Nurse practitioner managed care for persons with HIV infection

Continuing Links Between Substance Use and HIV Highlight the Importance of Nursing Roles

Links between HIV and substance use were identified early in the U.S. HIV epidemic. People who use drugs are at risk of HIV infection through shared injection equipment and risky sexual behaviors. In addition, substance use has negative health consequences for people living with HIV. The prescription opioid misuse epidemic, linked to injection drug use, hepatitis C infection, and HIV, poses a new threat to declining HIV rates. We reviewed evidence-based interventions that decrease HIV risk in people who use drugs (needle/syringe programs, medication-assisted treatment, engagement in HIV care, and preexposure prophylaxis/postexposure prophylaxis). The critical roles of nurses in HIV prevention/care for this population are described, including applying the principles of harm reduction, screening for substance use, and undertaking implementation and research efforts. As the nation's largest health care profession, nurses are positioned to contribute to the quality of HIV-related prevention/care for people who use drugs and to lead practice initiatives.

Clinical outcomes of HIV care delivery models in the US: a systematic review

With over 1 million people living with HIV, the US faces national challenges in HIV care delivery due to an inadequate HIV specialist workforce and the increasing role of non-communicable chronic diseases in driving morbidity and mortality in HIV-infected patients. Alternative HIV care delivery models, which include substantial roles for advanced practitioners and/or coordination between specialty and primary care settings in managing HIV-infected patients, may address these needs. We aimed to systematically review the evidence on patient-level HIV-specific and primary care health outcomes for HIV-infected adults receiving outpatient care across HIV care delivery models. We identified randomized trials and observational studies from bibliographic and other databases through March 2016. Eligible studies met pre-specified eligibility criteria including on care delivery models and patient-level health outcomes. We considered all available evidence, including non-experimental studies, and evaluated studies for risk of bias. We identified 3605 studies, of which 13 met eligibility criteria. Of the 13 eligible studies, the majority evaluated specialty-based care (9 studies). Across all studies and care delivery models, eligible studies primarily reported mortality and antiretroviral use, with specialty-based care associated with mortality reductions at the clinician and practice levels and with increased antiretroviral initiation or use at the clinician level but not the practice level. Limited and heterogeneous outcomes were reported for other patient-level HIV-specific outcomes (e.g., viral suppression) as well as for primary care health outcomes across all care delivery models. No studies addressed chronic care outcomes related to aging. Limited evidence was available across geographic settings and key populations. As re-design of care delivery in the US continues to evolve, better understanding of patient-level HIV-related and primary care health outcomes, especially across different staffing models and among different patient populations and geographic locations, is urgently needed to improve HIV disease management.

Increasing quality of life and reducing HIV burden: the PATH+ intervention

The heightened risk of persons with serious mental illness (SMI) to contract and transmit human immunodeficiency virus (HIV) is a public health problem. Our objective was test the effectiveness of a community-based advanced practice nurse intervention to promote adherence to HIV and psychiatric treatment regimens call Preventing AIDS Through Health for Positives (PATH+). We enrolled 238 HIV-positive subjects with SMI who were in treatment at community HIV provider agencies from 2004 to 2009. Participants in the intervention group were assigned an advanced practice nurse who provided community-based care management at a minimum of one visit/week and coordinated their medical and mental healthcare for 12 months. A parallel process latent growth curve model using three data points for biomarkers (baseline, 12 and 24 months) and five data points for health related quality of life (baseline, 3, 6, 12, and 24 months) showed moderate to excellent fit for modeling changes in CD4, viral load, and mental and physical SF-12 subscales. Results suggest that positive effects for PATH+ persisted at 24 months; 12 months after the intervention ended. This project demonstrates the effectiveness of a nurse-led, community-based, individually tailored adherence intervention. We demonstrated improved outcomes in individuals with HIV/SMI and regarding health-related quality of life and reductions in disease burden.

