditions.

Time-series analysis of recent antihyperglycemic medication prescribing trends for a diverse sample of Medicare enrollees with type 2 diabetes mellitus in an integrated health system.

PURPOSE: Despite high type 2 diabetes mellitus (T2DM) prevalence in Medicare enrollees, newer therapeutic options, and revised treatment guidelines, little is known about US antihyperglycemic prescribing trends after 2015. This research describes recent monthly antihyperglycemic prescribing trends in a large, diverse population of Medicare enrollees from the US Mid-Atlantic region. METHODS: Encounter data (July 2018-July 2020) for Medicare enrollees 65 years of age or older with T2DM were extracted from electronic health records of a large integrated health system. Descriptive time-series regression models were estimated to describe monthly prescribing rates (ie, prescription orders per 100 eligible plan members with T2DM) overall and by medication subgroups for all-eligible and continuously-eligible samples. Trends in monthly prescription orders per 100 eligible plan members with T2DM were reported. RESULTS: The monthly all-eligible member sample (n > 22,000) exhibited an overall positive baseline monthly prescribing rate of 23.88 T2DM medication orders per 100 members with T2DM and a significant positive monthly prescribing rate trend (ie, change) of 0.12 T2DM medication orders per 100 members with T2DM (P < 0.05). Subgroup T2DM medication order rates per 100 members with T2DM at baseline were 16.28 for first-generation medications, 3.87 for human insulins, 3.04 for insulin analogs, 0.58 for second-generation medications, and 0.11 for combination medications. Human insulins, insulin analogs, and second-generation medications had positive monthly trends (P < 0.05). Among second-generation medications, sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 (GLP-1) agonists had positive monthly trends (P < 0.05). Continuously eligible members with T2DM (n = 19,185) had no significant overall monthly prescribing trend; however, human insulins, insulin analogs, and second-generation medications and the SGLT-2 inhibitor class had positive monthly prescribing trends (P < 0.05). CONCLUSION: In a diverse Medicare sample, this study observed increasing monthly trends for second-generation medications, human insulins, and insulin analogs consistent with emerging evidence. Among second-generation medications, SGLT-2 inhibitors became the most commonly prescribed over time.

Maternal Health Care Among Refugees and Host Communities in Northern Uganda: Access, Quality, and Discrimination.

Introduction: Uganda is one of the largest refugee-hosting nations in the world, with the majority of the refugees having fled South Sudan. In the early 2000's the local government and refugee health systems were merged to create a more equal and integrated system for refugees and the host population. Our aim is to investigate whether mothers from the two groups experience the same access to and quality of maternal health services, and whether refugee- and host-community mothers perceive the maternal health services differently. Methods: In November-December 2019, we conducted a household survey of 1,004 Ugandan nationals and South Sudanese refugee mothers aged 15-49 in the West Nile region covering the districts of Arua, Yumbe, and Adjumani, and elicited information on access to maternal health care services, perceptions of the quality of services, and feelings of discrimination. The data was then analyzed using Ordinary Least Squares and logistic regression. Results: Our analyses do not reveal large differences between refugees and the host community in terms of access to and the quality of maternal health services. Results from bivariate models indicate that refugee mothers are 6% points less likely to receive antenatal care (p-value < 0.05) but are 8% points more likely to give birth at a health facility (p-value < 0.05). Refugee mothers are generally less satisfied with how they were treated during antenatal care (0.132 lower average value on a Likert scale, p-value < 0.01). Refugee mothers are also 4% points more likely to feel discriminated against during ANC compared to their counterparts in the host community (p-value < 0.05). Discussion: The way women feel treated at the health facility during maternal health care is an important aspect of quality care. While there seems to be equal access to resources between refugees and host community mothers in Northern Uganda in terms of access to and quality of care, there is still a discrepancy between the two groups in terms of how the women feel treated. Policymakers and practitioners in the health sector should pay attention to these perceived inequalities between refugees and women from the host communities to ensure equally inclusive treatment across groups.

Premature mortality associated with severe mental illness or substance use disorder in an integrated health care system.

