Entrustable Professional Activities in Clinical Education: A Practical Approach for Advanced Nursing Education

BACKGROUND

Competency attainment is foremost in the ethos of this project that provides a practical guide to implementing entrustable professional activities (EPAs) as one approach to competency acquisition in the clinical education component of a health care program. EPAs are units of work that provide evidence of required competencies for the clinical education component of a program of study for educators, preceptors, and students.

PROBLEM

The American Association of Colleges of Nursing has raised the importance of competency-based education and need for a practical approach to assess clinical competency challenges (eg, EPAs) in nursing education.

APPROACH

The implementation of EPAs in the clinical component of advanced nursing education is detailed as an example in this article. Prioritizing a systematic approach, the Knowledge to Action framework, was chosen to guide the process.

CONCLUSION

Nursing must act now to put in place a robust competency acquisition and validation system.

Practice scholarship satisfaction and impact as perceived by DNP-prepared nurses

BACKGROUND

Today's health systems are complex and are challenged to strive for high-quality care that leads to optimal health outcomes. Doctor of Nursing Practice (DNP)-prepared nurses have the necessary competencies to influence health systems and delivery, that lead to safe and effective practice, by implementing practice scholarship, the translation of science to transform health care delivery, and clinical inquiry to improve practice.

PURPOSE

The purpose of this study was to determine DNP-prepared nurses' satisfaction with their frequency of engagement in practice scholarship, and the relationship between the satisfaction and perceived impact of practice scholarship.

METHODS

In this cross-sectional study, DNP-prepared nurses (n = 309) were recruited from a U.S. national membership organization and were asked to complete an online survey.

RESULTS

Usable data findings (n = 269) revealed that 81% of participants reported feeling very, or moderately, satisfied with time spent engaging in practice scholarship or clinical inquiry in the areas of quality improvement, translation of research, and evidence-based practice; however, 19% expressed minimal satisfaction or dissatisfaction. There was a significant, moderate positive correlation between impact and satisfaction with time spent engaging in practice scholarship.

CONCLUSIONS

Unclear roles and the lack of objective data measurement of practice scholarship are hindering the ability of DNP-prepared nurses to work to the full extent of their education and scope of practice.

IMPLICATIONS

Further studies to develop processes and tools to measure the value and impact of DNP-prepared nurses on quality and safety, health care policies, systems, and population health are recommended.

Faculty perceptions, awareness and use of open educational resources for teaching and learning in higher education: a cross-comparative analysis

This paper explores faculty's perspectives and use of open educational resources (OER) and their repositories across different countries by conducting a multiple case study to find similarities and differences between academics' awareness, perceptions and use of OER, as well as examining related aspects of institutional policy and quality that may influence individual views. Data were collected through nine expert reports on each country studied (Australia, Canada, China, Germany, Japan, South Africa, South Korea, Spain and Turkey) and were analyzed through qualitative content analysis using thematic coding. Findings show the impact on individual OER adoption with regard to the individual control of diverse factors by faculty members; of institutional policies and quality measures on the externally determined factors (by the institution); and of institutional professional development and provision of incentives in more internally determined factors (by the faculty members themselves). These findings carry implications for higher education institutions around the world in their attempt to boost OER adoption by faculty members.

Impact of Practice Scholarship as Perceived by Nurses Holding a DNP Degree

OBJECTIVE

The aim of this study was to explore the perceived impact of practice scholarship among DNP-prepared nurses and the relationship of impact to primary work role and years since graduation.

BACKGROUND

Healthcare organizations continuously seek ways to improve health outcomes and reduce cost. Doctor of Nursing Practice-prepared nurses are educated with essential competencies to lead healthcare reform initiatives based on their practice scholarship contribution.

METHODS

A cross-sectional design was used to administer a self-report online survey to a convenience sample of 306 DNP graduates currently in practice.

RESULTS

The highest impact of practice scholarship was perceived on patients, populations, quality of care, and the profession. The impact on policy, cost, and cost savings was significantly lower. No significant difference was found on practice scholarship impact based on role or between years of experience since graduation.

CONCLUSION

Doctor of Nursing Practice competencies support practice scholarship outcomes. Organizational resources are needed to support the impact of practice scholarship.

