The nurse practitioner as a bridge to interprofessional research team collaboration in rural community clinics.

ABSTRACT: Clinical health outcomes and health disparities can be improved through interprofessional collaborations among multidisciplinary clinicians, health care services researchers, and patients. Bridging gaps between community clinics and urban academic centers allows added valuable perspectives that can lead to improved care and extend clinical research. Nurse practitioners (NPs) who serve as primary care providers in many rural community clinics can facilitate access to clinical trials for patients who are rarely included in health care services research as well as coordinate interprofessional research team collaboration. A NP working in a rural clinic can assist academic-based research teams in designing feasible strategies to address disparities and improve health care of underserved populations. The purpose of this article was to provide an example of a rural provider/urban academic research team collaborating to conduct a health literacy-directed randomized controlled trial to improve colorectal cancer screening in isolated rural community clinics.

Repeat Annual Colorectal Cancer Screening in Rural Community Clinics: A Randomized Clinical Trial to Evaluate Outreach Strategies to Sustain Screening.

PURPOSE: The majority of colorectal cancer (CRC) research using the fecal immunochemical test (FIT) has studied short-term screening results in predominantly urban areas. The purpose of this study was to evaluate the effectiveness of 2 outreach strategies embedded in a health literacy intervention on repeat CRC screening in rural community clinics. METHODS: A 2-arm randomized controlled trial was conducted in 4 rural clinics in Louisiana. During a regularly scheduled clinic visit, participants ages 50-75 received a FIT kit and brief educational intervention. Participants were randomized to receive an automated call or a personal call by a prevention counselor after 4 weeks and 8 weeks if FIT kits were not returned. In year 2, materials were mailed, and follow-up calls were conducted as in year 1. The primary outcome was repeat FIT-the return of the FIT kit in both years. PARTICIPANTS: Of 568 eligible participants, 55% were female, 67% were African American, and 39% had low health literacy. FINDINGS: Repeat FIT rates were 36.5% for those receiving the automated call and 33.6% for those receiving a personal call (P = .30). No annual FITs were returned in 30% of participants, while only 1 FIT was returned by 35% of participants (31% only year 1 and 4% only year 2). CONCLUSION: Sustaining CRC screening with FIT is challenging in rural clinics. A lower cost automated call was just as effective as the personal call in promoting repeat annual screening. However, more intensive strategies are needed to improve long-term FIT screening among rural participants.

Follow-up approaches to a health literacy intervention to increase colorectal cancer screening in rural community clinics: A randomized controlled trial.

BACKGROUND: Significant disparities exist in colorectal cancer (CRC) screening rates among those of low socioeconomic status, with fewer years of education, lacking health insurance, or living in rural areas. METHODS: A randomized controlled trial was conducted to compare the effectiveness of 2 follow-up approaches to a health literacy intervention to improve CRC screening: automated telephone call or personal call. Patients aged 50 to 75 years residing in 4 rural community clinics in Louisiana were given a structured interview that assessed demographic, health literacy and CRC screening barriers, knowledge, and attitudes. All were given health literacy-informed CRC education, a patient-friendly CRC screening pamphlet, simplified fecal immunochemical test (FIT) instructions, and a FIT kit, and a "teach-back" method was used to confirm understanding. Patients were randomized to 1 of 2 telephone follow-up arms. If they did not mail their FIT kit within 4 weeks, they received a reminder call and were called again at 8 weeks if the test still was not received. RESULTS: A total of 620 patients were enrolled. Approximately 55% were female, 66% were African American, and 40% had limited literacy. The overall FIT completion rate was 68%: 69.2% in the automated telephone call arm and 67% in the personal call arm. Greater than one-half of the patients (range, 58%-60%) returned the FIT kit without receiving a telephone call. There was no difference noted with regard to the effectiveness of the follow-up calls; each increased the return rate by 9%. CONCLUSIONS: Providing FIT kits and literacy-appropriate education at regularly scheduled clinic visits with a follow-up telephone call when needed was found to increase CRC screening among low-income, rural patients. The lower cost automated call was just as effective as the personal call.

Barriers and Facilitators to Colorectal Cancer Screening Among Rural Women in Community Clinics by Heath Literacy.