Effectiveness and Acceptability of Delivery of Antiretroviral Treatment in Health Centres by Health Officers and Nurses in Ethiopia

Objective

The World Health Organization (WHO) recommends shifting tasks from physicians to lower cadres for the delivery of antiretroviral treatment (ART) for countries short of physicians. Our objective was to evaluate the effectiveness and acceptability of ART delivery by health officers and nurses in Ethiopia.

Methods

A retrospective cohort study to evaluate outcomes of ART services in 25 health centresstaffed with health officers and/or nurses and 30 hospitals staffed with physicians in 2009. Median CD4-cell counts, mortality, loss to follow-up and retention were the primary outcomes. Interviews and focus group discussions were conducted with people living with HIV/AIDS, AIDS programme managers and health care providers to identify the types and acceptability of the tasks conducted by the health officers, nurses and community health workers.

Results

Health officers and nurses were providing ART, including ART prescription, for non-severe cases. The management of severe cases was exclusively the task of physicians. Community health workers were involved in adherence counselling and defaulter tracing. The baseline median CD4-cell counts per micro-liter of blood were 117 (interquartiles [IQ] 64,188) and 119 (IQ 67,190) at health centres and hospitals respectively. After 24 months on ART, the median CD4-cell counts per micro-literof blood increased to 321 (IQ 242, 414) and 301 (IQ 217, 411) at health centres and hospitals respectively. Retention in care was higher in health centres (76%, 95% confidence interval [CI] [73%-79%]) than hospitals (67%, 95% CI [66%-68%]). This difference is mainly due to the higher loss to follow-up rate in hospitals (25% versus 13%). Mortality was higher in health centres than hospitals (11% versus 8%), but the difference is not statistically significant. Service delivery by non-physicians was accepted by patients, health care providers and programme managers. However, the absence of a regulatory framework for task shifting, the lack of extra remuneration for the additional roles assumed by nurses and health officers, and the high cost for training and mentorship were identified as weaknesses.

Conclusion

ART delivery in health centres, based on health officers and nurses is feasible, effective and acceptable in Ethiopia. However, issues related to regulation, remuneration and cost need to be addressed for the sustainable implementation of these delivery models.

A randomized trial of a nursing intervention for HIV disease management among persons with serious mental illness

OBJECTIVE

The heightened risk of persons with serious mental illness to contract and transmit HIV is recognized as a public health problem. Persons with HIV and mental illness may be at risk for poor treatment adherence, development of treatment-resistant virus, and worse outcomes. The objective of this study was to test the effectiveness of a community-based advanced practice nurse (APN) intervention (PATH, Preventing AIDS Through Health) to promote adherence to HIV and psychiatric treatment regimens.

METHODS

Community-dwelling HIV-positive participants with co-occurring serious mental illnesses (N=238) were recruited from community HIV provider agencies from 2004 to 2008 to participate in the randomized controlled trial. Participants in the intervention group (N=128) were assigned an APN who provided community-based care management at a minimum of one visit per week and coordinated clients' medical and mental health care for one year. Viral load and CD4 cell count were evaluated at baseline and 12 months.

RESULTS

Longitudinal models for continuous log viral load showed that compared with the control group, the intervention group exhibited a significantly greater reduction in log viral load at 12 months (d=-.361 log 10 copies per milliliter, p<.001). Differences in CD4 counts from baseline to 12 months were not statistically significant.

CONCLUSIONS

This project demonstrated the effectiveness of community-based APNs in delivering a tailored intervention to improve outcomes of individuals with HIV and co-occurring serious mental illnesses. Persons with these co-occurring conditions can be successfully treated; with appropriate supportive services, their viral loads can be reduced.

Provider training and experience for people living with HIV/AIDS

BACKGROUND

The complexity of HIV/AIDS raises challenges for the effective delivery of care. It is important to ensure that the expertise and experience of care providers is of high quality. Training and experience of HIV/AIDS providers may impact not only individual patient outcomes but increasingly on health care costs as well.

OBJECTIVES

The objective of this review is to assess the effects of provider training and experience on people living with HIV/AIDS on the following outcomes: immunological (ie. viral load, CD4 count), medical (ie. mortality, proportion on antiretrovirals), psychosocial (ie. quality of life measures) and economic outcomes (ie health care costs).

