Glucose-6-Phosphate Dehydrogenase Deficiency is Associated with Cardiovascular Disease in U.S. Military Centers.

Glucose-6-phosphate dehydrogenase (G6PD) protects erythrocytes from oxidative stress and hemolysis; G6PD deficiency is the most prevalent enzymopathy. The United States military routinely performs tests to prevent exposing G6PD-deficient personnel to antimalarial drugs that might cause life-threatening hemolytic reactions. In addition, G6PD is a key determinant of vascular function, and its deficiency can lead to impaired nitric oxide production and greater vascular oxidant stress-precursors to atherosclerosis and cardiovascular disease. Using military medical records, we performed a retrospective, cross-sectional study to investigate whether deficient G6PD levels are associated with a higher prevalence of cardiovascular disease than are normal levels, and, if so, whether the relationship is independent of accepted cardiovascular risk factors. We analyzed the medical records of 737 individuals who had deficient G6PD levels and 16,601 who had normal levels. Everyone had been screened at U.S. military medical centers from August 2004 through December 2007. We evaluated our dependent variable (composite cardiovascular disease) at the individual level, and performed binary logistic regression of our independent variable (G6PD status) and control variables (modifiable cardiovascular risk factors). The adjusted odds ratio of 1.396 (95% CI, 1.044-1.867; P <0.05) indicated that G6PD-deficient individuals have 39.6% greater odds of developing cardiovascular disease than do those with normal levels. Early intervention may reduce the incidence of cardiovascular disease in military personnel and civilians who have deficient G6DP levels.

Patient-centered medical home implementation effects on emergency room utilization: a case study.

The Patient-Centered Medical Home (PCMH) concept has been commended for its potential to increase access to primary care while improving quality and health outcomes. Numerous studies have documented the benefits of the PCMH healthcare delivery modality inclusive of decreased emergency room (ER) visits among PCMH enrollees. Yet a debate wages on whether PCMHs are conceptually sound and clinically effective with few empirical studies dedicated to the study of this relatively new care delivery model (Friedberg et al. 2014; Agency for Health Research and Quality 2012; Cassidy 2010). As part of the campaign to implement the PCMH care delivery modality throughout the Military Health System, the Army Medical Command constructed a medical home at Ft. Campbell, Kentucky, in December 2010. The authors evaluated the effectiveness of this medical home in reducing ER visits and found enrollees were 67% less likely than standard primary care clinic enrollees to visit the ER when controlling for age, gender, race, beneficiary category, marital status, and outpatient visits. Additionally, men were nearly half as likely as women to visit the ER, and high outpatient users were twice as likely to visit the ER. This is an encouraging study for proponents of the PCMH model. Limitations and suggestions for future research are also presented.

Patient satisfaction in military medicine: model refinement and assessment of continuity of care effects.

The Military Health System (MHS) identified patient-centered care and satisfied beneficiaries as main objectives in their 2006 Strategic Plan. The objective of this study was to expand upon the previous MHS model to determine predictors of patient satisfaction behaviors based upon associated attitudes and beliefs in addition to determining the predictive qualities presented by continuity of care. A sample of 90,318 patient responses from 2002 to 2004 was drawn from the Customer Satisfaction Survey database. Hierarchical multiple linear regression analyses were conducted to assess the uniquely predictive effects of the independent variables on the outcome variable. Results indicated the constructs from previous studies of satisfaction within the MHS using an attitude model were consistent when tested in a behavioral model. Hypothesis tests also indicated continuity of care demonstrated uniquely predictive qualities suggesting inclusion in the model. The final satisfaction with visit model yielded F(29, 90, 288) = 7062.37, p < 0.01 with R2 = 0.694.

Building from within: identifying leadership competencies for future navy nurse executives.

