Achieving Comprehensive, Patient-Centered Cancer Services: Optimizing the Role of Advanced Practice Nurses at the Core of Precision Health.

OBJECTIVES: The field of oncology has been revolutionized by precision medicine, driven by advancements in molecular and genomic profiling. High-throughput genomic sequencing and non-invasive diagnostic methods have deepened our understanding of cancer biology, leading to personalized treatment approaches. Precision health expands on precision medicine, emphasizing holistic healthcare, integrating molecular profiling and genomics, physiology, behavioral, and social and environmental factors. Precision health encompasses traditional and emerging data, including electronic health records, patient-generated health data, and artificial intelligence-based health technologies. This article aims to explore the opportunities and challenges faced by advanced practice nurses (APNs) within the precision health paradigm. METHODS: We searched for peer-reviewed and professional relevant studies and articles on advanced practice nursing, oncology, precision medicine and precision health, and symptom science. RESULTS: APNs' roles and competencies align with the core principles of precision health, allowing for personalized interventions based on comprehensive patient characteristics. We identified educational needs and policy gaps as limitations faced by APNs in fully embracing precision health. CONCLUSION: APNs, including nurse practitioners and clinical nurse specialists, are ideally positioned to advance precision health. Nevertheless, it is imperative to overcome a series of barriers to fully leverage APNs' potential in this context. IMPLICATIONS FOR NURSING PRACTICE: APNs can significantly contribute to precision health through their competencies in predictive, preventive, and health promotion strategies, personalized and collaborative care plans, ethical considerations, and interdisciplinary collaboration. However, there is a need to foster education in genetics and genomics, encourage continuous professional development, and enhance understanding of artificial intelligence-related technologies and digital health. Furthermore, APNs' scope of practice needs to be reflected in policy making and legislation to enable effective contribution of APNs to precision health.

The implementation and impact of an advanced practice recognition program.

ABSTRACT: Meaningful job recognition is a pillar for sustaining healthy work environments and proven beneficial for job satisfaction and retention. However, few dedicated award recognition programs exist for advanced practice registered nurses (APRNs), and no available literature evaluates the impact on professional practice, sense of belonging, and job retention or satisfaction. The purpose of this study was to introduce a novel award recognition program for APRNs and physician associates (PAs) in a large academic medical system and evaluate it's impact on job satisfaction, retention, and sense of belonging. Five awards were created to recognize areas of achievement for clinically practicing APRNs or PAs within an academic health system. Nomination letters were collected, deidentified, and reviewed by an award committee. Winners were announced and received a plaque. A survey was sent to employed APRNs evaluating their response to the program. The survey was sent to both APRNs (83%) and PAs (17%). Survey end points included job satisfaction, willingness to stay in role for 1 and 5 years, sense of community, something to work toward, and increasing recognition of APRNs. Results showed statistical significance in three areas. Advanced practice registered nurses or PAs who were aware of award opportunities and/or nominated for an award showed higher job satisfaction, more likely to stay in job for 1 year, and felt a greater level of recognition. Dedicated APRN award programs may have a positive impact on job satisfaction and retention. This model may be extrapolated to provide greater opportunities for meaningful recognition among clinical APRNs.

Propuesta de modelo para la enfermera de práctica avanzada / Proposal of a model for advanced practice nurses

La propuesta que se presenta es fruto, por un lado, de los resultados del proyecto “IPACAT22: Consenso sobre los aspectos clave del modelo de la práctica avanzada en Cataluña”, realizado con la participación de 24 enfermeras representantes de asociaciones científicas enfermeras o multidisciplinares de Cataluña. Por otro lado, es también fruto del apasionante, relevante y a veces difícil debate entre los miembros del equipo con diferentes trayectorias profesionales y distintos puntos de vista que enriquecen el objetivo común. Es oportuno presentar los resultados del debate, basados en el rigor, y los resultados de los proyectos de investigación por la mejora y el avance de la enfermera de práctica avanzada. Este debate también desempeña un rol importante en el entorno profesional para ejercer un liderazgo efectivo en las organizaciones y en el sistema de salud. Estamos convencidas de que este documento puede ser un punto de partida para configurar el modelo de la enfermera de práctica avanzada en nuestro contexto.(AU)