Practice scholarship engagement as reported by nurses holding a doctor of nursing practice degree

BACKGROUND

Nearly 15 years after the introduction of the doctor of nursing practice (DNP) degree, stakeholders anticipate practice scholarship outcomes from graduates.

PURPOSE

To examine the frequency of engagement in practice scholarship, the relationship between the knowledge gained in DNP programs and the frequency of engagement in practice scholarship and the relationship between engagement in practice scholarship, work role, and years since graduation with a DNP degree, as reported by practicing nurses.

METHODOLOGY

This cross-sectional study recruited 306 practicing DNP graduates via a national organization and employed an electronic survey. Descriptive and inferential statistics, correlational analysis, and a one-way analysis of variance were conducted on demographics and outcome variables for 269 completed surveys.

RESULTS

The practice scholarship activity reported most frequently was evaluation of current clinical evidence and least frequently was dissemination of policy papers. Reported knowledge gained from DNP programs and frequency of engagement in practice scholarship indicate a weak positive correlation. There was a significant difference in the direct care work role and practice scholarship engagement compared with other roles, and between those practicing greater than 10 years and those with less experience.

CONCLUSIONS

Results highlight the underutilization of knowledge gained in DNP programs and engagement in practice scholarship. The study emphasizes the complexity of realizing practice scholarship outcomes of DNP-prepared nurses to influence patients, populations, systems, and policy as well as the advancement of the nursing profession.

IMPLICATIONS

This is a call to action for DNP graduates, academia, practice, and the nursing profession to support and value practice scholarship.

Drivers for seeking the doctor of nursing practice degree and competencies acquired as reported by nurses in practice

BACKGROUND

The American Association of Colleges of Nursing introduced the Doctor of Nursing Practice (DNP) degree in 2004. To date, few publications examine the competencies and impact of nurses with practice doctorates.

PURPOSE

The purpose of this study was to examine reasons for seeking a DNP degree, assess knowledge and competencies acquired from DNP programs, and to inform stakeholders about the skills acquired by nurses with practice doctorates.

METHODS

A cross-sectional design was used to administer a self-report survey to a convenience sample of DNP-prepared nurses in practice, recruited from a national membership organization. The electronic survey was designed using constructs developed from the literature, national organization position statements, and standards of doctoral nursing education.

RESULTS

A total of 306 participants responded to the survey, 270 were used after data review. The majority of respondents did not seek a DNP degree because it was required for a job, to gain additional supervised practice, or to receive additional training with a specialty population. The majority strongly agreed that they gained competency in translating and synthesizing research evidence into practice, designing and implementing quality improvement, and identifying, measuring, and evaluating outcomes.

CONCLUSIONS

Primary reasons for seeking a DNP degree were seeking knowledge, skills, competencies, confidence, and job opportunities.

IMPLICATIONS FOR PRACTICE

Doctor of Nursing Practice-prepared nurses hold unique, advanced knowledge, competencies and skills to affect health care across multiple settings. Study results suggest that highly skilled DNP-prepared nurses are equipped to lead quality improvement, engage in practice scholarship, and improve clinical outcomes.

[Complications and emergencies in the recovery room]

The recovery room as a central monitoring unit plays a crucial role in the perioperative care of patients. Here, the patient is monitored until the subsequent transfer to a further care ward; however, due to the previous anesthesia and surgery the recovery room also provides a high risk for (the development of) complications. The present article provides an overview of the most frequent complications to be expected in the recovery room (in adults), the diagnostics and the acute treatment.

The practice doctorate approach to assessing advanced nursing practice in Ireland

AIM

To describe the practice doctorate scholarly approach to assess advanced nursing practice in Ireland to address healthcare and nursing policy initiatives.

BACKGROUND

A global team from Ireland and the United States collaborated with stakeholders, using a practice doctorate approach to identify geographic healthcare needs, the current state of the education and the evolving roles of advanced nursing practice. In Ireland, current policy initiatives call for expanding the capacity for advanced nurse practitioners to meet healthcare needs in community settings.

SOURCES OF EVIDENCE

Further assessment data were required from stakeholders to inform graduate nursing education to prepare advanced practice nurses to fulfil increasingly complex healthcare needs. The practice doctorate approach included review of literature, current policy and assessment with interviews, dialogue and the development of working relationships with policymakers, academics and practitioners.

