Pharmacy staffing, workload, and productivity benchmarks in state psychiatric hospitals.

PURPOSE: Current benchmark statistics on staffing, workload, and productivity in hospital pharmacy departments of state psychiatric hospitals are described and assessed by hospital size. METHODS: An electronic survey of state psychiatric hospitals was conducted. Hospitals were categorized based on number of occupied beds. Descriptive statistics using Student's t tests, Pearson's chi-square tests, and Pearson's correlation coefficients were used to characterize the data and compare productivity by hospital size. RESULTS: Responses were received from 41 of 116 hospitals, yielding a response rate of 35.3%. Respondent hospitals did not differ from nonrespondents based on demographic data. Average inpatient census, patient days per year, expenditures, and workload were found to correlate positively with hospital size (r = 0.381-0.991, p < 0.05). Over 30% of hospitals reported using no indicators to monitor pharmacy productivity. Productivity ratios differed between very small-small and medium-large hospital groups: mean pharmaceutical expenditures per 100 occupied beds and per 1,000 patient days (p = 0.017 and 0.05, respectively), mean full-time equivalents (FTEs) per 1,000 doses dispensed or administered per month and per 100 occupied beds (p = 0.042 and 0.026, respectively), and mean pharmacist and technician FTEs per 100 occupied beds (p = 0.012 and 0.019, respectively). CONCLUSION: A survey of pharmacies in state psychiatric hospitals provided metrics data on staffing, workload, and productivity that may be used as benchmarks in efforts to improve workforce efficiency, pharmaceutical care services, and financial performance.

Healthcare Costs and Medication Adherence Among Patients with Fibromyalgia: Combination Medication vs. Duloxetine, Milnacipran, Venlafaxine, and Pregabalin Initiators.

OBJECTIVE: To examine medication adherence and healthcare costs for combination prescription initiators (duloxetine/milnacipran/venlafaxine with pregabalin) vs. monotherapy initiators (duloxetine, milnacipran, venlafaxine, and pregabalin) among patients with fibromyalgia syndrome (FMS). METHODS: Our retrospective cohort study used claims data for the South Carolina Blue Cross Blue Shield State Health Plan (SHP). Patients with FMS ≥ 18 years of age, with prescription initiation from July 1, 2007, through June 30, 2010, and SHP enrollment for 12 months pre- and post-index periods were included (combination: n = 100; pregabalin: n = 665; duloxetine: n = 713; milnacipran: n = 131; venlafaxine: n = 272). Medication adherence measures included high adherence (medication possession ratio ≥ 80%) and total supply days. Healthcare costs comprised direct medical expenditures. Propensity score methods of inverse probability of treatment weights were used to control for selection bias due to differing pre-index characteristics. RESULTS: Odds ratios for high adherence were significantly increased (P < 0.05) among the combination cohort vs. the venlafaxine (2.15), duloxetine (1.39), and pregabalin (2.20) cohorts. Rate ratios for total supply days were significantly higher (P < 0.05) for combination vs. venlafaxine (1.23), duloxetine (1.08), and pregabalin (1.32) cohorts. Expenditures for total health care were significantly higher (P < 0.05) for combination vs. duloxetine ($26,291 vs. $17,190), milnacipran ($33,638 vs. $22,886), and venlafaxine ($26,586 vs. $16,857) cohorts. CONCLUSIONS: Medication adherence was considerably better for combination prescription initiators; however, expenditures for total health care were higher. Still, our findings suggest important clinical benefits with the use of combination prescription therapy, and prospective studies of medication adherence are warranted to examine causal relationships with outcomes not captured by healthcare claims databases.

Assessing the relationship between neighborhood factors and diabetes related health outcomes and self-care behaviors.