OBJECTIVE: Research has reported shortened lifespans (by 15-30 years) for those with severe mental illness (SMI) or substance use disorder (SUD), particularly among public mental health treatment consumers. We assessed SMI- and SUD-associated mortality in the understudied setting of a large, nonprofit integrated health care system. METHOD: This retrospective cohort study examined 2010-2017 health system and death records for 564,592 adult patients. Half had SMI/SUD diagnosis; half were a demographically matched comparison group without SMI, other mental health, or SUD diagnoses. We estimated mortality risks, adjusting for demographic and physical health factors. RESULTS: Having SMI or SUD was associated with higher odds of death (adjusted odds ratio = 1.87) and an average 6.3 years of earlier death relative to comparison individuals. Co-occurring SMI and SUD conferred higher mortality risk from major natural and unnatural causes than did SMI with no SUD. CONCLUSIONS: Some indicators of premature mortality were lower than those reported for U.S. public mental health consumers, but risk level varied widely by diagnosis. While patients' having insurance and broad access to care may lower risk, access to care may be insufficient to overcome the many patient-, provider-, and system-level factors contributing to poor physical health in SMI and SUD.

Coordinating an Oncology Precision Medicine Clinic Within an Integrated Health System: Lessons Learned in Year One.

Precision medicine is a term describing strategies to promote health and prevent and treat disease based on an individual's genetic, molecular, and lifestyle characteristics. Oncology precision medicine (OPM) is a cancer treatment approach targeting cancer-specific genetic and molecular alterations. Implementation of an OPM clinical program optimally involves the support and collaboration of multiple departments, including administration, medical oncology, pathology, interventional radiology, genetics, research, and informatics. In this review, we briefly introduce the published evidence regarding OPM's potential effect on patient outcomes and discuss what we have learned over the first year of operating an OPM program within an integrated health care system (Aurora Health Care, Milwaukee, WI) comprised of multiple hospitals and clinics. We also report our experience implementing a specific OPM software platform used to embed molecular panel data into patients' electronic medical records.

An investigation into the effective factors on the acceptance and use of integrated health system in the primary health-care centers.

BACKGROUND: The successful application of the information systems in the health-care domain requires a reasonable recognition of the factors affecting the acceptance and use of such systems. The study aimed to investigate the factors affecting the acceptance and use of an integrated health system (IHS) in Isfahan primary health centers. MATERIALS AND METHODS: It was an applied and descriptive-analytical survey conducted in Isfahan, Iran. Research population included all IHS's users in the health centers no. 1 and 2 of Isfahan city from which a sample of 320 individuals were selected in total. Data were collected using a questionnaire developed based on the Unified Theory of Acceptance and Use of Technology model. Data were analyzed using partial least squares (PLS) method and SmartPLS software. RESULTS: The users' behavioral intention to use the IHS system was influenced by performance expectancy, effort expectancy, and social influence, but it was not significantly related to facilitating conditions. Behavioral intention to use the IHS also had a significant relationship with the use of system. Furthermore, performance expectancy was the most important predictor. CONCLUSIONS: According to the findings, if the system users perceive the positive role of system in performance improvement, its convenience to use, and positive attitude of others toward it, their willingness to accept and use system will increase. Furthermore, it was important for the users that the system helps them in resolving their daily work-related problems and making rational decisions.

Clinical and economic consequences of statin intolerance in the United States: Results from an integrated health system.

BACKGROUND: Although statins are considered safe and effective, they have been associated with statin intolerance (SI) in clinical and observational studies. OBJECTIVE: The objective of this study was to describe the clinical and economic consequences of SI through comparison of an SI cohort of patients with matched controls. METHODS: This study used data extracted from an integrated health system's electronic health records from 2008 to 2014. Adults with SI were matched to controls using a propensity score. Patients were hierarchically classified into 6 mutually exclusive cardiovascular (CV)-risk categories: recent acute coronary syndrome (ACS; ≤12 months preindex), coronary heart disease, ischemic stroke, peripheral artery disease, diabetes, or primary prevention. The study endpoints, low-density lipoprotein cholesterol (LDL-C) goal attainment, medical costs, and time to first CV event were compared using conditional logistic regression, generalized linear, and Cox proportional hazards models, respectively. RESULTS: Patients with SI (n = 5190) were matched with controls (n = 15,570). Patients with SI incurred higher medical costs and were less likely to reach LDL-C goals than controls. Patients with SI were at higher risk for revascularization procedures in all CV risk categories except ACS, and those in the diabetes risk category were at higher risk for any CV event. There was a lower risk of all-cause death among patients with SI. CONCLUSIONS: Patients with SI were less likely to reach LDL-C goals, incurred higher health care costs, and experienced a higher risk for nonfatal CV events than patients without SI. Alternative management strategies are needed to better treat high CV risk patients.