DISCUSSION

The current state and future vision of graduate nursing education are evolving. A force field analysis identified promoting and restraining factors to the desired state of development of the primary care advanced practice role. Relationship building with stakeholders and sharing of expertise was key to engage academia and policymakers to address identified restraining forces. Short-term outcomes included development of collaborative relationships between practice, academia and policymakers, curricular development for the primary care nurse practitioner and intentionally shared dissemination to promote community graduate nursing education.

IMPLICATIONS FOR NURSING PRACTICE

This innovative practice scholarship approach was used to assess and promote advanced nursing practice impact and promote the nursing profession globally.

IMPLICATIONS FOR POLICY

Successful collaboration between two global partners was achieved to promote policy objectives for both nursing and health care, with the ultimate goal of improving health outcomes and population health.

Nursing practice in mental health at family health strategy

The nurse practice model at the family health strategy is characterized by direct involvement in the patient's health-disease recovery process, deconstruction of social stigma involving mental health disorders, and the restoration of patient autonomy their social ties. This descriptive study follows a qualitative approach to document and analyse practices performed by mental health nurses at the family health strategy (FHS) in Rio das Ostras, Brazil. The study identifies practices implemented by Mental Health Nurses at FHS and the nurses’ own reflection and analysis on these mental health practices. Data was collected through semi-structured interviews. All interviewed nurses had worked in the primary mental health care for at least one year at the FHS units in Rio das Ostras. Data was analysed, grouped, and coded according to two categories: 1) The nurses’ professional practices in mental health at the FHS, and 2) The nurses’ view on mental health practices at the FHS. Results show that the main activities in mental health at FHS involve working with the matricial team, continuing education, reception, home visits, referrals, therapeutic workshops and community therapy. Nurse perspectives on professional practices involve prevention, establishment of bonds with patient, and nurses’ training to deliver care to patients who are suffering. The bond with and care for the patient, family and community, is one of the FHS differentiators. In that vein, the study looks at the link between health care delivery, territory and population attended. The health care based on territoriality, allows increased patient and family confidence.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Why Hire a Doctor of Nursing Practice-Prepared Nurse? The Value Added Impact of the Practice Doctorate

Nursing leaders are essential in promoting the doctor of nursing practice (DNP)-prepared nurse in various innovative roles (Nichols, O'Connor, & Dunn, 2014). However, according to the recently released RAND study, The DNP by 2015: A Study of the Institutional, Political, and Professional Issues That Facilitate or Impede Establishing a Post-Baccalaureate Doctor of Nursing Practice Program (Auerbach et al., 2014) employers and health care organizations need outreach and data to understand the added competencies and capabilities of DNP-educated nurses. Practicing DNPs are in an excellent position to demonstrate and educate our executive colleagues. The purpose of this article is (a) to foster nursing leadership's understanding of the uniquely prepared nursing practice doctorate, (b) to illustrate how the DNP-prepared nurse is being integrated/used to their potential within health care systems to maximize clinical and population health outcomes, and (c) to issue a call to action for nursing leadership to engage the DNP-prepared nurse to accomplish organizational goals.

16alpha-Bromoepiandrosterone (HE2000) limits non-productive inflammation and stimulates immunity in lungs

16alpha-Bromoepiandrosterone (HE2000) is a synthetic steroid that limits non-productive inflammation, enhances protective immunity and improves survival in clinical studies of patients with human immunodeficiency virus (HIV), malaria and tuberculosis infections. We now show that HE2000 decreased nitric oxide production by lipopolysaccharide (LPS)-stimulated RAW264.7 cells. Treatment with HE2000 also reduced non-productive inflammation associated with carrageenan-induced pleurisy and LPS-induced lung injury in mice. In the hapten-carrier reporter antigen popliteal lymph node assay, HE2000 increased absolute numbers of lymphocytes, antigen-presenting cells, hapten-specific immunoglobulin (Ig)M antibody-forming cells and shifted the interferon (IFN)-gamma/interleukin (IL)-4 balance towards IFN-gamma production. In the cystic fibrosis transmembrane conductance regulator (CFTR(-/-)) mouse model of acute Pseudomonas aeruginosa infection, treatment with HE2000 consistently reduced bacterial burden in lungs. All HE2000 effects were dose-dependent. In H1N1 infection in mice, HE2000 was safe but not effective as a monotherapy, as treatment did not effect survival. HE2000 reduced mortality related to excessive inflammation and opportunistic lung infections in animals and patients, and this might extend to those with H1N1 influenza infection.