BACKGROUND: Studies have shown that community and neighborhood characteristics can impact health outcomes of those with chronic illness, including T2DM. Factors, such as crime, violence, and lack of resources have been shown to be barriers to optimal health outcomes in diabetes. Thus, the objective of this study is to assess the effects of neighborhood factors on diabetes-related health outcomes and self-care behaviors. METHODS: Adult patients (N = 615) with type 2 diabetes mellitus (T2DM) were recruited from an academic medical center and a Veterans Affairs medical center in the southeastern United States. Validated scales and indices were used to assess neighborhood factors and diabetes-related self-care behaviors. The most recent HbA1c, blood pressure, and LDL cholesterol were abstracted from each patients' electronic medical record. RESULTS: In the fully adjusted model, significant associations were between neighborhood aesthetics and diabetes knowledge (ß = 0.141) and general diet (ß = -0.093); neighborhood comparison and diabetes knowledge (ß = 0.452); neighborhood activities and general diet (ß = -0.072), exercise (ß = -0.104), and foot care (ß = -0.114); food insecurity and medication adherence (ß = -0.147), general diet (ß = -0.125), and blood sugar testing (ß = -0.172); and social support and medication adherence (ß = 0.009), foot care (ß = 0.010), and general diet (ß = 0.016). Significant associations were also found between neighborhood violence and LDL Cholesterol (ß = 4.04), walking environment and exercise (ß = -0.040), and social cohesion and HbA1c (ß = -0.086). DISCUSSION: We found that neighborhood violence, aesthetics, walking environment, activities, food insecurity, neighborhood comparison, social cohesion and social support have statistically significant associations with self-care behaviors and outcomes to varying degrees. However, the key neighborhood factors that had independent associations with multiple self-care behaviors and outcomes were food insecurity, neighborhood activities and social support. CONCLUSION: This study suggests that food insecurity, neighborhood activities, aesthetics, and social support may be important targets for interventions in individuals with T2DM.

Impact of Outpatient Rehabilitation Medicare Reimbursement Caps on Utilization and Cost of Rehabilitation Care After Ischemic Stroke: Do Caps Contain Costs?

OBJECTIVE: To estimate the proportion of patients with ischemic stroke who fall within and above the total outpatient rehabilitation caps before and after the Balanced Budget Act of 1997 took effect; and to estimate the cost of poststroke outpatient rehabilitation cost and resource utilization in these patients before and after the implementation of the caps. DESIGN: Retrospective cohort study. SETTING: Medicare reimbursement system. PARTICIPANTS: Medicare beneficiaries from the state of South Carolina: the 1997 stroke cohort sample (N=2667) and the 2004 stroke cohort sample (N=2679). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Proportion of beneficiaries with bills within and above the cap before and after the cap was enacted, and total estimated 1-year rehabilitation Medicare payments before and after the cap. RESULTS: The proportion of patients with stroke exceeding the cap in 2004 after the Balanced Budget Act of 1997 was enacted was significantly lower (5.8%) than those in 1997 (9.5%) had there been a cap at that time (P=.004). However, when the proportion of individuals exceeding the cap among both the outpatient provider and facility files was examined, there was a greater proportion of patients with stroke in 2004 (64.6%) than in 1997 (31.9%) who exceeded the cap (P<.0001). The estimated average 1-year Medicare payments for rehabilitation services, when examining only the Part B outpatient provider bills, did not differ between the cohorts (P=.12), and in fact, decreased slightly from $1052 in 1997 to $833 in 2004. However, when examining rehabilitation costs using all available outpatient Medicare bills, the average estimated payments greatly increased (P<.0001) from $5691 in 1997 to $9606 in 2004. CONCLUSIONS: These findings suggest that billing practices may have changed after outpatient rehabilitation services caps were enacted by the Balanced Budget Act of 1997. Rehabilitation services billing may have shifted from Part B provider bills to being more frequently included in facility charges.

The effects of a prelicensure extern program and nurse residency program on new graduate outcomes and retention.

Organizations are looking to new graduate nurses to fill expected staffing shortages over the next decade. Creative and effective onboarding programs will determine the success or failure of these graduates as they transition from student to professional nurse. This longitudinal quantitative study with repeated measures used the Casey-Fink Graduate Nurse Experience Survey to investigate the effects of offering a prelicensure extern program and postlicensure residency program on new graduate nurses and organizational outcomes versus a residency program alone. Compared with the nurse residency program alone, the combination of extern program and nurse residency program improved neither the transition factors most important to new nurse graduates during their first year of practice nor a measure important to organizations, retention rates. The additional cost of providing an extern program should be closely evaluated when making financially responsible decisions.

Direct and indirect effects of neighborhood factors and self-care on glycemic control in adults with type 2 diabetes.