The proposal presented is the result, on one hand, of the outcomes of the Project “IPACAT22: Consensus on the key aspects of the model for advanced practice in Catalonia”, prepared with the participation of 24 nurses representing multidisciplinary or nursing scientific associations of Catalonia. On the other hand, it is also the result of the exciting, relevant, and sometimes difficult discussion among the team members with different professional careers and point of views which enhance the common objective. It is appropriate to present the outcomes of this discussion, based on rigour and results of the research projects for the improvement and progress of advanced practice nurses. This discussion also represents a major role in the professional setting, to conduct an effective leadership in organizations and the health system. We are convinced that this document can be a starting point to set up the model for the advanced practice nurse in our setting.(AU)

La Enfermería de Práctica Avanzada en la educación de posgrado para las enfermeras especialistas / Advanced Practice Nursing in Postgraduate Education for Specialist Nurses

Introducción: El término Enfermería de Práctica Avanzada tiene sus orígenes en la misma historia del desarrollo de la enfermería moderna, existe evidencia de que aumenta a nivel internacional, pero persiste la incertidumbre sobre la claridad del rol y la necesidad de progresar de manera coordinada. En la literatura revisada no se encuentra claridad acerca de la Enfermería de Práctica Avanzada para la educación y el desarrollo profesional de las enfermeras especialistas para considerarlas de práctica avanzada a pesar del conocimiento teórico y práctico que poseen. Objetivo: Identificar cómo se aborda desde la literatura científica, la Enfermería de Práctica Avanzada en la educación de posgrado para enfermeras especialistas. Métodos: Se realizó metarrevisión conocida como revisión paraguas o revisión de revisiones entre enero y abril de 2022. Búsqueda en bases de datos: BVS, SciELO y PubMed, con las palabras clave "enfermería de práctica avanzada" AND "enfermeras especialistas" AND "educación de postgrado en enfermería". Criterios de inclusión: estudios de revisión, disponibles a texto completo, publicados en los idiomas inglés, español o portugués. Criterios de exclusión: textos repetidos, los que solo se puede leer el resumen y aquellos que no se ajustaron al tema de estudio. Conclusiones: Varios de los estudios revisados describen el valor de la Enfermería de Práctica Avanzada para el desarrollo profesional y la mejora en la calidad de los servicios; no obstante, su valía aún no es bien reconocida en todos los contextos y se precisa avanzar en la consolidación de las especialistas para considerarlas de práctica avanzada(AU)

Introduction: The term advanced practice nursing has its origins in the very history of modern nursing development. Evidence shows that it is increasing internationally, but uncertainty persists about the clarity of the role and the need to progress in a coordinated way. In the reviewed literature, there is no clarity about advanced practice nursing for the education and professional development of specialist nurses to consider them of advanced practice, despite the theoretical and practical knowledge that they possess. Objective: To identify how advanced practice nursing is approached from the scientific literature in postgraduate education for specialist nurses. Methods: A meta-review known as umbrella review or review of reviews was conducted between January and April 2022. A search was conducted in the BVS, SciELO and PubMed databases, with the keywords enfermería de práctica avanzada [advanced practice nursing] AND enfermeras especialistas [nurse specialists] AND educación de postgrado en enfermería [postgraduate nursing education]. The following inclusion criteria were considered: review studies; available in full text; and published in English, Spanish or Portuguese. The following exclusion criteria were considered: repeated texts; those for which only the abstract could be read; and those that did not fit the study topic. Conclusions: Several of the reviewed studies describe the value of advanced practice nursing for professional development and the improvement in the quality of services; however, its value is still not well recognized in all contexts and progress is needed towards the consolidation of specialists to be considered of advanced practice(AU)

Enfermería de práctica avanzada en atención primaria de la salud / Advanced practice nursing in primary health care