Pharmacotherapy guidelines for the aged by family doctors for the use of family doctors

Part C of the guideline is preceded by Part B General Pharmacology IJCPT. 2008; 46: 600 - 617. Included in Part C are practical guidelines for improving the therapy of some age-specific diseases and problems commonly encountered in general practice. The article in this issue is dedicated to the therapy of Dementia and M. Parkinson. Further guidelines for the other age specific diseases and problems named above will be published in the following issues of IJCPT. An important feature of these guidelines are the inclusion of Levels of Evidence and of the Strength of Recommendations for the therapy which are shown when reliable studies are available. (For both see levels of evidence at the end of this article.).

Electron microscope characterization of CdSe/ZnSe quantum dots based on molecular dynamics structure relaxations

Molecular dynamics simulations using empirical potentials are applied to characterize the structure, the energy relaxation and the stability of pyramidal-shaped quantum dots in the CdSe/ZnSe system. The relaxed structure models are used for a reliable interpretation of electron microscope investigations to analyze the size, the shape and the strain fields of the quantum dots. Though the elastic strains modify the electron microsope image contrast by creating virtual truncations of the pyramids or additional black-white lobes, optimum imaging conditions chosen will reveal the shape and the size of the dots.

CD23 exhibits negative regulatory effects on allergic sensitization and airway hyperresponsiveness

The effects of an anti-CD23 monoclonal antibody (B3B4) in CD23-deficient and CD23-overexpressing mice were compared in a murine model of allergic sensitization. After sensitization and challenge with OA, mice developed increased serum levels of OA-specific IgE and IgG(1) with airway eosinophilia and AHR when compared with nonsensitized animals. Anti-CD23 treatment was studied under two protocols: 10-d OA aerosol exposure and intraperitoneal sensitization followed by aerosol challenge. In both protocols anti-CD23 significantly reduced IgE and IgG(1) levels, abolished eosinophilia, and normalized AHR in BALB/c and wild-type CD23+/+ mice but not in CD23-/- mice. These changes were associated with increases in IFN-gamma and decreases in IL-4 production, suggesting that CD23 binding may affect not only IgE production but also the Th1/Th2 imbalance during the development of allergic AHR. Absence of CD23 in gene-deficient mice significantly enhanced OA-specific IgE and IgG(1) levels, airway eosinophilia, and AHR when compared with CD23+/+ wild-type littermates after sensitization and airway challenge. Sensitized and challenged CD23 transgenic mice also developed eosinophilic airway inflammation and methacholine hyperresponsiveness. However, the extent of AHR, BAL, and tissue eosinophilia in these animals showed a significant negative correlation with levels of CD23 expression on splenic T and B cells, demonstrating a limiting role of CD23 in the development of allergic AHR.

Interleukin-4-dependent production of PPAR-gamma ligands in macrophages by 12/15-lipoxygenase

The peroxisome proliferator-activated receptor-gamma (PPAR-gamma) is a ligand-dependent nuclear receptor that has been implicated in the modulation of critical aspects of development and homeostasis, including adipocyte differentiation, glucose metabolism and macrophage development and function. PPAR-gamma is activated by a range of synthetic and naturally occurring substances, including antidiabetic thiazolidinediones, polyunsaturated fatty acids, 15-deoxy-delta prostaglandin J2 and components of oxidized low-density lipoprotein, such as 13-hydroxyoctadecadienoic acid (13-HODE) and 15-hydroxyeicosatetraenoic acid (15-HETE). However, the identities of endogenous ligands for PPAR-gamma and their means of production in vivo have not been established. In monocytes and macrophages, 13-HODE and 15-HETE can be generated from linoleic and arachidonic acids, respectively, by a 12/15-lipoxygenase that is upregulated by the TH2-derived cytokine interleukin-4. Here we show that interleukin-4 also induces the expression of PPAR-gamma and provide evidence that the coordinate induction of PPAR-gamma and 12/15-lipoxygenase mediates interleukin-4-dependent transcription of the CD36 gene in macrophages. These findings reveal a physiological role of 12/15-lipoxygenase in the generation of endogenous ligands for PPAR-gamma, and suggest a paradigm for the regulation of nuclear receptor function by cytokines.