BACKGROUND: Rural women lag rural men and urban women in colon cancer (CRC) screening completion. OBJECTIVE: To identify rural female patients' knowledge, beliefs barriers, self-efficacy, prior recommendation and completion of CRC screening using an FOBT and to compare these factors by health literacy (HL) level. METHODS: This descriptive study was conducted between 2015 and 2016 in 4 rural community clinics in south Louisiana. Patients overdue for screening were given a structured interview by a research assistant. RESULTS: 339 women were enrolled, mean age 58.5, 32% had limited HL, 66% were African American. Most (91.7%) had heard of CRC, yet only 71% knew of any CRC screening tests. Women with adequate HL had greater knowledge of specific tests than those with limited HL (78.4% vs 56.6%, p<0.001). Only 25.7% had been given information on CRC testing; those with adequate HL were more likely to have received information (30.1% vs 16.8%; p=0.017). Most women (93.2%) indicated they would want to know if they had CRC, while 72.2% reported a provider had recommended CRC screening. Only 24.9% said a healthcare provider had ever given them an FOBT or that they had ever completed an FOBT (22.7%). There were no differences in women's report of recommendation or completion by HL level.Self-efficacy for completing an FOBT was high; over 90% indicated they could get an FOBT, complete it and mail results to the lab. Level of confidence did not vary by literacy. Three of the four barrier items varied by HL with women with low HL being more likely to fear doing an FOBT because they thought FOBT instructions would be confusing (p=0.002), doing the test would be embarrassing (p=0.025) or messy (p=0.057). CONCLUSIONS: Rural women are receptive to CRC screening and view FOBTs as effective. Rural community clinics need to provide low cost FOBTs with literacy, gender and culturally appropriate information.

Understanding scoping reviews: Definition, purpose, and process.

BACKGROUND/PURPOSE: Scoping review design represents a methodology that allows assessment of emerging evidence, as well as a first step in research development. Despite its increasing use, to date no article reflecting use of scoping review methodology has been submitted for review at JAANP. The purpose of this article is to provide detailed information on scoping reviews, including definition, related processes, and uses, and discuss the relationship to nurse practitioner (NP) practice, policy, education, and research. The longer-term goal is that NPs will understand the related techniques, consider the methodology as a viable one for NP scholarship, and bring related reports to the forefront of NP publications. METHODS: This manuscript represents a brief report. Processes to develop the brief include detailed search and review of scoping review literature in CINAHL and PubMed. Both methodologic reports and reviews were included. Definitions and uses of scoping reviews were reviewed. CONCLUSION: The definition and process of scoping review are evolving. Although there is controversy regarding the methodology, there is increasing visibility of scoping review methodology in the published literature since the year 2000, with over 500 published reviews currently available. IMPLICATIONS FOR PRACTICE: A well-executed scoping review has potential to inform NP practice, policy, education, and research.

The essential SOAP note in an EHR age.

This article reviews the traditional Subjective, Objective, Assessment, and Plan (SOAP) note documentation format. The information in the SOAP note is useful to both providers and students for history taking and physical exam, and highlights the importance of including critical documentation details with or without an electronic health record.

Autoimmune hepatitis: a noninfectious killer.

PURPOSE: This article reviews autoimmune hepatitis (AIH) to promote early recognition, diagnosis, and referral for nurse practitioners (NPs) encountering this rare condition. DATA SOURCES: Selected research and clinical articles from Medline, PubMed, and CINAHL. CONCLUSIONS: AIH is a rare condition of unknown etiology affecting women 3.6 times more than men and may result in liver failure, subsequent liver transplantation, and death. Untreated AH is associated with up to 80% mortality. Collaboration and referral to gastroenterologists, hepatologists, and other specialists are needed to improve outcomes for this potentially devastating disease. IMPLICATIONS FOR PRACTICE: Corticosteroid treatment has long been the mainstay of treatment of AIH, although newer therapies are promising. NPs can dramatically improve outcomes by early recognition, diagnosis, referral, and monitoring for common side effects of treatment working collaboratively with specialists.

Assessing end-of-life preferences for advanced dementia in rural patients using an educational video: a randomized controlled trial.

