Correlations of receptor desensitization of gain-of-function GABRB3 variants with clinical severity.

Genetic variants associated with developmental and epileptic encephalopathies have been identified in the GABRB3 gene that encodes the ß3 subunit of GABAA receptors. Typically, variants alter receptor sensitivity to GABA resulting in either gain- or loss-of-function, which correlates with patient phenotypes. However, it is unclear how another important receptor property, desensitization, contributes to the greater clinical severity of gain-of-function variants. Desensitization properties of 20 gain-of-function GABRB3 variant receptors were evaluated using two-electrode voltage-clamp electrophysiology. The parameters measured included current decay rates and steady-state currents. Selected variants with increased or reduced desensitization were also evaluated using whole-cell electrophysiology in transfected mammalian cell lines. Of the 20 gain-of-function variants assessed, 13 were found to alter receptor desensitization properties. Seven variants reduced desensitization at equilibrium, which acts to worsen gain-of-function traits. Six variants accelerated current decay kinetics, which limits gain-of-function traits. All affected patients displayed severe clinical phenotypes with intellectual disability and difficult-to-treat epilepsy. Nevertheless, variants that reduced desensitization at equilibrium were associated with more severe clinical outcomes. This included younger age of first seizure onset (median 0.5 months), movement disorders (dystonia and dyskinesia), epilepsy of infancy with migrating focal seizures (EIMFS) and risk of early mortality. Variants that accelerated current decay kinetics were associated with slightly milder phenotypes with later seizure onset (median 4 months), unclassifiable developmental and epileptic encephalopathies or Lennox-Gastaut syndrome and no movement disorders. Our study reveals that gain-of-function GABRB3 variants can increase or decrease receptor desensitization properties and that there is a correlation with the degree of disease severity. Variants that reduced the desensitization at equilibrium were clustered in the transmembrane regions that constitute the channel pore and correlated with greater disease severity, while variants that accelerated current decay were clustered in the coupling loops responsible for receptor activation and correlated with lesser severity.

GABAA receptors in epilepsy: Elucidating phenotypic divergence through functional analysis of genetic variants.

Normal brain function requires a tightly regulated balance between excitatory and inhibitory neurotransmissions. γ-Aminobutyric acid type A (GABAA ) receptors represent the major class of inhibitory ion channels in the mammalian brain. Dysregulation of these receptors and/or their associated pathways is strongly implicated in the pathophysiology of epilepsy. To date, hundreds of different GABAA receptor subunit variants have been associated with epilepsy, making them a prominent cause of genetically linked epilepsy. While identifying these genetic variants is crucial for accurate diagnosis and effective genetic counselling, it does not necessarily lead to improved personalised treatment options. This is because the identification of a variant does not reveal how the function of GABAA receptors is affected. Genetic variants in GABAA receptor subunits can cause complex changes to receptor properties resulting in various degrees of gain-of-function, loss-of-function or a combination of both. Understanding how variants affect the function of GABAA receptors therefore represents an important first step in the ongoing development of precision therapies. Furthermore, it is important to ensure that functional data are produced using methodologies that allow genetic variants to be classified using clinical guidelines such as those developed by the American College of Medical Genetics and Genomics. This article will review the current knowledge in the field and provide recommendations for future functional analysis of genetic GABAA receptor variants.

Physician-patient race concordance from the physician perspective.

BACKGROUND: The benefits of racial/ethnic physician-patient concordance have been cited to support increasing the number of minority physicians. Few studies have examined the rates at which physicians of different race/ethnicity groups or specialties see concordant visits. We aim to determine whether differences exist in rates at which physicians of different race/ethnicity groups and physician specialties see visits by patients of concordant race/ethnicity. METHODS: We used data from the National Ambulatory Medical Care Survey, 2001-2006, a nationally representative survey of visits to private physician's offices. For physicians of each race/ethnicity group, the percentage of visits by patients in each race/ethnicity group was calculated. A concordant visit was defined as one in which a physician in a particular race/ethnicity group saw a patient of the some race/ethnicity group. Concordance rates were calculated overall, and for visits to primary care, medical specialties, and surgical specialties individually. RESULTS: White physicians see a higher percentage of concordant visits than any other race/ethnicity of physician (84.3%, p < 0.001 vs. all others), followed by Hispanic physicians and non-Hispanic black physicians, who had statistically similar rates (50.0%, and 46.8%, p > 0.05 for comparison), with non-Hispanic Asian physicians having the lowest rate of concordant visits (14.5%, p < 0.001 vs. all others). Minority surgical and medical specialists have significantly lower rates of concordant visits (33.4% and 33.6% respectively) compared to minority primary care physicians (49.5%, p < 0.001 for both comparisons). CONCLUSION: Concordance rates from the physician perspective differ by physician race/ethnicity and by physician specialty.