The purpose of this research is to forecast the relevant competencies and important skills, knowledge, and abilities (SKAs) for Navy nurse executives in the next 5 to 10 years. Using 2 iterations, Wave I and Wave II, of the Delphi technique, 6 competency domains emerged: business management, executive leadership, professional development, global awareness and interoperability, communications, and personnel management. For Wave I, 38 (19%) of 200 nurses identified what they considered to be the 5 most relevant competencies and skills, knowledge, and abilities. Reviewed by an expert panel, the results were used to develop the Wave II questionnaire to determine SKA importance ratings. Using the same respondent pool, 93 (47%) of the 200 nurses rated 100 SKA items. The top 3 rated SKAs were as follows: "Maintains the utmost integrity: has the trust of all members inside and outside of the organization," "Communication skills: ability to communicate in all forms," and "Ability to lead and mentor junior personnel." The Cronbach coefficient alpha was used to assess internal consistency. All results were above the recommended and acceptable level of .70. The results will provide the foundation for a leadership education continuum enabling the critical link among educational offerings, role-based experiences, timely mentoring, and specific career milestones.

Executive competencies of nurses in the Veterans Health Administration.

This study identifies competencies and accompanying skills, knowledge, and abilities (SKAs) required by the Veterans Health Administration (VHA) nurse executives. Using the Delphi decision-making method, 144 VHA directors of nursing identified five top competencies necessary for nurse executives. An expert panel sorted competencies into the eight core domains of the VHA high-performance development model. Next, nurse executives rated SKAs by using a 7-point importance scale. Response rates were 34% and 48.2% for Delphi rounds 1 and 2, respectively. Round 1 generated 245 unique nurse executive competencies. In round 2, the highest rated SKAs involved ethical conduct, decision-making, abilities to continuously learn and lead, staffing, and conflict-resolution skills. Competency list outcomes are expected to be useful for executive self-assessment, professional development, and identification of continuing education needs. Specific SKAs can provide a means for development of job requirements and career performance criteria.

Using Anscombe's quartet plus one to illustrate data set matching, proper model specification, and relationships between inferential tests.

In 1854, London experienced an epidemic of cholera that took more than 500 lives. In September of that year, Dr. John Snow plotted the locations of cases and of water pumps throughout the city. Using simple graphical analysis, Dr. Snow quickly identified that the source of the epidemic was the Broad Street water pump. He had the handle removed, and the cholera breakout ended. While computational analysis might have resulted in the same solution set eventually, the proper visualization of the data provided a quick solution whichprobably saved lives (Tufte, 2002). Health professionals must therefore understand that graphical analysis of data is critical to the understanding of multidimensional relationships. The following discussion illustrates the importance of data visualization as applied to the field of healthcare. We begin with an examination F.J. Anscombe's and Edward Tufte's important works regarding graphical analysis.

Patient satisfaction with dental hygiene providers in US military clinics.

PURPOSE: Military service members receive their dental care from military dental clinics. The purposes of this study were to assess satisfaction and to identify predictors of patient satisfaction with the hygiene provider in military dental treatment facilities. METHODS: Standardized surveys were administered from 2000 through 2004 by the Tri-Service Center for Oral Health Studies. Dependent variables were overall satisfaction with today's visit and overall satisfaction with the clinic's ability to take care of your needs. Independent variables were grouped by environment of care, beliefs about the care, and demographic characteristics. Principal component factor analysis and hierarchical multiple linear regression were used to test the hypotheses. RESULTS: A total of 98 792 surveys, with no missing data, from a sample of 130 801, were analyzed. Patients treated by hygiene providers were highly satisfied with dental care, as the mean score for satisfaction with today's visit was 6.61, and overall satisfaction with the clinic was 6.44 on a 7-point bipolar adjective rating scale. Factor analysis revealed that beliefs about care (46.7%) and environment (26.8%) were the most important factors to satisfaction. Both regression models developed for patient satisfaction achieved statistical significance. Model one, overall satisfaction with today's visit, obtained R(2) =.311, with F (6, 98785) = 8923, p<.0001. Model two, overall satisfaction with the clinic, obtained R(2) =.284 with F (6, 98785) = 7848, p<.0001. CONCLUSIONS: This study demonstrated that beliefs about care are the most important factors associated with patient satisfaction with the hygiene provider. The interpersonal experience has a strong association with patients' assessment of care and thus, training providers about the relationship of satisfaction with the interpersonal experience can enhance overall satisfaction.