OBJECTIVE: Few studies have evaluated the end-of-life preferences of elderly patients in rural communities and whether preferences are associated with level of health literacy. DESIGN: Randomized controlled trial of a goals-of-care video decision aid of advanced dementia. PARTICIPANTS: Elderly subjects (65 years or older) at a primary care clinic in rural Louisiana. METHODS: Half of subjects heard a verbal description of advanced dementia and the goals of care; the other half heard the same verbal description and then viewed the video decision aid. End points were the preferred goal of care in advanced dementia: life-prolonging care (cardiopulmonary resuscitation [CPR], etc.), limited care (hospitalization but not CPR), or comfort care (symptom relief). The principal category for analysis was the difference in proportions of subjects preferring comfort care for each characteristic including randomization group and health literacy level. RESULTS: Seventy-six subjects were randomized to the verbal (n = 43) or video (n = 33) arms of the study. Among subjects receiving the verbal description of advanced dementia and the goals of care, 31 (72%) preferred comfort; 5 (12%) chose limited; and 7 (16%) desired life-prolonging. In the video group, 30 (91%) preferred comfort; 3 (9%) chose limited; and none desired life-prolonging (χ(2) = 6.3, df = 2, p = 0.047). Factors associated with greater likelihood of opting for comfort included greater health literacy (unadjusted odds ratio [OR] 12.1; 95% confidence interval [CI], 2.4-62.6) and randomization to the video (unadjusted OR 3.9; 95% CI, 1.0-15.1). CONCLUSION: Rural subjects with higher health literacy were more likely to want comfort care compared to those with lower levels of health literacy. Furthermore, subjects who viewed a video decision aid were more likely to opt for comfort compared to those who solely listened to a verbal description. These findings suggest that video can help elicit preferences and that interventions to empower such patients need to be designed in a manner that is sensitive to health literacy.

Growth hormone use in children: necessary or designer therapy?

Society often rewards the beautiful, the smart, and the intelligent. The possibility that children with idiopathic short stature (ISS) will sustain psychological damage as a result of ridicule from their peers is a concern. The desire for children to become tall adults provides a difficult quandary for parents and caregivers. Growth hormone (GH) treatment in children requires subcutaneous injections six to seven times weekly. The cost of treating with GH can be more than $52,000, and many third-party payers do not cover the cost of GH treatment. Research to date would indicate that while the administration of GH may improve final adult height in children with ISS, children treated with GH will remain short when compared with peers. More research is needed to study whether the administration of GH is beneficial for children with ISS. This article will discuss ISS and the use of GH in children.

Multidrug-resistant and extensively drug-resistant tuberculosis: The new face of an old disease.

PURPOSE: To provide an overview of tuberculosis (TB), especially the persistent threat of multidrug-resistant (MDR) and extensively drug-resistant (XDR), and the role of the nurse practitioner (NP) in diagnosis, treatment, and public health surveillance. DATA SOURCES: Public health sources such as the World Health Organization and the Centers for Disease Control as well as current literature. CONCLUSIONS: One hundred twenty-five years after the discovery of Mycobacterium tuberculosis, the disease remains a persistent threat and a leading cause of death worldwide. Medication adherence and prevention are critical to successfully treating and ultimately eradicating this killer disease. Healthcare providers need to be knowledgeable in the detection and diagnosis of TB and to understand that they assume responsibility for public health by monitoring treatment adherence and/or appropriate referral. IMPLICATIONS FOR PRACTICE: The persistent and increasing threat of MDR-TB and XDR-TB is a significant public health threat. Healthcare providers need to be knowledgeable and vigilant in diagnosing and treating this disease.

Pediatric overweight or obesity: does the label really matter?

PURPOSE: To discuss the issue of early identification of overweight and obesity in infants and young children and provide some clinical recommendations based on the current evidence and the World Health Organization's (WHO) newly released guidelines for growth and development. DATA SOURCES: Comparison of the growth charts from the WHO and the Centers for Disease Control as well as current literature. CONCLUSIONS: Although healthcare providers and the general public recognize overweight and obesity as serious problems, there is still disagreement on what constitutes obesity in infants and young children and when and how to intervene. More research on interventions and outcomes is particularly needed. IMPLICATIONS FOR PRACTICE: The primary care provider deals with the sequelae of obesity on a daily basis. Some recommendations are provided for nurse practitioners who care for infants and children based on current evidence and expert opinion.

Measuring nurse practitioner productivity.

As the role of the nurse practitioner (NP) evolves, the need to demonstrate productivity becomes more important. Productivity data provides NPs with practice statistics to generate business or use in contract negotiations with potential clients such as employers, managed care organizations, and insurance companies. However, beyond the numbers of patients seen per day or amount of reimbursement a provider brings to the practice, NPs may provide additional benefit that is not captured with physician productivity measures. Information to acquaint NPs with key aspects of recording productivity and ways NPs can organize productivity data within their practice to determine worth of service are presented.