Impact of integrated health system changes, accelerated due to an earthquake, on emergency department attendances and acute admissions: a Bayesian change-point analysis.

OBJECTIVE: To chart emergency department (ED) attendance and acute admission following a devastating earthquake in 2011 which lead to Canterbury's rapidly accelerated integrated health system transformations. DESIGN: Interrupted time series analysis, modelling using Bayesian change-point methods, of ED attendance and acute admission rates over the 2008-2014 period. SETTING: ED department within the Canterbury District Health Board; with comparison to two other district health boards unaffected by the earthquake within New Zealand. PARTICIPANTS: Canterbury's health system services ∼500 000 people, with around 85 000 ED attendances and 37 000 acute admissions per annum. MAIN OUTCOME MEASURES: De-seasoned standardised population ED attendance and acute admission rates overall, and stratified by age and sex, compared before and after the earthquake. RESULTS: Analyses revealed five global patterns: (1) postearthquake, there was a sudden and persisting decrease in the proportion of the population attending the ED; (2) the growth rate of ED attendances per head of population did not change between the pre-earthquake and postearthquake periods; (3) postearthquake, there was a sudden and persisting decrease in the proportion of the population admitted to hospital; (4) the growth rate of hospital admissions per head of the population declined between pre-earthquake and postearthquake periods and (5) the most dramatic reduction in hospital admissions growth after the earthquake occurred among those aged 65+ years. Extrapolating from the projected and fitted deseasoned rates for December 2014, ∼676 (16.8%) of 4035 projected hospital admissions were avoided. CONCLUSIONS: While both necessarily and opportunistically accelerated, Canterbury's integrated health systems transformations have resulted in a dramatic and sustained reduction in ED attendances and acute hospital admissions. This natural intervention experiment, triggered by an earthquake, demonstrated that integrated health systems with high quality out-of-hospital care models are likely to successfully curb growth in acute hospital demand, nationally and internationally.

O pesquisador de fronteira e outras subjetivações: uma questão de método / The frontier researcher and other subjectivities: a matter of method / El investigador de frontera y otras subjetividades: una cuestión de método

O objetivo geral deste artigo é cartografar caminhos e vicissitudes do pesquisador de fronteira, aquele que, encarnado na sua pesquisa, assume politicamente sua posição de buscar novos caminhos textuais para suas reflexões acerca da ciência e de suas práticas, incluindo a questão do método. Inspirada na Teoria do Ator-Rede, sigo pistas dos actantes envolvidos na entrada das terapias naturais, integrativas e complementares no Sistema Único de Saúde – SUS brasileiro. Pergunto como é pesquisar na fronteira e reflito sobre as subjetivações produzidas no processo de pesquisar desse lugar inquietante.

The general goal of this article is to map the frontier researcher’s routes andchanges. By frontier researcher, I mean the professional that, totally involved in his/her research, publicly assumes his/her political stand of looking for new concrete routes for his/her reflexions on science and its practices, including the matter of method. Inspired by the Actor Network Theory (ANT), I follow the tracks made by acting agents involved in the introduction of natural, integral and complementary therapies in theBrazilian Integrated Health System (SUS). I raise the question of how it is to do research at the frontier and ponder on the subjectivities produced in the process of researching from this instigating point.

El objetivo general de este trabajo consiste entrazar el camino y vicisitudes del investigador de frontera. Llamo investigador de frontera al profesional que, totalmente involucrado em su investigación, asume publicamente suposición política de buscar nuevos y concretos horizontes para sus reflexiones sobre La ciencia y sus prácticas, incluyendo la cuestión del método. Inspirada por la Teoría Actor-Red, acompaño los trazos dejados por los agentes actuantes involucrados en la introducción de las terapias naturales, integrales y complementares en el sistema único de salud brasileño (SUS). Presento la cuestión sobre cómo es el acto de hacer investigaciones en la frontera y hago una reflexión sobre las subjetividades en ese proceso a partir de tal punto inquietante.