Introducción: La enfermería de práctica avanzada está constituida por los cuidados de calidad que brinda una enfermera experta en conocimientos y competencias clínicas, que le permite tomar decisiones complejas en beneficio de poblaciones vulnerables, por lo que es una actividad clave en la atención primaria de salud. Objetivo: Analizar la evidencia científica relacionada a las experiencias de la implementación de enfermería de práctica avanzada en la atención primaria de salud. Métodos: Revisión sistemática de artículos publicados entre el año 2010 al 2020 en bases de datos SciELO, LILACS, Science Direct, REDALYC, PubMed y Elsevier en idioma castellano, inglés y portugués, para lo cual se utilizó la metodología de Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Se aplicó el uso de los Descriptores en Ciencias de la Salud (DeCS), Descriptores MeSH y la combinación de los operadores booleanos OR y AND. Se revisaron 405 artículos y luego de aplicar los criterios de inclusión y exclusión se seleccionaron 15. Conclusiones: La mayoría de los estudios revisados respaldan la necesidad de potenciar el progresivo desarrollo de la Enfermería de Práctica Avanzada y su incorporación en el sistema de salud para responder a las necesidades de salud de la población, pese a que existen dificultades en su implementación en especial en la regulación y la formación(AU)

Introduction: Advanced practice nursing is made up of quality care provided by a nurse expert in clinical knowledge and skills, allowing her to make complex decisions for the benefit of vulnerable populations, which is why it is a key activity in primary health care. Objective: To analyze the scientific evidence related to the experiences of the implementation of advanced practice nursing in primary health care. Methods: Systematic review of articles published between 2010 and 2020 in SciELO, LILACS, Science Direct, REDALYC, PubMed and Elsevier databases in Spanish, English and Portuguese, for which the Preferred Reporting Items for Systematic methodology was used. Reviews and Meta-Analyses (PRISMA); Likewise, the use of Descriptors in Health Sciences (DeCS), MeSH Descriptors and the combination of the Boolean operators OR and AND were applied. 405 articles were reviewed and after applying the inclusion and exclusion criteria, 15 were selected. Conclusions: Most of the reviewed studies support the need to promote the progressive development of Advanced Practice Nursing and its incorporation into the health system to respond to the health needs of the population, despite the fact that there are difficulties in its implementation in especially in regulation and training(AU)

Validación de instrumento de definición rol de enfermera de práctica avanzada en nivel terciario de atención en Cuba / Validation of a Role-Defining Instrument for advanced Practice Nursing at the Tertiary Level of Healthcare in Cuba

Introducción: La enfermería, como profesión, ha desarrollado una mejoría a nivel de los sistemas de salud, sobre todo en el área asistencial. Las necesidades demandadas por la sociedad han recibido como respuesta la evolución del rol, así como un incremento de funciones y responsabilidades en la profesión, lo que ha propiciado la aparición de un nuevo referente: la enfermera de práctica avanzada. Objetivo: Validar el instrumento de definición del rol de la enfermera de práctica avanzada en el nivel terciario de atención en Cuba. Métodos: Estudio metodológico realizado en el Complejo Científico Ortopédico Internacional "Frank País" en La Habana y en el Cardiocentro de la provincia de Villa Clara, Cuba, en el año 2022, mediante pilotaje con 15 enfermeras del Servicio Ortopedia y Traumatología y 15 enfermeras que laboran en el Cardiocentro de Villa Clara. Se calculó un índice con la aplicación de la lógica difusa de Crespo y para determinar consistencia interna del instrumento, se empleó el Alfa de Cronbach. Resultados: Con la aplicación de la lógica difusa de Crespo, se observó correlación entre los ítems, la consistencia interna y el análisis por factores. La fiabilidad del test mostró coeficiente Alfa de Cronbach de 0,95 y también 0,95 Alfa de Cronbach estandarizado, resultados que potencian la alta consistencia interna de la escala aplicada. Conclusiones: El instrumento de rol de la enfermera de práctica avanzada se considera validado para el personal de enfermería del tercer nivel de atención en Cuba, al obtener alta confiabilidad, mediante pilotaje con índices adecuados de validez y confiabilidad(AU)

