Nursing informatics: an evolving specialty

Health care organizations will continue to invest heavily in clinical information systems to help improve patient safety, reduce variability of care, and increase the efficiency of their staff. These clinical information systems can assist in reducing medication errors through sophisticated medication management solutions and provide clinical decision support to aid in the decision making of all clinicians. They can also help offset the effects of a growing worker shortage, especially hard-felt in nursing, by reducing redundant tasks, improving communication, and streamlining clinical data collection. As these clinical systems are implemented, there is an increased need for information management of all of this complex data. By bringing both clinical and information systems expertise to bear, the informatics nurse plays a crucial role in ensuring that these goals are met to help the organization maximize its use of clinical information technology.$     

Linking nursing workload and performance indicators in ambulatory care

More and more ambulatory care organizations are using nursing report cards to monitor and evaluate the quality and effectiveness of nursing care in the ambulatory setting. Nurse staffing levels is usually one of the items included in a nursing report card and the one most scrutinized by ambulatory care administrators. One strategy employed by the nursing leadership at the South Texas Veterans Healthcare System to justify nurse staffing levels is linking administrative staffing monitors with nurse-sensitive outcomes via workload and performance indicators. Through this approach, nurse leaders are able to justify nurse staffing level changes, needed technology changes, process improvements, and/or workflow needs to administrators with positive results and support.     

Optimum taxation with errors in administration

The paper compares the welfare levels which can be achieved by two distinct tax regimes: lump-sum taxation, where one attempts to identify individuals and allocate transfers or subsidies on the basis of characteristics, and income taxation, where characteristics are not observed but personal incomes are measured and taxed. Where there are no errors in classifying individuals, lump-sum taxation is superior, but, where mistakes are made in the allocation of lump-sum grants or subsidies, income taxation may be more attractive. The level of errors where the regimes are equally desirable in terms of social welfare is computed in simple models following that of Feldstein (1973). Where there is strong aversion to inequality, then income taxation becomes preferable at quite small errors.In analysing income taxation it is shown that in the Feldstein model with endogenous wages the marginal tax rate (in optimum income taxation) on the more skilled is negative and that on the less skilled is positive in contrast to the standard results [see Seade (1977)] with exogenous wages.     

Mail-order pharmacy use and medication adherence among Medicare Part D beneficiaries with diabetes

Abstract

Objective:

To examine medication adherence among Medicare Part D beneficiaries initiating oral anti-diabetic medications and explore whether there is any association of using mail-order pharmacy (vs. retail pharmacy) with better adherence in this patient population.

Research design and methods:

Using administrative pharmacy claims data, we conducted a retrospective cohort study on Medicare Part D beneficiaries who newly initiated oral anti-diabetic treatment between July 1, 2008 and December 31, 2008. Mail-order pharmacy users were matched to retail pharmacy users via propensity scoring, controlling for patient demographic and clinical characteristics. Adherence with oral anti-diabetic medications during the benefit year of 2009 was assessed using the proportion of days covered (PDC). Comparison of medication adherence between the mail-order pharmacy group and retail pharmacy group was conducted in the propensity matched sample using the paired t-tests and McNemar’s tests.

Results:

A total of 22,546 patients who initiated oral anti-diabetic medications were identified. The average PDC was 0.60 and only 41.6% of the study population attained good adherence (defined as PDC?≥?0.8) with oral anti-diabetic medications during calendar year 2009. The matched sample included 1361 patients in each of the mail-order and retail pharmacy cohorts. Compared with the retail pharmacy group, mail-order pharmacy users demonstrated a significantly higher PDC (0.68 vs. 0.61; P?<?0.001) throughout the benefit year. More patients in the mail-order pharmacy group (49.7%) attained good adherence with their oral anti-diabetic medications compared to 42.8% in the retail pharmacy group (P?<?0.001).

Limitations:

The study was subject to limitations inherent in retrospective claims database analysis.

Conclusions:

Adherence with oral anti-diabetic medications among Medicare Part D beneficiaries is suboptimal. Patients using mail-order pharmacy had better adherence to oral anti-diabetic medications than those who used retail pharmacies. However, the causal relationship between mail-order pharmacy use and adherence should be further examined in a randomized study setting.     

Validating HRSA's nurse supply and demand models: a state-level perspective

In addition to federal initiatives, solutions to the nursing shortage must also be devised at the state level. Understanding the timing and severity of the nursing shortage in a particular state is paramount to devising appropriate solutions In 2005, the Health Resources and Services Administration released new versions of the Nurse Supply Model and Nurse Demand Model designed to project the supply of RNs and demand for RNs, LPNs, and nurse aides in the United States through the year 2020. The process used by two state-level analysts to project nurse supply and demand in North Carolina using the HRSA models is described. The authors conclude that the models work well for state-level forecasting but that users should carefully assess the default data provided with the model against independent data sources specific to their states.     

