Ambulatory care registered nurse performance measurement

On March 1-2, 2010, a state-of-the-science invitational conference titled "Ambulatory Care Registered Nurse Performance Measurement" was held to focus on measuring quality at the RN provider level in ambulatory care. The conference was devoted to ambulatory care RN performance measurement and quality of health care. The specific emphasis was on formulating a research agenda and developing a strategy to study the testable components of the RN role related to care coordination and care transitions, improving patient outcomes, decreasing health care costs, and promoting sustainable system change. The objectives were achieved through presentations and discussion among expert inter-professional participants from nursing, public health, managed care, research, practice, and policy. Conference speakers identified priority areas for a unified practice, policy, and research agenda. Crucial elements of the strategic dialogue focused on issues and implications for nursing and inter-professional practice, quality, and pay-for-performance.     

American Academy of Ambulatory Care Nursing position statement: the role of the registered nurse in ambulatory care

Ambulatory care nurses are leaders in their practice settings and across the continuum of care. They are uniquely qualified to influence organizational standards related to patient safety and care delivery in the ambulatory care setting. The current ambulatory care setting is diverse and multifaceted, requiring nurses highly skilled in patient assessment and with the ability to implement a broad range of nursing interventions in a variety of settings. The future of the American health care system depends upon our ability to utilize RNs to the fullest extent of their expertise, licensure, and certification.     

State of the registered nurse workfore in the United States

In this final installment of this exclusive six-part series on the state of the RN workforce in the United States, the authors summarize the major findings of each piece and offer specific and actionable recommendations for nurse leaders, educators, and policymakers.     

An innovative role for nurse practitioners in managing chronic disease

Under the current care delivery model, persons with chronic illnesses, such as diabetes, are not receiving all recommended interventions and failing to meet targeted outcomes. The Chronic Care Model provides a framework for new approaches and roles for many members of the multidisciplinary team. Using the Chronic Care Model as a guide, a group of hospital-based clinics in an academic system incorporated nurse practitioners into the care model for patients with diabetes. Through use of planned visits, a patient registry, drug intensification protocols, and collaboration with other members of the team, the pilot sample improved processes of care and clinical outcomes. Use of nurse practitioners in this model of care for chronically ill patient populations has economic implications, as the payers begin to pay for performance.     

Recent trends in the registered nurse labor market in the U.S.: short-run swings on top of long-term trends

Drawing from labor economics, background information is provided for a deeper understanding of recent changes in the nurse labor market. The difference between the short and long-run supply of RNs are distinguished, and the economic forces that determine RNs' decision to be active in the labor market are explained. The ways the nurse labor market may change in the next few years are discussed.     

An online portal to support the role of the nurse manager

To encourage retention in nursing administration while building leadership capacity, efforts must be made to support the manager's practice and professional development. Functions and duties of the nurse manager need to be simplified and supplemental development materials need to be readily available. Innovations that organize necessary document templates and ease access to materials that enhance their leadership skills have real value. One institution's innovation to build nurse manager capacity was an online portal for nurse managers. The site offers information that enriches the role of nurse manager and represents one supplemental pathway to continuous leadership development.     

Nurses who do not nurse: factors that predict non-nursing work in the U.S. registered nursing labor market

Registered nurses (RNs) who work outside of nursing have seldom been examined. This aim of this study was to compare the 122,178 (4%) of RNs who are employed outside of nursing to those who work in nursing jobs in terms of sociodemographic, market, and political variables to determine if these groups are substantively different from one another. Using a logit regression model, wages were a significant predictor of working outside of nursing for unmarried nurses but not for married nurses. Married and unmarried male nurses were more likely to work outside of nursing. Baccalaureate education, children under age 6, higher family income, and years since graduation increased the odds of working outside of nursing for married nurses. Ultimately, identifying characteristics on which these groups differ may inform future policy directions that could target nurses who may leave nursing at a time when retention efforts might be effective to alter their trajectory away from the profession.     

Primary care workload in the management of chronic pain. A retrospective cohort study using a GP database to identify resource implications for UK primary care

Summary

The management of chronically painful conditions is relatively labour intensive, as there is no single treatment regime that can be reliably forecast to control symptoms across a broad range of patients and underlying conditions. The achievement of effective and well tolerated analgesia therefore carries considerable workload implications. This study set out to quantify the impact of managing therapy with nonsteroidal antiinflammatories and nonopiate analgesics within UK general practice.

Two separate cohorts of patients were defined from the MediPlus GP database, in order to characterise the workload impact of both established and new patients being treated with antiinflammatory/analgesic agents. Where treatment changes occurred, the underlying reasons for these changes were identified, if possible. The relative importance of these reasons was appraised and expressed both in terms of the number of appointments used and the direct costs attributable.