Religiosity, Mental Health and Substance Use among Black and Hispanic Adults during the First Six Months of the COVID-19 Pandemic in New York City.

The purpose of this study was to investigate the association between personal religiosity, mental health, and substance use outcomes among Black and Hispanic adults during the first six months of the COVID-19 outbreak in New York City (NYC). Phone interviews were conducted with 441 adults to obtain information on all variables. Participants self-reported race/ethnicity as Black/African American (n = 108) or Hispanic (n = 333). Logistic regression were used to examine associations between religiosity, mental health, and substance use. There was a significant inverse association of religiosity and substance use. Religious people had a lower prevalence of drinking alcohol (49.0%) compared to non-religious people (67.1%). Religious people also had substantially lower prevalence of cannabis or other drug use (9.1%) in comparison to non-religious people (31%). After adjusting for age, sex, race/ethnicity, and household income, the association of religiosity with alcohol use and with cannabis/other drug use remained statistically significant. Despite restricted access to in-person religious activities and congregational supports, the findings suggest that religiosity itself may be helpful from a public health perspective, independent of serving as a conduit for other social services.

Adverse Childhood Experiences and Insufficient Sleep Among U.S. Children and Adolescents.

OBJECTIVE: To examine associations between adverse childhood experiences (ACEs) and age-specific insufficient sleep duration (ISD) in American youth. METHODS: Data from the 2016-2017 National Survey of Children's Health, a sample of 46,209 youth ages 6 to 17 were analyzed. The main outcome was sleep duration that did not meet the recent recommendations of the American Academy of Sleep Medicine. Nine types of ACEs, as well as a cumulative count of ACEs, were examined as independent variables in unadjusted and adjusted logistic regression models. RESULTS: Approximately half of U.S. children and adolescents (ages 6-17) experienced at least one ACE and a third did not get sufficient sleep. Among those exposed to any ACE, 40.3% had ISD. Seven of the 9 ACEs examined were significantly associated with a 20% to 60% increase in odds of not getting sufficient sleep (adjusted ORs between 1.2 and 1.6). Children exposed to 2 or more ACEs were nearly twice as likely as those exposed to no ACE to have ISD (adjusted OR = 1.7, 95% CI: 1.5-1.9). Moreover, each individual ACE, except parental death was significantly associated with more than 1 hour less sleep than recommended. CONCLUSIONS: This study reports the association of specific and cumulative ACEs with ISD in a nationally representative sample of American youth. The study findings underscore the importance of screening for both ACEs and insufficient sleep during primary care encounters and addressing potential sleep problems in those exposed to ACEs.

Organizational climate and intensive care unit nurses' intention to leave.