Official fiscal forecasts in EU member states under the European Semester and Fiscal Compact – An empirical assessment

The efficacy of official forecasts in the EU has been under the spotlight since the introduction of the euro, with biases widely reported prior to the 2008–12 financial and sovereign bond market crisis. Changes to the EU fiscal rules and procedures, in the form of the European Semester and Fiscal Compact, in the early 2010s were adopted to improve forecasting, including through providing a role for independent fiscal institutions. Using data for 22 countries between 2013 and 2019, this paper shows that, despite these changes, biases, of a pessimistic form, remain in forecasts of budget balance and output variables in Stability and Convergence Programmes and the European Commission's Spring Forecasts. Econometric analysis indicates forecast errors in both the headline budget balance and the structural budget balance being explained by forecast errors in output variables and by EU fiscal rule requirements. Member states under an excessive deficit procedure provide optimistic headline budget balance forecasts compared to non-EDP countries, while those that have not met their medium-term objective report smaller forecast errors for the structural budget balance. Independent fiscal institutions are linked to a smaller bias to forecasts of the structural budget balance but have no effect on the forecast errors of the headline budget balance.     

Funding an accelerated baccalaureate nursing track for non-nursing college graduates: an academic/practice collaboration

To expand nursing programs to better meet workforce demands, nursing education must offer nontraditional students more educational opportunities that are flexible, streamlined, and low cost. Accelerated programs, particularly programs tailored to attract individuals with degrees in other fields and looking for career changes, are great examples. The cost factors related to a successful accelerated degree program designed for non-nursing college graduates are described. Based on the experiences with a previously implemented accelerated BSN program offered from 1987-1994 at one university, a revised accelerated option model was developed that included ongoing involvement with four community hospitals, shared budget responsibilities, student stipends, and a 3-year work commitment by graduates at a sponsoring hospital. The investment of approximately $1.6 million over 7 years resulted in the education and graduation of 75 new registered nursing professionals to meet the health care needs of the citizens of the community.     

Nurse-physician communication: an organizational accountability

Dysfunctional nurse-physician communication has been linked to medication errors, patient injuries, and patient deaths. The organization is accountable for providing a context that supports effective nurse-physician communication. Organizational strategies to create such a context are synthesized from the structural, human resource, political, and cultural frameworks of organizational behavior.     

The economic value of reducing medication dosing frequency with drug delivery technologies: an evidence assessment

Objective: To critically evaluate published cost-effectiveness studies of novel drug products requiring less-frequent medication dosing compared to conventional formulations of the same drug substance.

Methods: A search was conducted in the Medline and Embase databases for cost-effectiveness studies published before May 2009 that compared two or more drug delivery technologies formulated with the same active drug substance. The Quality of Health Economic Studies (QHES) grading criteria for cost-effectiveness studies was applied to the selected publications.

Results: The literature search identified approximately 907 articles of which six cost-effectiveness studies met the inclusion criteria. The studies spanned four chronic conditions, were conducted from various international perspectives and used decision-analytic models to project economic outcomes. The base-case results of all six studies indicated that the drug product with sustained therapeutic efficacy was either more effective and less costly (‘dominant’) or more cost effective than the conventional formulation of the same drug substance. Quality scores ranging from 70 to 84 (scale 0 to 100) were assigned to the studies, with a mean of 78.

Limitations: This review likely did not capture all relevant drug delivery technologies and drug products. Only one reviewer critically evaluated the cost-effectiveness studies and independently assigned quality scores using the QHES grading criteria, which may be limited in its ability to identify poorly analyzed studies.

Conclusion: Evaluation of the published literature suggests that drug products with less-frequent medication dosing can be cost effective when compared to conventional formulations, but assessments are challenging because of complex relationships among therapeutic drug levels, dosing frequency, medication adherence, and health outcomes. Additional product-specific, comparative, pragmatic studies in this area are needed.     

Economic impact of compliance to treatment with antidiabetes medication in type 2 diabetes mellitus: a review paper

Abstract

Objectives: Suboptimal compliance and failure to persist with antidiabetes therapies are of potential economic significance. The present research aims to describe the impact of poor compliance and persistence with antidiabetes medications on the cost of healthcare or its components for patients with type 2 diabetes mellitus (T2DM).

Methods: Literature search was conducted in PubMed for relevant articles published in the period between 1 January 2000 and 30 April 2009. Thus, it is possible that relevant articles not listed in PubMed, but available in other databases are not included in the current review. Studies describing economic consequence of compliance and/or persistence with pharmaceutical antidiabetes treatment were identified. The variability in the studies reviewed was high, making it extremely difficult to make a comparison between them.

Results: Of 449 articles corresponding to the primary search algorithm, 12 studies (all conducted in USA) fulfilled the inclusion criteria regarding the economic impact of compliance and/or persistence with treatment on the overall cost of T2DM care or its components. Compliance was assessed via medication possession ratio (MPR) in ten studies, where it ranged from 0.52 to 0.93 depending on regimen. Persistence was assessed in one study. Mean total annual costs per T2DM patient varied between the studies, ranging from $4570 to $17338. In seven studies, medication compliance was inversely associated with total healthcare costs, while in four other studies inverse associations between medication compliance and hospitalisation costs were reported. In one study increased adherence did not change overall healthcare costs.