AIM: To determine whether neighborhood factors have direct or indirect effects, via self-care behaviors on glycemic control. METHODS: Adult patients with type 2 diabetes were recruited from an academic medical center and Veterans Affairs Medical Center in the southeastern United States. Confirmatory factor analysis was used to create latent variables for neighborhood factors and diabetes self-care behavior. Structural equation modeling was used to test direct and indirect effects between neighborhood factors and glycemic control as assessed by HbA1c levels. RESULTS: CFA yielded four latent variables for neighborhood factors (neighborhood violence, access to healthy food, social support, and neighborhood aesthetics) and one latent variable diabetes self-care. We found that social support (ß=0.28, z=4.86, p<0.001) and access to healthy foods (ß=-0.17, z=-2.95, p=0.003) had direct effects on self-care; self-care (ß=-0.15, z=-2.48, p=0.013) and neighborhood aesthetics (ß=0.12, z=2.19, p=0.03) had direct effects on glycemic control; while social support (ß=-0.04, z=-2.26, p=0.02) had an indirect effect on glycemic control via self-care. CONCLUSION: This study showed that self-care behaviors and neighborhood aesthetics have direct effects on glycemic control, social support and access to health foods had direct effects on self-care, and social support had an indirect effect on glycemic control via self-care.

Effect of neighborhood factors on diabetes self-care behaviors in adults with type 2 diabetes.

OBJECTIVE: The objective of this study was to identify latent variables for neighborhood factors and diabetes self-care and examine the effect of neighborhood factors on diabetes self-care in adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: 615 subjects were recruited from an academic medical center and a Veterans affairs medical center in the southeastern United States. Validated scales were used to assess neighborhood factors and diabetes-related self-care. Confirmatory factor analysis (CFA) was used to determine the latent constructs. Structural equation modeling (SEM) was then used to assess the relationship between neighborhood factors and diabetes self-care. RESULTS: Based on a theoretical framework, CFA yielded four latent variables for neighborhood factors (neighborhood violence, access to healthy food, social support, and neighborhood esthetics) and one latent variable diabetes self-care (including diet, exercise, foot care, blood sugar testing and medication adherence). SEM showed that social support (r=0.28, p<0.001) and access to healthy foods (r=-0.16, p=0.003) were significantly associated with self-care behaviors, while neighborhood violence (r=-0.06, p<0.001) and esthetics (r=-0.07, p=0.278) were not χ(2) (180, N=611)=192, p=0.26, RMSEA=0.01, CFI=0.999). In the final trimmed model, social support (r=0.31, p<0.001) and access to healthy foods (r=-0.20, p<0.001) remained significantly associated with self-care behaviors χ(2) (76, N=611)=60, p=0.91, RMSEA=0.00, CFI=1.0). CONCLUSION: This study developed latent factors for neighborhood characteristics and diabetes self-care and found that social support and access to healthy foods were significantly associated with diabetes self-care and should be considered as targets for future interventions.

Early treatment withdrawal from evidence-based psychotherapy for PTSD: telemedicine and in-person parameters.

OBJECTIVE: To determine differences in reported barriers to treatment completion associated with telemedicine vs. in-person delivery of evidence-based treatment for PTSD in combat veterans. METHOD: The present study was derived from two ongoing randomized controlled trials (RCTs) comparing in-person vs. telemedicine delivery of exposure therapy for PTSD. A one-time telephone assessment of participants who dropped out from the treatment phase of these two studies was conducted, with measures focusing on reported reasons for dropout, and perceived comfort and efficacy of the treatment modality. Dichotomous data were analyzed via chi-square and logistic regression; continuous data via ANOVA. RESULTS: Forty-seven of 69 total dropouts participated. There was no difference in rate of dropout between modalities. A greater proportion of participants receiving in-person exposure therapy reported difficulties with logistical aspects of care (e.g., parking), whereas a greater proportion of participants receiving telemedicine therapy reported difficulty tolerating certain stressful aspects of treatment; however, those receiving telemedicine delivered treatment completed more sessions before dropping out. Participants in both conditions reported that they liked and were confident in their therapist Conclusions: Dropout reasons varied according to type of treatment delivery. Recommendations for future research are given in terms of modification of treatment protocol according to delivery modality.