OBJECTIVE: The purposes of this study were to a) estimate the incidence of intensive care units nurses' intention to leave due to working conditions; and b) identify factors predicting this phenomenon. DESIGN: Cross-sectional design. SETTING: Hospitals and critical care units. SUBJECTS: Registered nurses (RNs) employed in adult intensive care units. INTERVENTIONS: Organizational climate, nurse demographics, intention to leave, and reason for intending to leave were collected using a self-report survey. MEASUREMENTS AND MAIN RESULTS: Nurses were categorized into two groups: a) those intending to leave due to working conditions; and b) others (e.g., those not leaving or retirees). The measure of organizational climate had seven subscales: professional practice, staffing/resource adequacy, nurse management, nursing process, nurse/physician collaboration, nurse competence, and positive scheduling climate. Setting characteristics came from American Hospital Association data and a survey of chief nursing officers. RESULTS: A total of 2,323 RNs from 66 hospitals and 110 critical care units were surveyed across the nation. On average, the RN was 39.5 yrs old (SD = 9.40), had 15.6 yrs (SD = 9.20) experience in health care, and had worked in his or her current position for 8.0 yrs (SD = 7.50). Seventeen percent (n = 391) of the respondents indicated intending to leave their position in the coming year. Of those, 52% (n = 202) reported that the reason was due to working conditions. Organizational climate factors that had an independent effect on intensive care unit nurse intention to leave due to working conditions were professional practice, nurse competence, and tenure (p < .05). CONCLUSIONS: Improving professional practice in the work environment and clinical competence of the nurses as well as supporting new hires may reduce turnover and help ensure a stable and qualified workforce.

Opioid Medications Prescribing and the Pain-Depression Dyad in Primary Care: Analysis of 2014-2015 National Ambulatory Medical Care Survey (NAMCS) Data.

BACKGROUND: Increased drug overdose deaths have become a serious public health problem. Primary care providers prescribe about 50% all opioid medications. This study examined opioids prescribing during primary visits to patients with a pain-depression dyad and patient demographic characteristics associated with opioids prescribing. METHOD: This study analyzed data from the 2014 to 2015 National Ambulatory Medical Care Survey and included primary care visits by adult patients (aged 18 years or older) with noncancer pain. RESULTS: An opioid medication was prescribed in 26.4% (95% CI, 22.6% to 30.6%) of the primary care visits by patients with noncancer pain. Opioid medications were more likely to be prescribed during visits by patients with a pain and depression dyad (adjusted odds ratios [AOR] = 1.8; 95% CI, 1.4 to 2.4). Narcotic analgesics were more likely to be prescribed during visits by patients aged 46 to 64 years; by male patients or non-Hispanic white patients. DISCUSSION/CONCLUSIONS: Pain-depression dyad is associated with higher odds of opioids prescribing during primary care visits. Future studies are needed to understand the complexity of these factors and identify effective strategies to prevent opioids addiction and overdose among patients with pain and depression.

Palliative Care Consultation in Cardiogenic Shock Requiring Short-Term Mechanical Circulatory Support: A Retrospective Cohort Study.

BACKGROUND: Little is known about palliative care consultation (PCC) for patients with cardiogenic shock requiring short-term mechanical circulatory support (STMCS). OBJECTIVE: To describe the utilization of PCC in this population. DESIGN: Retrospective cohort study in a university medical center intensive care unit (ICU). SETTING/PARTICIPANTS: In total, 195 patients aged >18 years with cardiogenic shock requiring STMCS were included. The cohort was divided into three categories: no PCC, early PCC (within seven days of STMCS), and late PCC (eight or more days after STMCS). Follow-up occurred during the index hospitalization. RESULTS: Mean age was 59.3 ± 13.9 years; 67.9% were men. Mean follow-up period was 33.8 ± 37.7 days. Overall inpatient mortality was 52.3%. Ninety-four patients (48.2%) received PCC; 49 (25.1%) and 45 (23.1%) received early and late PCCs, respectively. STMCS duration, ICU stay after STMCS, and hospital stay after STMCS were significantly shorter in the no PCC group than the early PCC group (4 vs. 12 days, p < 0.001; 11 vs. 19 days, p = 0.004; and 16 vs. 19 days, p = 0.031; respectively). ICU stay after STMCS and hospital stay after STMCS were significantly shorter in the early PCC group than the late PCC group (19 vs. 38 days, p < 0.001; 19 vs. 49 days, p < 0.001; respectively). However, time from initial PCC to discharge was not significantly different between early and late PCC groups (18 vs. 31 days, p = 0.13). CONCLUSIONS: PCC was utilized in almost half of patients with cardiogenic shock requiring STMCS. PCC tends to occur toward the end of life regardless of the duration of STMCS. The optimal PCC timing remained unclear.

