The use of angiotensin-converting enzyme inhibitors in patients with acute myocardial infarction in community hospitals. Michigan State University Inter-Institutional Collaborative Heart (MICH) Study Group.

BACKGROUND: Previous studies documenting underutilization of angiotensin-converting enzyme inhibitors (ACEIs) in acute myocardial infarction (AMI) have been limited to Medicare populations. HYPOTHESIS: This study examines ACEI prescription rates and predictors in a community sample of hospitalized patients with AMI. METHODS: The charts of 1163 community patients with AMI, prospectively identified at admission between January 1, 1994, and April 30, 1995, were reviewed. RESULTS: Only 64 of 158 (40%) patients considered ideal candidates for ACEI prescription were discharged with a prescription for an ACEI. In a multivariate logistic regression model, prior ACEI utilization [adjusted odds ration (OR) = 3.26; 95% confidence interval (CI) = 2.05-5.20], presence of congestive heart failure (OR = 2.33; CI = 1.50-3.61) and black race (OR = 2.20; CI = 1.34-3.64) were identified as positive predictors of ACEI prescription. Conversely, lack of left ventricular ejection fraction (LVEF) measurement (OR = 0.46; CI = 0.28-0.75), LVEF > 40 ( OR = 0.27; CI = 0.18-0.40), and acute renal failure (OR = 0.08; CI = 0.01-0.44) were negative predictors. Women were also less likely to be discharged with an ACEI prescription (OR = 0.71; CI = 0.48-1.05). Furthermore, women were significantly less likely to have LVEF measured prior to discharge than were males (77 vs. 85%, p = 0.001). CONCLUSION: This study underscores the need for improvement in the utilization of ACEI in eligible patients with AMI. It also identifies opportunities for improvement in prescription rates, especially in women.

Evaluating and improving the cost-effectiveness of the implantable cardioverter-defibrillator.

The implantable cardioverter defibrillator (ICD) is an expensive, widely used device for severe ventricular arrhythmias. Marginal cost-effectiveness analysis is a technique to examine the incremental cost of treatment strategy in relation to its effectiveness. In this study, we used this technique to analyze the cost-effectiveness of the ICD compared with that of electrophysiology (EP)-guided drug therapy and examined ways in which it may be improved. We analyzed Michigan Medicare discharge abstracts (1989 to 1992) and local physician visit, test, and ICD charges. Effectiveness was from 218 previously described patients with ICDs in whom the time of first event (first appropriate shock or death) was determined and presumed to represent "control" (EP-guided drug therapy) mortality. We assumed a 4-year life cycle for the ICD generator and 3.4% operative mortality and used a 5% discount to prevent value. Data were analyzed in a 1-month cycle Markov decision model over a 6-year horizon, and results were updated to 1993 dollars. ICD effectiveness was an increase in discounted mean life expectancy of 1.72 years. Cost-effectiveness was $31,100/year of life saved (YLS). Results were minimally or modestly sensitive to variations in preoperative mortality; resource use; consideration only of patients with ICDs who were receiving any antiarrhythmic drug or specifically amiodarone; and to a decrease in the percentage of first shocks that would equal death without the ICD until the assumed percentage decreased to < 38%. At ejection fraction of < 0.25 and > or = 0.25, cost-effectiveness was $44,000/YLS and $27,200/YLS, respectively, and without preimplant EP study was $18,100/ YLS.(ABSTRACT TRUNCATED AT 250 WORDS)

Constipation. Consensual and empirical validation.

This article describes the process of consensual and empirical validation used for one nursing diagnosis, constipation. The process is illustrated with a cluster of studies, both qualitative and quantitative. Implications for practice, education, and research are described.

Tracheal suctioning: a tool for evaluation and learning needs assessment.

A 21-item observation tool developed by one of the authors was used to assess learning needs of 30 registered nurses who regularly suction intubated patients. Of the nurses observed, 97 percent had excellent regard for proper equipment utilization and 91 percent for maintenance of sterile environment. These high percentages were responsible for pulling the overall average scores to 65 percent, thus partially disguising the acute need for patient assessment (38 percent), psychological support (57 percent), and procedure (62 percent). Scores for subgroups of nurses--associate degree (group 1), diploma (group II), And baccalaureate (group III)--were 72, 69, and 65, respectively. Of particular concern were low scores in the assessment and psychological support categories. Despite increased emphasis on both of these areas in nursing programs in the last decade, AD graduates received scores of 52 and 57 percent while diploma graduates received scores of 38 and 58 percent and baccalaureate graduates received scores of 26 and 55 percent.

Outcome criteria: a process for validation at the unit level.

This study reports the development of a process for the validation of sets of outcome criteria. The process can be simply and inexpensively utilized at the unit level by staff nurses. It was tested by the investigators and did serve to differentiate between valid and invalid outcomes of nursing care.

Core competencies of masters-prepared nurses.

To identify a common core of process competencies that all masters-prepared nurses are expected to attain, regardless of area of clinical concentration or functional-role goal, a 68-item Process Competency Scale was devised from a conceptual model of the multiple roles of masters-prepared nurses: practitioner, educator, manager, and change agent. Responses from 118 questeionnaires from four groups of respondents revealed that 25 competency items met the criteria established for a core competency. There was uniform agreement that nursing educators should be high-level practitioners and that practitioners of nursing should attain teacher competencies.