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsycInfo, PsycLit, Social Sciences Abstracts, and Sociological Abstracts from January 1, 1980 through May 29, 2009.  Electronic searches were performed for abstracts from major international AIDS conferences. Reference lists from pertinent articles, books and review articles were retrieved and reviewed.

SELECTION CRITERIA

Randomized controlled trials (RCTs), controlled clinical trials, cohort, case control, cross-sectional studies and controlled before and after designs that examined the qualifications/training and patient volume of HIV/AIDS care of providers caring for persons known to be infected with HIV/AIDS were included.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed trial quality and extracted data. Study authors were contacted for further information as required. Assessment of confounding factors was undertaken independently by two reviewers.

MAIN RESULTS

A total of four studies (one randomized controlled trial, three non- randomized studies) involving 8488 people living with HIV/AIDS were included. The main findings of this review demonstrated a trend to improved outcomes when treated by a provider with more training/expertise in HIV/AIDS care in the outpatient (clinic) setting. Due to the heterogeneity of the included studies, we could not perform a meta-analysis. We present a descriptive review of the results.

AUTHORS' CONCLUSIONS

The results demonstrate improved medical outcomes when treated by a provider with more training/expertise in HIV/AIDS care in the outpatient (clinic) setting. Since all of these studies were conducted in North America, this does not address any issues regarding the level of training/expertise required by providers working in countries with more limited resources. Practitioners who do not consider themselves 'experts' in HIV/AIDS care and care for few of these patients need to seriously consider this review which demonstrates a trend towards worse patient outcomes when receiving care by those with low caseloads/training in HIV/AIDS care.

Antiretroviral treatment roll-out in a resource-constrained setting: capitalizing on nursing resources in Botswana

PROBLEM

As programmes to deliver antiretroviral therapy (ART) are implemented in resource-constrained settings, the problem becomes not how these programmes are going to be financed but who will be responsible for delivering and sustaining them.

APPROACH

Physician-led models of HIV treatment and care that have evolved in industrialized countries are not replicable in settings with a high prevalence of HIV infection and limited access to medical staff. Therefore, models of care need to make better use of available human resources.

LOCAL SETTING

Using Botswana as an example, we discuss how nurses are underutilized in long-term clinical management of patients requiring ART.

RELEVANT CHANGES

We argue that for ART-delivery programmes to be sustainable, nurses will need to provide a level of clinical care for patients receiving this therapy, including prescribing ART and managing common adverse effects.

LESSONS LEARNED

Practicalities involved in scaling up nurse-led models of ART delivery include overcoming political and professional barriers, identifying educational requirements, agreeing on the limitations of nursing practice, developing clear referral pathways between medical and nursing personnel, and developing mechanisms to monitor and supervise practice. Operational research is required to demonstrate that such models are safe, effective and sustainable.

Setting and organization of care for persons living with HIV/AIDS

BACKGROUND

Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi-disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood.

OBJECTIVES

Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS.

SEARCH STRATEGY

Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages.

SELECTION CRITERIA

Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis.

MAIN RESULTS

Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed.

AUTHORS' CONCLUSIONS

Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.

Review: use of health care services among persons living with HIV infection: state of the science and future directions

Health care services for persons living with HIV have broadened from short-term, crisis-oriented, and palliative care to include preventive, acute, and long-term services because of advances in HIV treatment and earlier detection. This integrated literature review on utilization of HIV-related health care services provides information on barriers to access, disparities in treatments, and factors contributing to wasteful use of services. Early research focused on describing and quantifying use of in-hospital care. As HIV transformed into a chronic disease, research on utilization expanded into outpatient settings. Predisposing factors such as race, gender, and injection drug use, and enabling factors (i.e., insurance, social support systems, housing) were strong predictors of utilization patterns. Clinical factors, such as immune status, symptoms, and depression, as well as contextual factors (i.e., characteristics of clinicians, urban/rural residence) determined the amounts of services obtained. Additional research is recommended on the utilization of nursing and preventive services and care in rehabilitation settings, home health, and nursing homes. Understanding the patterns and predictors of resource use can facilitate health professionals' efforts in improving the health care delivery system for individuals with HIV infection.