Similar results were obtained for both cohorts. Changes of therapy reflected side effects, intolerance and allergy in 23-25% of cases, lack of efficacy in 20-22%, and resolution of the underlying condition in 7-10% of cases. No reason was attributable in 44-47% of changes. Extrapolating these results to a national level suggests that management of therapy in these patients accounts for 4.6 million appointments per year, equivalent to 793 whole time GPs, at a total cost of around £69 million. The use of nonsteroidal antiinflammatories and nonopiate analgesics is associated with a significant impact on primary care workload, with poor efficacy being the trigger for almost as many consultations as poor tolerability. Addressing this issue may offer an important contribution towards reducing maximum waiting time for appointments in general practice towards the target of 48 hours.     

The role of e-Health in the changng health care environment

In 2005 health care organizations spent 2.3% of total operating expenses on information technology and are slowly developing the infrastructure necessary to expand e-Health capabilities. E-Health is being recognized as a method to improve the overall health status of the population. It is important to build partnerships among health care providers, local community organizations, and national health care associations to ensure the continued development of e-Health initiatives. This study has managerial implications associated with the strategic application of e-Health systems and policy implications on future resource allocation.     

Quantifying the defensive medicine contribution to primary care costs

Background:

Defensive medicine represents one cause of economic losses in healthcare. Studies that measured its cost have produced conflicting results.

Objective:

To directly measure the proportion of primary care costs attributable to defensive medicine.

Research design and methods:

Six-week prospective study of primary care physicians from four outpatient practices. On 3 distinct days, participants were asked to rate each order placed the day before on the extent to which it represented defensive medicine, using a 5-point scale from 0 (not at all defensive) to 4 (entirely defensive).

Main outcome measures:

This study calculated the order defensiveness score for each order (the defensiveness/4) and the physician defensive score (the mean of all orders defensiveness scores). Each order was assigned a weighted cost by multiplying the total cost of that order (based on Medicare reimbursement rates) by the order defensiveness score. The proportion of total cost attributable to defensive medicine was calculated by dividing the weighted cost of defensive orders by the total cost of all orders.

Results:

Of 50 eligible physicians, 23 agreed to participate; 21 returned the surveys and rated 1234 individual orders on 347 patients. Physicians wrote an average of 3.6?±?1.0 orders/visit with an associated total cost of $72.60?±?18.5 per order. Across physicians, the median physician defensive score was 0.018 (IQR?=?[0.008, 0.049]) and the proportion of costs attributable to defensive medicine was 3.1% (IQR?=?[0.5%, 7.2%]). Physicians with defensive scores above vs below the median had a similar number of orders and total costs per visit. Physicians were more likely to place defensive orders if trained in community hospitals vs academic centers (OR?=?4.29; 95% CI?=?1.55–11.86; p?=?0.01).

Conclusions:

This study describes a new method to directly quantify the cost of defensive medicine. Defensive medicine appears to have minimal impact on primary care costs.     

Trends and volatilities in foreign patents registered in the USA

This study analyses the patent trends and volatilities for the top 12 foreign patenting countries in the US market from 1975 to 1997. Japan is ranked first in terms of foreign patents registered in the USA, followed by Germany. Patent registrations from each of these countries have increased steadily over time, but at different rates. Using monthly time series data for 1975–1997, the time-varying volatility of Australian, Japanese and German patents registered in the USA is examined in detail. The asymmetric AR(1)-GJR(1,1) model is found to be suitable for Australia and Japan, while the best fitting model for Germany is the symmetric AR(1)-GARCH(1,1) model.     

Health IT adoption,productivity and quality in primary care

Within the last decade, there has been a growing push towards the use of electronic medical records and health information technology (IT) within primary care physician practices. Despite financial subsidies, smaller practices remain reluctant to adopt these information systems. Using a nationally representative survey of physicians, this study explores the relationship between physician, practice and area attributes and the adoption of health IT systems. Controlling for these attributes, the analysis subsequently studies the relationship between health IT, physician productivity and perceived quality of care. It finds that smaller practices and physicians with lower incomes are less likely to adopt health IT systems and that adoption varies with the type of medical conditions the practice typically treats. With regards to productivity, health IT adopters are more likely to see fewer patients and spend a larger amount of time on each visit with marginal increases in time on administrative tasks and no differences in perceived ability to deliver quality health care.     

Measuring performance in primary care: econometric analysis and DEA

We use data from the Health Service Indicators database to compare different methods of measuring the performance of English Family Health Services Authorities (FHSAs) in providing primary care. A variety of regression and data envelopment analysis methods are compared as summary efficiency measures of individual FHSA performance. The correlation of the rankings of FHSAs across DEA and regression methods, across two years of data and across three different specifications of the technology of primary care are examined. Efficiency scores are highly correlated within variants of the two methods, and across years for a given method. Inter method correlations are smaller and correlations across different specifications of the primary care production process are negligible and sometime negative.