Marginal costing methods highlight the contributing cost of comorbid conditions in Medicare patients: a quasi-experimental case-control study of ischemic stroke costs.

BACKGROUND: Cost of illness studies are needed to provide estimates for input into cost-effectiveness studies and as information drivers to resource allocation. However, these studies often do not differentiate costs associated with the disease of interest and costs of co-morbidities. The goal of this study was to identify the 1-year cost of ischemic stroke compared to the annual cost of care for a comparable non-stroke group of South Carolina (SC) Medicare beneficiaries resulting in a marginal cost estimate. METHODS: SC data for 2004 and 2005 were used to estimate the mean 12 month cost of stroke for 2,976 Medicare beneficiaries hospitalized for Ischemic Stroke in 2004. Using nearest neighbor propensity score matching, a control group of non-stroke beneficiaries were matched on age, gender, race, risk factors, and Charlson comorbidity index and their costs were calculated. Marginal cost attributable to ischemic stroke was calculated as the difference between these two adjusted cost estimates. RESULTS: The total cost estimated for SC stroke patients for 1 year (2004) was $81.3 million. The cost for the matched comparison group without stroke was $54.4 million. Thus, the 2004 marginal costs to Medicare due to Ischemic stroke in SC are estimated to be $26.9 million. CONCLUSIONS: Accurate estimates of cost of care for conditions, such as stroke, that are common in older patients with a high rate of comorbid conditions require the use of a marginal costing approach. Over estimation of cost of care for stroke may lead to prediction of larger savings than realizable from important stroke treatment and prevention programs, which may damage the credibility of program advocates, and jeopardize long term funding support. Additionally, correct cost estimates are needed as inputs for valid cost-effectiveness studies. Thus, it is important to use marginal costing for stroke, especially with the increasing public focus on evidence-based economic decision making to be expected with healthcare reform.

Interprofessional teamwork skills as predictors of clinical outcomes in a simulated healthcare setting.

PURPOSE: Teaching interprofessional (IP) teamwork skills is a goal of interprofessional education. The purpose of this study was to examine the relationship between IP teamwork skills, attitudes and clinical outcomes in a simulated clinical setting. METHODS: One hundred-twenty health professions students (medicine, pharmacy, physician assistant) worked in interprofessional teams to manage a "patient" in a health care simulation setting. Students completed the Interdisciplinary Education Perception Scale (IEPS) attitudinal survey instrument. Students' responses were averaged by team to create an IEPS attitudes score. Teamwork skills for each team were rated by trained observers using a checklist to calculate a teamwork score (TWS). Clinical outcome scores (COS) were determined by summation of completed clinical tasks performed by the team based on an expert developed checklist. Regression analyses were conducted to determine the relationship of IEPS and TWS with COS. RESULTS: IEPS score was not a significant predictor of COS (p=0.054), but TWS was a significant predictor (p<0.001) of COS. Results suggest that in a simulated clinical setting, students' interprofessional teamwork skills are significant predictors of positive clinical outcomes. CONCLUSION: Interprofessional curricular models that produce effective teamwork skills can improve student performance in clinical environments and likely improve teamwork practice to positively affect patient care outcomes.

Nurse staffing and skill mix patterns: Are there differences in outcomes?

The purpose of this study was to examine the impact on patient outcomes of nurse staffing and registered nurse (RN) skill mix patterns used by medical-surgical units in California hospitals after enactment of nurse-to-patient staffing ratio laws, and determine if there are differences in patient outcomes for conditions that are considered sensitive to nursing care. Results from this study demonstrated an association between total nursing hours per patient day (NHPPD) and two outcomes: urinary tract infections (UTI) and length of stay (LOS). A stronger association was observed between the RN proportions of the total nursing hours of care and the same outcomes. The higher the total NHPPD and RN proportion, the lower the LOS and the lower the odds of hospitalized patients' developing UTI.

Post-traumatic stress disorder screening test performance in civilian primary care.