End of Life with Left Ventricular Assist Device in Both Bridge to Transplant and Destination Therapy.

BACKGROUND: The difference of end-of-life care for left ventricular assist device (LVAD) patients, between destination therapy (DT) and bridge to transplant (BTT), and the effect of palliative care in this population remain unknown. OBJECTIVE: The primary outcomes of this retrospective cohort study were the place of death, do-not-resuscitate (DNR) order, palliative care consultation in the last month, and hospice enrollment. Secondary outcomes were time on the LVAD, life-sustaining treatment in the last week of life, LVAD deactivation, and clinical trajectory. SETTING/SUBJECTS: Eighty-nine patients who newly underwent LVAD therapy between 2010 and 2016 and died before May 2017 were divided into DT (59) and BTT (30). RESULTS: At death, BTT patients (61.1 ± 8.9 years) were significantly younger (p = 0.046) than DT patients (65.8 ± 12.9 years). Median (25th-75th percentile) time on LVAD was significantly shorter (p = 0.042) in BTT (152 days, 41.3-375.8) than in DT (358 days, 64-892), but the Kaplan-Meier curves were not significantly different (p = 0.055). The place of death (p = 0.092), DNR order (DT; 70.2%, BTT; 76.7%, p = 0.52), palliative care consultation in the last month (DT; 57.1% and BTT; 41.6%, p = 0.22), and hospice enrollment (DT; 8.5%, BTT; 10.0%, p = 1.0), as well as any of secondary outcomes, were not significantly different between groups. After January 2014, palliative care consultation in the last month increased significantly from 14.2% to 78.9% (p < 0.001), and death in intensive care unit decreased significantly (from 79.4% to 52.8%, p = 0.024) with less frequent mechanical ventilation (from 71.4% to 50.0%, p = 0.047) and renal replacement therapy (42.9% to 19.2%, p = 0.017). CONCLUSIONS: The clinical course of deceased LVAD patients, circumstances, and treatments at the end of life did not differ significantly between the BTT and DT groups. Palliative care consult seemed associated with less resource utilization. Palliative care team should get involved in the care of LVAD patients, not only for DT but also for BTT.

A U.S. population-based survey of Staphylococcus aureus colonization.

BACKGROUND: The epidemiology of staphylococcal colonization and community-associated methicillin-resistant Staphylococcus aureus (MRSA) is changing, and little is known from the national perspective. OBJECTIVE: To describe the U.S. epidemiology of S. aureus nasal colonization, compare risk factors for colonization with methicillin-sensitive S. aureus (MSSA) versus MRSA, and compare antibiotic resistance patterns and genetic factors of colonizing strains of S. aureus. DESIGN: Secondary analysis of data from the National Health and Nutrition Examination Survey (NHANES), a stratified, multistage probability sample. SETTING: United States. PARTICIPANTS: 2001-2002 NHANES participants older than 1 year of age. MEASUREMENTS: Colonization of MSSA and MRSA, risk factors for colonization, antimicrobial resistance, and percentage of isolates with selected genetic factors. RESULTS: The prevalence of colonization with S. aureus and with MRSA was 31.6% and 0.84%, respectively, in the noninstitutionalized U.S. population. People younger than 65 years of age, men, persons with less education, and persons with asthma were more likely to acquire S. aureus. Persons of black race and those of Mexican birth had lower risk for S. aureus colonization. Persons 65 years of age or older, women, persons with diabetes, and those who were in long-term care in the past year were more likely to have MRSA colonization. Hispanic persons had statistically significantly less risk than white persons. Isolates of MRSA with staphylococcal chromosomal cassette mec type IV (which is often associated with community-associated MRSA) were statistically significantly more likely to be sensitive to erythromycin, clindamycin, and ciprofloxacin. LIMITATIONS: Colonizing isolates may be different from isolates associated with infection. Risk factors identified may differ from those associated with invasive disease. The 2001-2002 NHANES data are several years old and may not reflect the most recent changes in epidemiology, but they are the only national data available. CONCLUSIONS: Characteristics of persons with MSSA and MRSA seem to differ. These findings may be useful for differentiating those who may be at risk for MRSA.