TEM characterization of self-organized CdSe/ZnSe quantum dots

CdSe quantum dots (QDs) grown on ZnSe were investigated by various transmission electron microscopy (TEM) techniques including diffraction contrast imaging, high-resolution and analytical transmission electron microscopy both of plan-view as well as cross-section specimens. The size of the QDs ranges from about 5-50 nm, where from the contrast features in plan-view imaging two classes can be differentiated. In the features of the smaller dots there is no inner fine structure resolvable. The larger ones exhibit contrast features of fourfold symmetry as expected for pyramid-like islands. Corresponding simulations of diffraction contrast images of truncated CdSe pyramids with the edges of the basal plane orientated parallel to <100> are in relatively good agreement with this assumption. In TEM diffraction contrast imaging of cross-section samples the locations of the quantum dots are visualized by additional dark contrast features. The QDs have a distinct larger extension in growth direction compared to the almost uniformly thick CdSe wetting layer. The presence of the CdSe QDs was also confirmed by energy-dispersive X-ray spectroscopy.

Dysregulation of the cyclin-dependent kinase inhibitor p21WAF1/CIP1/MDA6 increases the susceptibility of human leukemia cells (U937) to 1-beta-D-arabinofuranosylcytosine-mediated mitochondrial dysfunction and apoptosis

The effects of dysregulation of the cyclin-dependent kinase inhibitor p21WAF1/CIP1 on the apoptotic response of U937 monocytic leukemia cells to 1-beta-D-arabinofuranosylcytosine (ara-C) were examined. After a 6-h exposure to 1 microM ara-C, cells stably transfected with a p21WAF1/CIP1 antisense construct were significantly more sensitive to the induction of classic apoptotic morphology, DNA fragmentation, caspase-3 activation, poly(ADP-ribose) polymerase degradation, and underphosphorylation of the retinoblastoma protein (pRb) than their empty-vector counterparts. Enhanced susceptibility of antisense-expressing cells to ara-C was accompanied by a corresponding reduction in clonogenic and suspension culture growth. The increased sensitivity of these cells to ara-C-mediated lethality could not be attributed to cytokinetic perturbations, nor did ara-CTP formation or (ara-C)DNA incorporation differ significantly between the cell lines. Moreover, synchronization of p21 antisense-expressing cells in S-phase by aphidicolin block resulted in a further increase in ara-C-mediated apoptosis, suggesting enhanced drug sensitivity of the S-phase cell fraction. After exposure to ara-C, p21 antisense-expressing cells displayed a greater decline in mitochondrial membrane potential (deltapsi(m)) and generation of reactive oxygen species than their empty-vector counterparts, as well as early potentiation (e.g., within 2-4 h) of cytochrome c release into the cytosolic S-100 fraction. Lastly, ara-C-mediated increases in mitogen-activated protein kinase activity over basal levels were attenuated in p21 antisense-expressing cells. Collectively, these findings indicate that dysregulation of the cyclin-dependent kinase inhibitor p21WAF1/CIP1 increases the susceptibility of U937 human leukemia cells to ara-C-related lethality, and this phenomenon occurs as a relatively early event that is independent of cell cycle or pharmacodynamic factors and is associated with mitochondrial perturbations implicated in activation of the apoptotic protease cascade.

Instillation of calf lung surfactant extract (calfactant) is beneficial in pediatric acute hypoxemic respiratory failure. Members of the Mid-Atlantic Pediatric Critical Care Network

OBJECTIVE

Prospective study of the efficacy of calf lung surfactant extract in pediatric respiratory failure.

DESIGN

Multi-institutional, prospective, randomized, controlled, unblinded trial.

SETTING

Eight pediatric intensive care units (ICU) of tertiary medical centers.