PURPOSE: we determined the test performance characteristics of four brief post-traumatic stress disorder (PTSD) screening tests in a civilian primary care setting. METHODS: this was a cross-sectional cohort study of adults attending a family medicine residency training clinic in the southeastern USA. Four hundred and eleven participants completed a structured telephone interview that followed an index clinic visit. Screening tests included: PTSD Symptom Checklist-Civilian Version (17 items), SPAN (four items), Breslau's scale (seven items) and Primary Care PTSD screen (PC-PTSD) (four items). A modified Clinician-Administered PTSD Scale was used to determine past month PTSD for comparison. Receiver operating characteristic analysis based on area under the curve (AUC) was used to assess diagnostic efficiency (>0.80 desired). Cut-off scores were selected to yield optimal sensitivity and specificity (>80%). RESULTS: past month PTSD was substantial (women = 35.8% and men = 20.0%; P < 0.01). AUC values were PTSD Symptom Checklist (PCL) (0.897), SPAN (0.806), Breslau's scale (0.886) and PC-PTSD (0.885). Optimal cut-scores yielded the following sensitivities and specificities: PCL (80.0% and 80.7%; cut-off = 43), SPAN (75.9% and 71.6%; cut-off = 3), Breslau's scale (84.5% and 76.4%; cut-off = 4) and PC-PTSD (85.1% and 82.0%; cut-off = 3). Overall and gender-specific screening test performances were explored. CONCLUSIONS: results confirm: (i) PTSD was common, especially among women; (ii) all four PTSD screening tests were diagnostically adequate; (iii) Two of four PTSD screening tests showed adequate sensitivity and specificity (>80%) and (iv) The PC-PTSD screening test (four items) appeared to be the best single screening test. There are few studies to establish the utility of PTSD screening tests within civilian primary care.

Traumatic events and mental health in civilian primary care: implications for training and practice.

BACKGROUND AND OBJECTIVES: Primary care research into post-traumatic stress disorder (PTSD) is less developed than primary care depression research. This study documents lifetime traumatic events and past month depression and PTSD in adult patients of a large family medicine residency practice. METHODS: We used a telephone survey of 411 adult patients from a family medicine residency practice in the Southeastern United States. Standardized measures were used. RESULTS: Seventy-nine percent of study enrollees completed the study. Women were significantly more likely than men to have been diagnosed with PTSD (35.8% versus 20.0%) or depression (36.1% versus 21.1%), with a high degree of diagnosis overlap (76.5%). Most adults (>90%) reported one or more traumatic events. Men reported more war zone/combat events; women reported more sexual victimization. More than 80% of patients thought family physicians should ask about traumatic events; only a minority recalled being asked (26.8% men, 43.6% women). Regression models determined that current depression and several traumatic events were significant correlates of current PTSD. CONCLUSIONS: Key gender differences in frequency of lifetime traumatic events, past month depression and PTSD, and patient attitudes about trauma questions existed. Current PTSD was best predicted by a combination of coexisting depression and traumatic events. Discussion explores training and practice implications.

Introducing students to patient safety through an online interprofessional course.

Interprofessional education (IPE) is increasingly called upon to improve health care systems and patient safety. Our institution is engaged in a campus-wide IPE initiative. As a component of this initiative, a required online interprofessional patient-safety-focused course for a large group (300) of first-year medical, dental, and nursing students was developed and implemented. We describe our efforts with developing the course, including the use of constructivist and adult learning theories and IPE competencies to structure students' learning in a meaningful fashion. The course was conducted online to address obstacles of academic calendars and provide flexibility for faculty participation. Students worked in small groups online with a faculty facilitator. Thematic modules were created with associated objectives, online learning materials, and assignments. Students posted completed assignments online and responded to group members' assignments for purposes of group discussion. Students worked in interprofessional groups on a project requiring them to complete a root cause analysis and develop recommendations based on a fictional sentinel event case. Through project work, students applied concepts learned in the course related to improving patient safety and demonstrated interprofessional collaboration skills. Projects were presented during a final in-class session. Student course evaluation results suggest that learning objectives and content goals were achieved. Faculty course evaluation results indicate that the course was perceived to be a worthwhile learning experience for students. We offer the following recommendations to others interested in developing an in-depth interprofessional learning experience for a large group of learners: 1) consider a hybrid format (inclusion of some face-to-face sessions), 2) address IPE and broader curricular needs, 3) create interactive opportunities for shared learning and working together, 4) provide support to faculty facilitators, and 5) recognize your learners' educational level. The course has expanded to include students from additional programs for the current academic year.