The evolution of sexual health nursing in Australia: a literature review

Background: The purpose of this paper is to describe and encapsulate the elements of the sexual health nurse’s role in Australia. In Australia, sexual health nursing is a fast evolving speciality operating within a climate of diverse role expectations, settings and population groups. Today’s health care climate demands that nurses’ roles and their impact on patient care be held up to scrutiny. Methods: A literature review was conducted that used descriptive analysis to elicit the recurrent themes appearing in the Australian sexual health nursing literature that would describe the role. Results: A model of sexual health nursing was evident with the two primary themes of professional responsibility and patient care. The professional role included a philosophy of sharing nursing experiences, collaboration, employment in multiple settings, and the development of the role into advanced practice, appropriate academic and clinical preparation and a commitment to research. The patient care role included the provision of individual and holistic patient care, ability to access specific at-risk groups, clinical effectiveness, patient education and community development roles. Conclusion: Australian sexual health nurses make a specific and measurable contribution to the health care system. They are likely to continue to advance their role supported by appropriate research that validates their models of practice, continues their philosophy of sharing their experiences and that documents the impact they have on the health outcomes of individuals and populations.

Linking HIV/AIDS clients' self-care with outcomes

The self-care practice of HIV/AIDS patients has become an important topic to help HIV/AIDS patients maintain their maximum level of well-being in chronic illness management. This article presents a self-care outcomes model that is applicable to HIV/AIDS nursing practice and research, and it identifies attributes and outcomes related to HIV/AIDS patients'self-care. The self-care outcomes model was developed based on the Outcomes Model for Health Care Research and literature review. Key variables related to HIV/AIDS self-care were summarized and discussed based on nine dimensions: client inputs, client processes, client outcomes, provider inputs, provider processes, provider outcomes, setting inputs, setting processes, and setting outcomes. This article reveals that self-care in HIV/AIDS is complex and may be influenced by many factors relating to individual, family, and health care system. More research with advanced multivariate statistical models and randomized controlled trial design will help determine the effectiveness of self-care strategies and interventions.

Organizational characteristics and restraint use for hospitalized nursing home residents

OBJECTIVES

To examine the effect of organizational characteristics on physical restraint use for hospitalized nursing home residents.

DESIGN

Secondary analysis of data obtained between 1994 to 1997 in a prospective phase lag design experiment using an advanced practice nurse (APN) intervention aimed at reducing physical restraint for a group of hospitalized nursing home residents.

SETTING

Eleven medical and surgical units in one 600-bed teaching hospital.

PARTICIPANTS

One hundred seventy-four nursing home residents aged 61 to 100, hospitalized for a total of 1,085 days.

MEASUREMENTS

Physical restraint use, APN intervention, age, perceived fall risk, behavioral phenomena, perceived treatment interference, mental state, severity of illness, day of week, patient-registered nurse (RN) ratio, patient-total nursing staff ratio, and skill mix.

RESULTS

Controlling for the APN intervention, age, and patient behavioral characteristics (all of which increased the likelihood of restraint use), weekend days as an organizational characteristic significantly increased the odds of restraint (weekend day and patient-RN ratio on physical restraint use: odds ratio (OR) = 1.92, 95% confidence interval (CI) = 1.38-2.68, P <.001; weekend day and patient-total staff ratio on physical restraint use: OR = 1.91, 95% CI = 1.37-2.66, P <.001; weekend day and skill mix on physical restraint use: OR = 1.91, 95% CI = 1.37-2.67, P <.001).

CONCLUSION

Key findings suggest that organization of hospital care on weekends and patient characteristics that affect communication ability, such as severely impaired mental state, English as a second language, sedation, and sensory-perceptual losses, may be overlooked variables in restraint use.