Prevalence of the metabolic syndrome among US middle-aged and older adults with and without diabetes--a preliminary analysis of the NHANES 1999-2002 data.

OBJECTIVE: This study examined the racial differences in the distribution of the individual and clustered metabolic syndrome components among diabetics and nondiabetics and the presence of inflammatory markers. STUDY DESIGN AND METHOD: This is a secondary data analysis of the National Health and Nutrition Examination Survey (NHANES) from 1999-2002. The analysis only included adults aged > or = 40 years who were White, Black, and Mexican American. Differences in the rate of metabolic syndrome, each of its components, and inflammation markers among the three racial groups were examined by using chi-square tests. RESULTS: An estimated 12 million adults > or = 40 years of age have diagnosed and undiagnosed diabetes. Most diabetics have metabolic syndrome (69.9% for Whites, 64.8% for Blacks, and 62.4% for Mexican Americans). Abdominal obesity is more prevalent among Whites with diabetes than Mexican Americans (80.6% vs 67.8%, P = .008). Hypertension is significantly greater among Blacks with diabetes (73.1%) as compared to Whites (58.6%) and Mexican Americans (50.8%); hypertension in those without diabetes was 47.5% among Blacks, 32.4% among Whites, and 23.4% among Mexican Americans. Among nondiabetics, Blacks have higher prevalence of elevated serum C-reactive protein (17.4%) and high plasma fibrinogen (49.7%) than Whites (9.7% and 36%, respectively). CONCLUSION: These data demonstrate racial differences in the prevalence of components of the metabolic syndrome among diabetics and nondiabetics. They raise questions about the current definition of the metabolic syndrome, which weights each component equally. Further research is necessary to more precisely quantify the characteristics of metabolic syndrome in different racial and ethnic groups.

Does receiving care in a medical home reduce racial/ethnic disparities in ED visits among children with asthma in the United States?

Evidence has shown the implementation of medical home model improves care quality and outcomes. However, it is not clear whether receiving care from a medical home has any impact on racial/ethnic disparities in emergency department (ED) use by children with asthma. This study using the US National Survey of Children with Special Health Care Needs, 2009-2010, estimated racial/ethnic disparities in ED use. Generalized liner models were used to examine factors associated with ED use. Racial/ethnic differences in ED use were attenuated after adjusting for socio-economic variables. Ratios of prevalence ratios were calculated to examine the effect modification of medical home on ED use associated with race/ethnicity. The adjusted prevalence ratio of ED use of the Black to non-Hispanic White was 1.51 (95% confidence interval (CI): 1.36-1.67) with medical home and 1.35 (95% CI: 1.24-1.47) without medical home. Among those with care from a medical home Latino children had higher ED use compared with White children. There is no evidence that the self-reported care from a medical home narrows the gaps in ED use between non-Hispanic White and Black or Latino children with asthma.

Combining training in knowledge translation with quality improvement reduced 30-day heart failure readmissions in a community hospital: a case study.

RATIONALE, AIMS AND OBJECTIVES: Training programmes in evidence-based practice (EBP) frequently fail to translate their content into practice change and care improvement. We linked multidisciplinary training in EBP to an initiative to decrease 30-day readmissions among patients admitted to a community teaching hospital for heart failure (HF). METHODS: Hospital staff reflecting all services and disciplines relevant to care of patients with HF attended a 3-day innovative capacity building conference in evidence-based health care over a 3-year period beginning in 2009. The team, facilitated by a conference faculty member, applied a knowledge-to-action model taught at the conference. We reviewed published research, profiled our population and practice experience, developed a three-phase protocol and implemented it in late 2010. We tracked readmission rates, adverse clinical outcomes and programme cost. RESULTS: The protocol emphasized patient education, medication reconciliation and transition to community-based care. Senior administration approved a full-time nurse HF coordinator. Thirty-day HF readmissions decreased from 23.1% to 16.4% (adjusted OR = 0.64, 95% CI = 0.42-0.97) during the year following implementation. Corresponding rates in another hospital serving the same population but not part of the programme were 22.3% and 20.2% (adjusted OR = 0.87, 95% CI = 0.71-1.08). Adherence to mandated HF quality measures improved. Following a start-up cost of $15 000 US, programme expenses balanced potential savings from decreased HF readmissions. CONCLUSION: Training of a multidisciplinary hospital team in use of a knowledge translation model, combined with ongoing facilitation, led to implementation of a budget neutral programme that decreased HF readmissions.