PATIENTS

Forty-two children with acute hypoxemic respiratory failure characterized by diffuse, bilateral pulmonary infiltrates, need for ventilatory support, and an oxygenation index of >7.

INTERVENTION

Instillation of intratracheal surfactant (80 mL/m2).

MEASUREMENTS AND MAIN RESULTS

Ventilator parameters, arterial blood gases, and derived oxygenation and ventilation indices were recorded before and at intervals after surfactant administration. Complications and outcome measures, including mortality, duration of mechanical ventilation, and length of pediatric ICU and hospital stay, were also examined. Patients who received surfactant demonstrated rapid improvement in oxygenation and, on average, were extubated 4.2 days (32%) sooner and spent 5 fewer days (30%) in pediatric intensive care than control patients. There was no difference in mortality or overall hospital stay. Surfactant administration was associated with no serious adverse effects.

CONCLUSIONS

Administration of calf lung surfactant extract, calfactant, appears to be safe and is associated with rapid improvement in oxygenation, earlier extubation, and decreased requirement for intensive care in children with acute hypoxemic respiratory failure. Further study is needed, however, before widespread use in pediatric respiratory failure can be recommended.

Cytomegalovirus retinitis, human immunodeficiency virus antibody positivity and normal T helper cell numbers

We describe a 46-year-old man in whom retinitis was diagnosed as his initial HIV and AIDS defining illness. A diagnosis of CMV infection was made based on the clinical appearance of the fundus and confirmed by DNA polymerase chain reaction (PCR) on his vitreous biopsy. His CD4+ T lymphocyte count at the time was 580 x 10(6)/l (16%) with a CD4:CD8 ration of 0.28. He had a splenectomy following trauma more than 20 years earlier. He responded very well to intravenous and oral ganciclovir and remains recurrence-free almost 2 years later. This case and others highlight two issues: (i) CMV retinitis in HIV positive is not confined to those with very low CD4+ T lymphocyte counts; (ii) previous splenectomy may have an impact on CD4+ cell numbers and function.

Chronic varicella-zoster virus epithelial keratitis in patients with acquired immunodeficiency syndrome

OBJECTIVE

To characterize further a chronic epithelial keratitis caused by varicella-zoster virus infection in patients with acquired immunodeficiency syndrome (AIDS).

METHODS

Patients with AIDS and chronic epithelial keratitis associated with varicella-zoster virus from 3 institutions were identified. Patient records were reviewed retrospectively for the following data: medical and demographic characteristics, techniques of diagnosis, physical findings, course, response to treatment, and outcome.

RESULTS

Sixteen patients were studied. CD4+ T-lymphocyte cell counts were available in 11 patients, with a median of 0.034 x 10(9)/L (range, 0-0.094 x 10(9)/L). Two patients had no history of a zosteriform rash. In the remaining patients, the interval between rash and keratitis ranged from 0 days to 6 years. In all cases, the keratitis was chronic and characterized by gray, elevated, dendriform epithelial lesions that stained variably with fluorescein and rose bengal. The peripheral and midperipheral cornea was most commonly affected, and, in 13 of the 16 patients, the lesions crossed the limbus. Pain was a prominent feature, occurring in 12 of 16 patients. In 9 of 12 patients tested, varicella-zoster virus was identified by culture, direct fluorescent antibody testing, polymerase chain reaction testing, or a combination of these studies, with direct fluorescent antibody testing (6 of 8 positive results) and polymerase chain reaction testing (3 of 3 positive results) appearing to be the most sensitive. Response to antiviral medication was variable.

CONCLUSIONS

In patients with AIDS, varicella-zoster virus may cause a chronic infection of the corneal epithelium. The keratitis is characterized by dendriform lesions, prolonged course, and frequently by extreme pain. It can occur without an associated dermatitis.

Conscious experience and information

Conscious experience, our main source of information, has special properties. Primary among them is privacy, or privileged access by persons to their own conscious states. The consequent theoretical and practical problems for research on both consciousness and information are delineated.

Management of dialysis catheters

The goals of dialytic therapy are to provide safe, effective care and to emphasize the continuous improvement of quality. To provide such effective care requires the availability of a functional dialysis access. This is a critical (and sometimes the most difficult) component of dialysis. Care should focus not only on the maintenance of function but also on the prevention of complications. This article will familiarize the healthcare professional with the types, uses, and management of peritoneal and hemodialysis catheters.