Conclusions: Improved compliance may lead to reductions of the total healthcare costs in T2DM, Further research is needed in countries other than the US to assess impact of compliance and persistence to pharmacotherapy on T2DM costs in country-specific settings.     

Comparing Travel Cost Models And The Precision Of Their Consumer Surplus Estimates: Albert Park And Maroondah Reservoir

This study examines different types of Travel Cost Models to estimate and compare the recreational values of two parks in Victoria, Australia: Maroondah Reservoir and Albert Park. Zonal Travel Cost models and a number of different functional forms are used in this study. Standard errors are used to estimate upper and lower bounds for the recreational value estimates, enabling comparison between the precision of the different types of Travel Cost Models and functional forms estimated. The double log functional form city zone Travel Cost Model was chosen as the best estimate for Albert Park's recrea-tional value at $22.9 million per year. Maroondah Reservoir's best estimate is provided by the double log functional form regional zone Travel Cost Model at a value of $2.5 million per year, consider-ably less than that of Albert Park. Albert Park is found to have a comparatively larger 'proximity power' (attracting many more visitors) while Maroondah Reservoir exhibited a larger degree of 'pulling power' (a higher proportion of its visitors travel further distances).     

When do the USDA forecasters make mistakes?

This study analysed forecasts for all US corn, soya bean and wheat categories published within the World Agricultural Supply and Demand Estimates (WASDE ) reports over the 1987/88 through 2009/10 marketing years in an attempt to identify patterns and better understand when the USDA forecasters make mistakes. Two general sources of errors were investigated: behavioural and macroeconomic factors. The first objective was to examine how these factors affect the size of the forecast error and the second concentrated on the direction of the error due to these effects. Our findings suggest that the largest increase in the size of USDA forecast errors was associated with structural changes in commodity markets that took place in the mid-2000s. Corn, soya bean and wheat forecast errors also grew during the periods of economic growth and with changes in exchange rates, while inflation and changes in oil price had a much smaller impact. With respect to behavioural sources, we identified patterns consistent with leniency and pessimism across different categories. Predictability of forecast errors based on the information available at the time the forecasts are made provides evidence of inefficiency and suggests that these forecasts may be improved using the findings of this study.     

Impact of risperidone long-acting injectable on hospitalisation and medication use in Canadian patients with schizophrenia

Summary

A retrospective chart review was used to assess hospitalisation and medication switching in patients with schizophrenia initiated on either intramuscular risperidone long-acting injectable (RLAI) (n=69) or oral atypical antipsychotics (n=93) in Canada.

In the RLAI-treated patients, compared with an identical period prior to RLAI use (40.8 months), there were significant decreases in hospitalisation (50.7 vs. 4.3%; p<0.0001) and duration of hospitalisation (23.5 vs. 0.3 days per patient; p<0.0001) when patients were switched to RLAI (mean treatment period 41.5 months). Compared with patients receiving oral atypicals for 57.2 months, RLAI patients had a reduced risk of hospitalisation (95% confidence interval 1.8–16.5% vs. 54.7–76.4%) and medication switching (95% confidence interval 34.6–58.4% vs. 55.7–76.4%).

By virtue of its periodic intramuscular administration, RLAI offers the efficacy and tolerability of an atypical medication without the compliance issues associated with oral drugs, and leads to significant decreases in hospitalisation.     

Value-added care: a paradigm shift in patient care delivery

Spiraling costs in health care have placed hospitals in a constant state of transition. As a result, nursing practice is now influenced by numerous factors and has remained in a continuous state of flux. Multiple changes within the last 2 decades in nurse/patient ratio and blend of front-line nurses are examples of this transition. To reframe the nursing practice into an economic equation that captures the cost, quality, and service, a paradigm shift in thinking is needed in order to assess work redesign. Nursing productivity must be evaluated in terms of value-added care, a vision that goes beyond direct care activities and includes team collaboration, physician rounding, increased RN-to-aide communication, and patient centeredness; all of which are crucial to the nurse's role and the patient's well-being. The science of appropriating staffing depends on assessment and implementation of systematic changes best illustrated through a "systems theory" framework. A throughput transformation is required to create process changes with input elements (number of front-line nurses) in order to increase time spent in value-added care and to decrease waste activities with an improvement in efficiency, quality, and service. The purpose of this pilot study was two-fold: (a) to gain an understanding of how much time RNs spent in value-added care, and (b) whether increasing the combined level of RNs and unlicensed assistive personnel increased the amount of time spent in value-added care compared to time spent in necessary tasks and waste.     

The Iowa model: a proposed model for nursing administration

The purpose of the Iowa Model is to serve both as a heuristic device and as a framework for articulating knowledge for nursing administration research, practice, and education. The model delineates two domains of knowledge (systems and outcomes), each with three levels (patient aggregates, the organization, and the health care system). Concepts useful for knowledge development are identified for each level. Practice, research, and curricular applications of the model are made.