Outcomes-based trial of an inpatient nurse practitioner service for general medical patients

Although teaching hospitals are increasingly using nurse practitioners (NPs) to provide inpatient care, few studies have compared care delivered by NPs and housestaff or the ability of NPs to admit and manage unselected general medical patients. In a Midwest academic teaching hospital 381 patients were randomized to general medical wards staffed either by NPs and a medical director or medical housestaff. Data were obtained from medical records, interviews and hospital databases. Outcomes were compared on both an intention to treat (i.e. wards to which patients were randomized) and actual treatment (i.e. wards to which patients were admitted) basis. At admission, patients assigned randomly to NP-based care (n = 193) and housestaff care (n= 188) were similar with respect to demographics, comorbidity, severity of illness and functional parameters. Outcomes at discharge and at 6 weeks after discharge were similar (P>0.10) in the two groups, including: length of stay; charges; costs; consultations; complications; transfers to intensive care; 30-day mortality; patient assessments of care; and changes in activities of daily living, SF-36 scores and symptom severity. However, after randomization, 90 of 193 patients (47%) assigned to the NP ward were actually admitted to housestaff wards, largely because of attending physicians and NP requests. None the less, outcomes of patients admitted to NP and housestaff wards were similar (P>0.1). NP-based care can be implemented successfully in teaching hospitals and, compared to housestaff care, may be associated with similar costs and clinical and functional outcomes. However, there may be important obstacles to increasing the number of patients cared for by NPs, including physician concerns about NPs' capabilities and NPs' limited flexibility in managing varying numbers of patients and accepting off-hours admissions.

A conceptual framework for evaluating the nurse practitioner role in acute care settings

The conceptualization and enactment of the ACNP role varies across settings, potentially leading to variability in outcome achievement. A conceptual framework for evaluating the ACNP role is proposed. The framework is an adaptation of the Nursing Role Effectiveness Model which was developed to facilitate the identification and investigation of nursing-sensitive outcomes. The framework represents the complex system of interrelated factors that are present in the ACNP practice situation and that affect role effectiveness. It includes three components: (i) structure--encompassing patient, ACNP and organizational variables; (ii) process--consisting of the ACNP role components (clinician, educator, researcher and administrator) and the ways in which the role is enacted; and (iii) outcomes--including patient- and cost-related outcomes. The framework proposes specific relationships among the structure, process and outcomes components. Empirical support for the framework propositions is provided, based on a review of pertinent literature. Implications for future ACNP impact studies are discussed.

Acceptance of nurse practitioners and physician assistants in meeting the perceived needs of rural communities

Nurse practitioners and physician assistants have provided a partial solution to the shortage of primary care services in medically underserved rural areas. This paper describes the results of a study exploring community acceptance of nurse practitioners and physician assistants in rural medically underserved areas. Community acceptance in the context of this study implies not only satisfaction with care received, but also willingness of the community to support NP/PA practice through its infrastructure and encourage members to initially seek and continue to receive care from an NP or PA. Five focus groups were conducted in each of five rural medically underserved communities. The two most pervasive findings were the lack of previous exposure to NPs and PAs and the general belief that NPs and PAs would be accepted in these communities if certain conditions could be met. The theme of conditional acceptance included both personal and system factors. Personal factors included friendliness, competence, willingness to enter into the life of the community, and the ability to keep information confidential. System factors considered critical for acceptance included service type, integration with the existing health care system, cost, geographic proximity, and availability. The results of this study offer insight into community attitudes and suggest marketing strategies for those who plan to introduce NP or PA services into rural communities.