Effect of antibacterial home cleaning and handwashing products on infectious disease symptoms: a randomized, double-blind trial.

BACKGROUND: Despite the widespread household use of cleaning and personal hygiene products containing antibacterial ingredients, their effects on the incidence of infectious disease symptoms have not been studied. OBJECTIVE: To evaluate the effect of antibacterial cleaning and handwashing products for consumers on the occurrence of infectious disease symptoms in households. DESIGN: Randomized, double-blind clinical trial. SETTING: Northern Manhattan inner-city neighborhood, New York. PARTICIPANTS: 238 primarily Hispanic households (1178 persons) that included at least one preschool-age child. INTERVENTIONS: Households were randomly assigned to use either antibacterial or nonantibacterial products for general cleaning, laundry, and handwashing. All products were commercially available, but the packaging was blinded and the products were provided free to participants. MEASUREMENTS: Hygiene practices and infectious disease symptoms were monitored by weekly telephone calls, monthly home visits, and quarterly interviews for 48 weeks. RESULTS: Symptoms were primarily respiratory: During 26.2% (717 of 2736) of household-months, 23.3% (640 of 2737) of household-months, and 10.2% (278 of 2737) of household-months, one or more members of the household had a runny nose, cough, or sore throat, respectively. Fever was present during 11% (301 of 2737) of household-months, vomiting was present in 2.2% (61 of 2737), diarrhea was present in 2.5% (69 of 2737), and boils or conjunctivitis were present in 0.77% (21 of 2737). Differences between intervention and control groups were not significant for any symptoms (all unadjusted and adjusted relative risks included 1.0) or for numbers of symptoms (overall incidence density ratio, 0.96 [95% CI, 0.82 to 1.12]). CONCLUSIONS: The tested antibacterial products did not reduce the risk for symptoms of viral infectious diseases in households that included essentially healthy persons. This does not preclude the potential contribution of these products to reducing symptoms of bacterial diseases in the home.

Does provision of health counseling differ by patient race?

BACKGROUND AND OBJECTIVES: Empirical data on health counseling provided to patients of different racial groups in primary care settings are limited, and existing studies have yielded inconsistent findings. This study's purpose was to use a national medical care survey to examine whether the visit-based rates of health counseling/education differed between black and white patients in primary care practice settings. METHODS: We performed secondary data analysis of visits to primary care providers made by black and white adult patients in the National Ambulatory Medical Care Survey (NAMCS). RESULTS: From 1997 to 2000, visits by adult patients to their own primary care providers accounted for 41% of all ambulatory care visits. White patients made approximately 961 million of these visits, and black patients made about 120 million visits. Black patients were more likely to get health counseling for diet (odds ratio [OR]=1.2, 95% confidence interval [CI]=1.1-1.4), exercise (OR=1.3, 95% CI=1.1-1.5), and human immune deficiency virus/sexually transmitted disease (HIV/STD) (OR=3, 95% CI=1.7-5.1) but less likely to get mental health counseling (OR=0.6, 95% CI=0.4-.09) as compared with white patients. Stratifying by visit type, blacks had lower rates of receiving exercise counseling during non-illness care visits (18.9% versus 14.8%). There were no statistically significant differences in dietary or exercise counseling between black and white patients with diabetes or hypertension. CONCLUSIONS: Black patients received similar or higher rates of certain types of health counseling than whites during the clinical encounters with their primary care providers. However, there was a significantly lower rate of mental health counseling provided to black patients. Reasons for this disparity require further investigation.

Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up.