The Presidential Scholars Program at the Medical University of South Carolina: an extracurricular approach to interprofessional education.

The Medical University of South Carolina (MUSC) developed a Presidential Scholars Program (PSP) in order to foster interprofessional collaboration among students from the different health professions on campus. Now in its seventh year, the program provides approximately 40 selected students each year from six different colleges with a two-semester interprofessional educational experience. Students work in small interprofessional teams on a project designed to address a broad-based health care issue; they also participate in other structured educational sessions throughout the year. As one means for assessing student impressions of the interprofessional collaborative experience, a survey was administered prior to and immediately after the experience. Additionally, a sample of non-scholar MUSC students was randomly selected for completion of the survey as a control group. Results indicate that PSP students have a significantly greater understanding of each other and deeper appreciation of the value of interprofessional collaboration at the end of the year. The Presidential Scholars Program at MUSC provides a unique and innovative opportunity for students to work with individuals within other health care disciplines, reduces stereotypes of the various professions and teaches important team skills. Future research would involve alumni follow-up in order to further evaluate the long-term impact of the program.

Barriers to hospice enrollment among lung cancer patients: a survey of family members and physicians.

OBJECTIVE: Most patients diagnosed with lung cancer present with advanced stage disease and have a poor chance of long-term survival. Despite the advantages of hospice care for lung cancer patients, many are enrolled late in the course of their illness or not at all. We sought to identify reasons for this pattern. METHOD: A list of perceived barriers to hospice enrollment was generated and used to create two self-administered surveys, one for physicians and one for caregivers. After focus group testing, the finalized instruments were mailed to physicians in South Carolina and to caregivers of lung cancer patients who died under hospice care with a local hospice between 2000 and 2004. RESULTS: Fifty-three caregivers and 273 physicians responded to the survey. From the caregivers' perspectives, leading reasons for deferred hospice enrollment included patients' unanticipated rapid transition from well to sick and a belief that hospice means giving up hope. From the physicians' perspectives, impediments to earlier hospice enrollment included patients and caregivers overestimating survival from lung cancer and an (incorrect) assumption that patients need to be "DNR/DNI" prior to hospice enrollment. SIGNIFICANCE OF RESULTS: Lung cancer patients may benefit from earlier introduction to the concepts of hospice care and more education regarding prognosis so that an easier transition in goals of care could be achieved. A smaller proportion of lung cancer patients may benefit from earlier hospice enrollment.

The value of the Doctorate in Health Administration and Leadership at the Medical University of South Carolina.

This article describes the innovative Doctorate in Health Administration and Leadership Program at the Medical University of South Carolina. It is the first DHA program in the country and has now been in existence for eleven years. The article provides a description of the program's structure and a discussion of the program challenges and benefits to faculty as they deliver the executive doctorate program. Benefits and suggestions from a qualitative study of program graduates are presented, as well as a discussion of future plans.

Attitudes towards screening for lung cancer among smokers and their non-smoking counterparts.

BACKGROUND: There has been resurgence of interest in lung cancer screening using low-dose computed tomography. The implications of directing a screening programme at smokers has been little explored. METHODS: A nationwide telephone survey was conducted. Demographics, certain clinical characteristics and attitudes about screening for lung cancer were ascertained. Responses of current, former and never smokers were compared. RESULTS: 2001 people from the US were interviewed. Smokers were significantly (p < 0.05) more likely than never smokers to be male, non-white, less educated, and to report poor health status or having had cancer, and less likely to be able to identify a usual source of healthcare. Compared with never smokers, current smokers were less likely to believe that early detection would result in a good chance of survival (p < 0.05). Smokers were less likely to be willing to consider computed tomography screening for lung cancer (71.2% (current smokers) v 87.6% (never smokers) odds ratio (OR) 0.48; 95% confidence interval (CI) 0.32 to 0.71). More never smokers as opposed to current smokers believed that the risk of disease (88% v 56%) and the accuracy of the test (92% v 71%) were important determinants in deciding whether to be screened (p < 0.05). Only half of the current smokers would opt for surgery for a screen-diagnosed cancer. CONCLUSION: The findings suggest that there may be substantial obstacles to the successful implementation of a mass-screening programme for lung cancer that will target cigarette smokers.