A template-based approach to support utilization of clinical practice guidelines within an electronic health record

Practice guidelines are an integral part of evidence-based health care delivery. When the authors decided to install the clinical documentation component of an electronic health record in a nurse practitioner faculty practice, however, they found that they lacked the resources to integrate it immediately with other systems and components that would support the processing of clinical rules. They were thus challenged to devise an initial approach for decision support related to clinical practice guidelines that did not include interfacing with an inference engine and set of decision rules. The authors developed a prototypic application within the WAVE electronic health record that demonstrates the feasibility of representing a guideline as structured encoded text organized into an online patient-encounter template. Although this approach may be more broadly applicable, it is described within the context of the management of diabetes mellitus by nurse practitioners. The advantages of the approach relate primarily to the integration of the guideline recommendations with the encounter form, the online interaction of the clinician with the system, and the ease of creation and modification of the guideline-based encounter form. However, there are several limitations of the current approach as a result of the inability to do inference and the lack of integration with patient-specific data to trigger specific rules.

Symptom experience

OBJECTIVE

To provide an overview of symptom experience, symptom occurrence, and symptom distress.

DATA SOURCES

Published articles relating to the symptom experience, symptom occurrence, and symptom distress of patients with cancer.

CONCLUSIONS

Symptom experience must include both the occurrence and distress associated with the symptom. To adequately assess symptom experience, obtaining information from patient about the occurrence and distress of the symptom experience is essential.

IMPLICATIONS FOR NURSING PRACTICE

Nurses and other health care professionals can perform an essential role in the identification and management of symptom experience, thereby improving patient quality of life.

The future of graduate education in nursing: scholarship, the health of communities, and health care reform

The authors critically examine the urgent needs posed by national health care reform and the forces impinging on the nursing profession to prepare nurse practitioners to meet these needs. With references to other struggles in nursing's professional history, the authors caution against exclusive investment in the nurse practitioner role as the discipline's hope for long overdue recognition of nursing's value to society. They argue that with health care reform, nurses have the chance to make graduate nursing education more responsive to the actual health needs of the populace and more relevant for practice in communities. The actions advocated include reflecting carefully on the articulation of nurse practitioner roles with others in the discipline, taking a partisan stand with vulnerable groups, developing substantive expertise in community-based practice and research, applying an understanding of the broader environmental context of health, and committing as a discipline to practice and scholarship that really makes a difference in the health of the public.

The Georgia Rural-Based Nurse Model: primary care for persons with HIV/AIDS

The need for specialized HIV education for nurses working in rural areas will increase as the incidence of HIV infection increases in rural areas. Public health nurses provide a viable alternative to providers in acute care facilities and will continue to be the primary care providers for persons with HIV/AIDS in rural areas. While approaches to HIV/AIDS education should include clinical treatment as the core, clinical knowledge alone will not promote the development of caring communities. The Rural-Based Nurse Model provides a comprehensive curriculum that addresses the many complex issues associated with the care of persons with HIV/AIDS. Additionally, participants are linked with care providers who serve clients across the continuum of HIV disease. Through meaningful educational opportunities and provider networking, this program has the potential for improving the quality of care in rural areas for persons with HIV/AIDS. HIV/AIDS education programs will require individualized community strategies that consider existing resources and barriers. However, the Rural-Based Nurse Model provides a formula for HIV/AIDS education that can be easily adapted to other settings.

Perioperative nurse practitioners

Perioperative nursing roles are evolving in response to health care reform, technological developments, and changing opportunities for advanced practice nursing. One response to these changes is the development of the perioperative nurse practitioner role. The perioperative base for this new advanced practice role is described in this article. The advanced practice role is effective in other specialty settings and can be developed readily in a variety of surgical settings. This role requires a master's degree in nursing to provide the academic and practice preparation for clinical decision making and patient management in the perioperative setting. Future opportunities for perioperative advanced practice nursing are discussed.

Variables, variability, and variations research: implications for medical informatics

Variations research is one important strategy in the quality management movement designed to improve the quality of health care and to control costs. Information systems are being utilized in variations research to provide an array of potential variables, to provide measures of the variability inherent in these variables, and to assist with the study of the linkages of patient and provider characteristics with interventions and outcomes. This article presents a systems model of inputs, processes, and outcomes with explication of factors related to client, provider, and setting as a heuristic strategy for variable specification. The implications of variable specification, the design and measurement of variability, and the key issue of control in variations research are linked with a discussion of the implications for medical informatics.