This study reports results of the 2-year follow-up phase of a randomized study comparing outcomes of patients assigned to a nurse practitioner or a physician primary care practice. In the sample of 406 adults, no differences were found between the groups in health status, disease-specific physiologic measures, satisfaction or use of specialist, emergency room or inpatient services. Physician patients averaged more primary care visits than nurse practitioner patients. The results are consistent with the 6-month findings and with a growing body of evidence that the quality of primary care delivered by nurse practitioners is equivalent to that by physicians.

Diabetes care processes and outcomes in patients treated by nurse practitioners or physicians.

PURPOSE: The purpose of this study was to compare selected diabetes care processes and outcomes of nurse practitioners (NPs) and physicians (MDs) in the primary care of adults with type 2 diabetes. METHODS: Adults with type 2 diabetes and no regular source of primary care were enrolled from the emergency room and randomized to an NP or MD practice. Chart reviews were conducted to assess processes of care; patient interviews and hemoglobin A1C (A1C) testing were performed to measure patient outcomes. RESULTS: NPs were more likely than MDs to document provision of general diabetes education and education about nutrition, weight, exercise, and medications. They were more likely to document patient height, urinalyses results, and A1C values. No differences were found in documenting current medications; alcohol, illicit drug, or tobacco use; depression; weight and blood pressure; foot and cardiovascular exams; blood glucose and creatinine testing; or referral to ophthalmologists. No differences were found in patient outcomes. CONCLUSIONS: This study provides preliminary evidence of interdisciplinary differences in the processes of care employed by primary care NPs and MDs in caring for patients with type 2 diabetes. NPs documented the provision of diabetes education and selected monitoring tests more frequently than MDs; however, these differences were not reflected in 6-month patient outcomes.

Characteristics of patient visits to nurse practitioners in hospital outpatient departments.

Nurse practitioners (NPs) are the largest and the fastest growing groups among nonphysician practitioners in the United States. However, there has been lack of studies on the supply, demand, and use of nurse practitioners in hospital outpatient departments (OPDs) across the nation. Using the National Hospital Ambulatory Medical Care Survey (1997-2000), this study describes patient visits to NPs in general medicine, pediatrics, and obstetrics/gynecology clinics in hospitals across the nation. The percentage of patient visits involving NPs increased from 5.9 percent in 1997 to 7.3 percent in 2000. NPs have greater roles in hospital OPDs in nonmetropolitan areas than in metropolitan areas. Regional difference in patient visits to NPs supports the relationship between the practice environment and the use of NPs. As expected, NPs continue to serve the health care needs of women and children in hospital OPDs. Of all OPD visits with a NP service, NPs saw patients with no presence of a physician in 82 percent of these visits. As the role of the NP evolves in the U.S. health care delivery system, further studies on the clinical practice of NPs in hospital OPDs can help evaluate the impact of NPs in providing quality of patient care at minimum cost.

Do nurse practitioners make a difference in provision of health counseling in hospital outpatient departments?

PURPOSE: This study examined whether nurse practitioners (NPs) had any impact on the type and amount of health counseling provided during patient visits to hospital outpatient departments (OPDs). DATA SOURCES: This is a secondary data analysis of the National Hospital Ambulatory Medical Care Survey from 1997 to 2000. Only patient visits to hospital OPDs were included. Rates of health counseling provided at patient visits involving an NP were compared with those without an NP. Adjusted odds ratio was reported separately for each type of health counseling provided at patient visits for nonillness care, for chronic problems, and for acute problems. CONCLUSIONS: Health counseling for diet, exercise, human immunodeficiency virus (HIV) and sexually transmitted disease (STD) prevention, tobacco use, and injury prevention are more likely to be provided at nonillness care visits involving an NP than at those not involving an NP. The presence of an NP is associated not only with higher rates of counseling for diet, exercise, and tobacco use provided at patient visits for chronic problems but also with higher rates of counseling for diet and HIV/STD prevention provided at patient visits for acute problems. IMPLICATIONS FOR PRACTICE: This study indicates an important role NPs can play in providing preventive services in outpatient hospital departments. The findings reflect the emphasis of the NP education on health counseling and patient education in clinical practice.