The development of a conceptual model for evaluating dental patient satisfaction.

The purpose of this study was to identify levels and predictors of patient satisfaction and develop a conceptual model for dental patient satisfaction in military treatment facilities. Respondents completed 658,443 surveys during 17 fiscal quarters, beginning with the fourth quarter of 2000. The final data set contained 309,261 surveys, with no missing data. Principal component factor analysis was used for data reduction and hierarchical multiple linear regression to assess the predictive effects of the dependent variables on the two independent variables: (1) overall satisfaction with today's visit and (2) overall satisfaction with the clinic. On a 7-point, bipolar adjective rating scale, patients' mean score was 6.53 regarding satisfaction with visit, suggesting that patients are highly satisfied. Patients' beliefs about care received and environment of care were the most important satisfaction attributes. These findings are useful in educating providers about the relationship of consumer satisfaction with the interpersonal experience.

Executive competencies in healthcare administration: preceptors of the Army-Baylor University Graduate Program.

The purpose of this research was to identify the mentoring and executive competencies required among preceptors of the Army-Baylor University Graduate Program in Health and Business Administration, and to specify the requisite skills, knowledge, and abilities (SKAs) needed to achieve those competencies. In the first wave of inquiry, a list of 123 competencies and associated SKAs was elicited from a network of 80 current and past preceptor executives employing a Delphi methodology using e-mail. An expert panel, which consisted of seven past program directors, examined and sorted the list into four preceptor content domains, viz., Health Systems Management (HS Management), Leadership, Residency Administration, and Community Involvement. Frequency analyses showed that the HS Management domain constituted over half of the competencies, with particular emphasis on strategic thinking, planning, billing, finance, manpower, and contracting. In the second wave, the preceptor Delphi network reviewed the expertpanel list and made 7-pointSKA importance ratings on an 80-item structured questionnaire representative of the four domains. Findings indicated thataverage SKA ratings were reliable and agreed upon to a high degree among preceptors. Results, rank ordered by SKA item means within preceptor content domains and overall, suggested that the most important rated items centered on teamwork, negotiation, interpersonal skills, communication, leadership vision, and customer and healthcare business operations. Outcomes from the competency list are expected to be useful for preceptor mentoring, self-assessment, and for professional development. Additionally, specific SKAs can provide a means for developing job requirements and career performance criteria at a behavioral task level, and can contribute information for identifying continuing education and conference topical needs.

Patient satisfaction in military medicine: model refinement and assessment of Department of Defense effects.

A sample of 154,893 patient responses from the Customer Satisfaction Survey database was drawn for 1999 to 2000. Average patient satisfaction levels consistently appeared to be high (between 6, very satisfied, and 7, completely satisfied, on the 7-point rating scale). Hierarchical regression results essentially replicated all three major constructs of an earlier theoretical attitude model. Refinements included adjustment and addition of categorical age and military beneficiary status for individual patient variables, addition of two beliefs about the care itself, substitution of waiting time variables, and addition of reason for visit situation variables. Hypothesis test results indicated that patient satisfaction constructs were homogeneous across the uniformed services for patients from all service branches, both enrolled and not enrolled within TRICARE regions, and among branch of service medical center, hospital, and clinic facilities. The final attitude model coefficient of multiple determinations obtained was R2 = 0.701 [F(25,154,867) = 14,539.33, p < 0.0001].

Army junior dental officer retention.