The complications of trauma and their associated costs in a level I trauma center

OBJECTIVES

To estimate the expected costs for acute trauma care, to quantify the costs associated with the development of complications in injury victims, and to determine the deficit incurred by patients in whom complications develop.

DESIGN

A retrospective, cohort design.

SETTING

A referral trauma center.

PATIENTS

A total of 12,088 patients admitted to a single regional trauma center during a period of 5 years.

INTERVENTIONS

This is an observational study, and no interventions specific to this study are included in the design.

MAIN OUTCOME MEASURES

(1) The expected costs for injury victims based on readily available clinical data. (2) The costs associated with the most important complications of trauma. (3) The effect of complications on inadequate reimbursement for trauma care.

RESULTS

The expected costs were estimated using a linear model incorporating demographic variables and measures of injury severity. The expected costs averaged $14,567, and the observed costs averaged $15,032. Six complications were important predictors of cost. These included adult respiratory distress syndrome, acute kidney failure, sepsis, pneumonia, decubitus ulceration, and wound infections. For 1201 individuals with these complications, the predicted costs averaged $23,266 and the observed costs averaged $47,457. The mean excess costs for a single complication ranged from $6669 to $18,052. Multiple complications led to greater increases in excess cost, averaging $110,007 for the 62 patients with 3 or more complications. Costs exceeded reimbursement to a much greater degree in those in whom any of the 6 complications developed.

CONCLUSION

Expected hospital costs can be estimated using admission clinical data. Each of 6 complications was associated with enormous increases in costs, indicating their importance as a cause of avoidable expenditures in injury victims and identifying situations in which reimbursement may not be adequate.

Does fluoridation reduce the use of dental services among adults?

OBJECTIVES

The authors determine whether prevention influences the use of health services. Fluoridation's effect on restorative dental demand among 972 Washington state employees and spouses, aged 20 to 34 years, in two fluoridated communities and a nonfluoridated community was examined.

METHODS

At baseline, adults were interviewed by telephone, and oral assessments were conducted to measure personal characteristics, lifetime exposure to fluoridated water, oral disease, and the quality of restorations. Adults were followed for 2 years to measure dental demand from dental claims. Each adult's baseline and claims data were linked with provider and practice variables collected from the dentist who provided treatment.

RESULTS

Relative to adults with no lifetime exposure to fluoridated water, adults drinking fluoridated water for half or more of their lives had less disease at baseline and a lower but nonsignificant probability of receiving a restoration in the follow-up period. In the 2-year follow-up period, however, more than half of the restorations were performed to replace fillings of satisfactory or ideal quality at baseline. When only teeth with decay and unsatisfactory fillings at baseline were considered, adults with high fluoridation exposure had a lower probability of receiving a restoration than adults with no exposure. Market effects also were detected in demand equations; relative to adults in the nonfluoridated community, adults residing in the fluoridated community with a large dentist supply received a greater number of restorations, suggesting potential supplier-induced demand from less disease and fewer patients.

CONCLUSIONS

Among adults aged 20 to 34 years with private dental insurance, fluoridation reduces oral disease but may or may not reduce use of restorative services, depending on dentists' clinical decisions.

The relationship between price of services, quality of care, and patient time costs for general dental practice

OBJECTIVE

To examine the relationships between price of services, quality of care, and patient time costs in private practices of general dentists.

DATA SOURCE/STUDY SETTING

In October 1992, a 3.7 percent sample of eligible general dentists in part-time or full-time private practice in 1991 was randomly drawn from a sampling frame tailored from data gathered by the 1991-1992 American Dental Association Distribution of Dentists census of all United States dentists.

DATA COLLECTION

A mail survey was used to collect data on dentist demographic characteristics, dental practice characteristics practice finances, and insurance. The survey was completed and returned by 3,048 general dentists (77 percent response rate). Local area population characteristics were obtained from secondary sources.

STUDY DESIGN

Two-stage least squares regression was used to evaluate the structural relationships between price of services, quality of care, and time costs to patients. Structural equations were estimated for four different quality of care measures and two time costs.