OBJECTIVES: The objectives of the survey were to quantify the extent of indebtedness of junior dental officers and to determine the impact of a loan repayment program on career decisions. METHODS: We designed a customized survey instrument because no preexisting, validated, survey instrument was available. A query was performed in the Medical Operations Data System to identify all captains (0-3) currently on active duty in the Army (N = 348). The survey sample included 64 junior officers with a 2000 date of rank to captain (0-3), of whom only 52 were in the Medical Command Outlook address book or the Army Knowledge Online white pages. The questionnaire was sent out to these targeted junior dental officers through their official e-mail accounts. Dentists assigned to Korea and to dental field units do not use the same e-mail system as the rest of the Dental Command; therefore, their addresses were not available. In an attempt to increase response rates, commanders were asked to emphasize the importance of responding to the questionnaire. RESULTS: From the sample population of 52 officers who were queried directly, 34 responses were received, for a response rate of 65%. However, commanders forwarded the survey to all Dental Command captains and 102 responses were received. The respondents represented 30% of the total Army inventory of captains; 92% of respondents reported that they had dental school loans, with 43% reporting loans in excess of dollar 50,000. The average dental school indebtedness was approximately dollar 60,700. More than 60% of all respondents reported that loan repayment could change their minds about remaining on active duty. Officers not included in the original sample rated the impact of loan repayment statistically higher than did officers in the original sample. CONCLUSIONS: The findings were that the majority of junior Army dental officers had significant student loans and many of these officers indicated that they would consider remaining on active duty if loan repayment or other monetary inducements were offered.

U.S. Army-Baylor University Health Care Administration Program: evidenced-based outcomes in the military health system.

The purpose of this research is to assess the impact of an educational program on the Military Health System on some of the evidence-based educational outcomes for the Individual (student) and the Society (all Army Medical Treatment Facilities). The U.S. Army-Baylor University HCA program provides a unique opportunity to assess the impact of an educational program on the Military Health System (MHS). Since the majority of the graduate students are military officers who serve in military medical treatment facilities (MTFs), tracking their career progression allows assessing the value added of the U.S. Army-Baylor University HCA experience from 1951 to 2001 (n = 2234). The context of Society outcomes includes all the Army MTFs where U.S. Army-Baylor University HCA graduates execute their leadership skills. During the time from 1994 to 2001, all of the Army MTFs in the MHS (n = 38) were examined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In a similar but shorter time frame (1997-2001), DoD patient satisfaction assessments were conducted. The Individual outcomes (career advancement, increase in status, higher professional association membership) demonstrate that the selection criteria used for program admission appear to be successful. The Society outcomes showed higher JCAHO scores and satisfied consumers in Army facilities with Baylor graduates as the Deputy Commander for Administration (DCA). Continued internal program assessments (curriculum reviews) and external reviews (Accrediting Commission on Education for Health Services Administration accreditations of 5 years in 1987, 8 years in 1993 and 7 years in 2001, and 7 ACHE student chapter awards) attest to the strengths of the U.S. Army-Baylor University HCA program. Educating the MHS shareholders (patients, beneficiaries, professional and support staff, senior leaders) and leveraging technology to. share best practices for all administrators (including non-Baylor graduates) will help improve the quality patient care of the Military Health System and other healthcare systems.

Patient satisfaction in military medicine: status and an empirical test of a model.

The Department of Defense (DoD) is concerned about how well military medical treatment facilities in the military health system perform. Patient expectations, attitudes, and health care use have been examined in numerous studies; the results are fairly consistent. Eligible beneficiaries report moderate satisfaction with the health care received. In 1994-2001, annual DoD and monthly ambulatory patient surveys were conducted in military medical treatment facilities. The DoD surveys document how patients perceive the care provided. The obvious research concerns are: requirements for conducting surveys; who should be surveyed: eligible beneficiaries or actual users; when; where; representative sample; how often to conduct assessment; data collection methods; analytic schemes; overall trends; predictors of satisfaction; use of results; and timeliness of findings. This study examines these issues and analyzes raw data from selected annual DoD and monthly ambulatory surveys. The overall level of perceived satisfaction has been "good" over the years surveys were used. The model demonstrated the use of examining demographic and attitudinal components of patient satisfaction in military medical facilities.