PRINCIPAL FINDINGS

Price of services and quality of care were significantly related to each other. Higher quality of care was associated with higher price of services and, reciprocally, higher price of services was associated with higher quality of care. Shorter waits for a new patient appointment were associated with higher prices. Higher price of services, lower quality of care, and longer waits for a new patient appointment were related to shorter in-office waiting time.

CONCLUSIONS

The implication of these findings is that if price of services is constrained, then the quality of care provided by the dentist may also be reduced.

Cytomegalovirus-associated acute retinal necrosis syndrome

PURPOSE

To describe a case of acute retinal necrosis syndrome in which a polymerase chain reaction-based assay provided evidence for cytomegalovirus as the causative agent of the syndrome.

METHODS

Polymerase chain reaction-based assays were used to analyze a vitreous aspirate from a 70-year-old man with acute retinal necrosis syndrome. The specimen was tested for cytomegalovirus, varicella-zoster virus, and herpes simplex virus type 1 and type 2.

RESULTS

The polymerase chain reaction assay for cytomegalovirus was positive, and polymerase chain reaction assays for varicella-zoster virus and herpes simplex virus type 1 and type 2 were negative.

CONCLUSION

Cytomegalovirus may be a causative agent of acute retinal necrosis syndrome.

Calf's lung surfactant extract in acute hypoxemic respiratory failure in children

OBJECTIVE

Open-label trial of the safety and short-term efficacy of calf's lung surfactant in pediatric respiratory failure.

DESIGN

Multi-institutional, uncontrolled, observational trial.

SETTING

Six pediatric intensive care units of tertiary medical centers.

PATIENTS

Twenty-nine children with acute hypoxemic respiratory failure, characterized by diffuse, bilateral, pulmonary infiltrates, need for ventilator support, and an oxygenation index of > or = 7.

INTERVENTIONS

Up to four doses of intratracheal surfactant (80 mL/m2).

MEASUREMENTS AND MAIN RESULTS

Ventilator parameters, arterial blood gases, and derived oxygenation and ventilation indices were recorded before, and at intervals after, surfactant administration. Complications and outcome measures were also noted. There was immediate improvement in oxygenation and moderation of ventilator support associated with surfactant administration in 24 of 29 patients. A modest but statistically insignificant effect was seen with subsequent doses. The only complications occurred in three patients who developed airleaks, two of which were coincident with surfactant administration. The overall mortality rate was 14%, which compares favorably with other published series.

CONCLUSIONS

Administration of calf's lung surfactant appears to be safe and is associated with rapid improvement in oxygenation and moderation of ventilator support in children with acute hypoxemic respiratory failure. These results set the stage for a randomized, controlled study.

Managing care, incentives, and information: an exploratory look inside the "black box" of hospital efficiency

OBJECTIVE

We sought to estimate the impact of individual dimensions of hospitals' managed care strategies on the cost per hospital discharge.

STUDY SETTING/DATA SOURCES

Thirty-seven member hospitals of seven health systems in the Pacific, Rocky Mountain, and Southwest regions of the United States were studied.

STUDY DESIGN

Separate cross-sectional regression analyses of 21,135 inpatient discharges were performed in 1991 and 23,262 discharges in 1992. The multivariate model was estimated with hospital cost per discharge as the dependent variable. Model robustness was checked by comparing regression results at the individual discharge level with those at the level of the hospital/clinical condition pair.

DATA COLLECTION/EXTRACTION METHODS

Information on hospitals' managed care strategies was provided by mail and phone survey of key informants in 1991 and 1992. Other hospital characteristics were collected from AHA Annual Survey data, and discharge data from hospital abstracting systems.

PRINCIPAL FINDINGS

The pooled discharge analysis indicated three dimensions of hospital managed care strategy that consistently related to lower costs per hospital discharge: the proportion of hospital revenues derived from per case or capitation payment, the hospital's mechanisms for sharing information on resource consumption with clinicians, and the use of formalized, systematic care coordination mechanisms.

CONCLUSIONS

Three strategies appear to hold promise for enhancing the efficiency of inpatient resource use: (1) "fixed price" hospital payment incentives, (2) hospital approaches to sharing resource use information with clinicians, and (3) the application of formal care management mechanisms for specific clinical conditions.