Introduction: Nursing, as a profession, has developed an improvement at the level of health systems, especially in the healthcare area. The needs demanded by society have been responded with the evolution of the role, as well as an increase of functions and responsibilities in the profession, which has led to the emergence of a new reference: the advanced practice nurse. Objective: To validate the instrument for defining the role of advanced practice nurse at the tertiary level of healthcare in Cuba. Methods: A methodological study was carried out in Complejo Científico Ortopédico Internacional "Frank País", in Havana, and in the Cardiocentro of Villa Clara Province, Cuba, in the year 2022, through piloting with 15 nurses of the orthopedics and traumatology service and 15 nurses working at the Cardiocentro of Villa Clara. An index was calculated with the application of Crespo's fuzzy logic, while Cronbach's alpha was used for determining the internal consistency of the instrument. Results: With the application of Crespo's fuzzy logic, correlation between items, internal consistency and factor analysis were observed. The reliability of the test showed a Cronbach's alpha coefficient of 0.95 and also a standardized Cronbach's alpha of 0.95, results that enhance the high internal consistency of the applied scale. Conclusions: The role-defining instrument for advanced practice nurse is considered validated for the nursing staff of the tertiary level of healthcare in Cuba, by obtaining high reliability, through piloting with adequate validity and reliability indexes(AU)

Enfermería de práctica avanzada del primer nivel de atención a población materna infantil en Villa Clara, Cuba / Advanced Practice Nursing at the Primary Level of Healthcare Provided to a Mother and Infant Population in Villa Clara Province, Cuba

Introducción: La Práctica Avanzada de Enfermería constituye una práctica con alcance expandido, que busca responder a problemáticas de los pacientes en un área clínica específica. Objetivo: Identificar de las funciones declaradas práctica avanzada a nivel internacional, las que realiza el personal de enfermería de la atención materna infantil en el primer nivel de atención. Métodos: Estudio descriptivo transversal, en Villa Clara, Cuba, entre febrero y diciembre del 2021. Universo de 671 licenciados, muestreo probabilístico con un 95 por ciento de confiabilidad de la muestra seleccionada, con 326 enfermeros que laboran en los 35 policlínicos y atienden el programa Materno Infantil. Se aplicó el instrumento de definición del rol de Enfermera de Práctica Avanzada, se calculó el promedio de las funciones agrupadas por dominios, la desviación estándar y coeficiente de variación entre sus ítems; el Alfa de Cronbach y un índice, que estableció correlación entre los ítems para medir consistencia interna de la escala por dimensiones y a nivel global. Resultados: El total de los dominios se encuentra por encima del indicador establecido para cada dimensión que la acredita como práctica avanzada. No se encontró ningún dominio con el índice bajo, los seis mantuvieron una validez y fiabilidad por encima de 0,5. La consistencia interna por alfa de Cronbach obtenida fue alta. Conclusiones: Las funciones de práctica avanzada reconocidas a nivel internacional se ejecutan por las enfermeras, incluidas en el estudio en su práctica diaria, en tanto los diferentes dominios del instrumento alcanzaron valores superiores al indicador establecido(AU)

Introduction: Advanced nursing practice presents an expanded scope that seeks to respond to patient problems in a specific clinical area. Objective: To identify, from among the functions declared as advanced practice at the international level, those performed by the nursing personnel in mother and infant care at the first level. Methods: A cross-sectional and descriptive study was carried out in Villa Clara, Cuba, between February and December 2021. The study universe was made up of 671 graduates. Through probabilistic sampling with 95 percent of reliability, a sample was selected, consisting of 326 nurses working in the 35 polyclinics of the province and in charge of the Mother and Infant Care Program. An advanced practice nurse role delineation instrument was applied. The calculations were made corresponding to the average number of functions grouped by domains, standard deviation, and the coefficient of variation between its items; as well as Cronbach's alpha and an index establishing a correlation between the items for measuring the internal consistency of the scale by dimensions and globally. Results: All the domains are above the indicator established for each dimension accrediting it as advanced practice. No domain was found with a low index; all six maintained a validity and reliability above 0.5. The internal consistency obtained using Cronbach's alpha was high. Conclusions: The internationally recognized advanced practice functions are performed by the nurses, included in the study as part of their daily practice, since the different domains of the instrument reached values above the established indicator(AU)

Feasibility of an Advance Care Planning Program (ACP) for Korean Community-Dwelling Older Adults and ACP Training of Advance Practice Nurses.

This study aimed to develop a locally suitable advance care planning (ACP) program for older community-dwelling adults and a training program for nurse facilitators in Korea, and to evaluate their feasibility from the facilitators' experiences. This was a mixed methods pilot study that assessed the feasibility of an ACP program by analyzing survey, checklist, and focus group interview data. The ACP program was named CLOSE (Communicating and Listening to Our Seniors' voices about End-of-life care). Home health care nurses (N = 9) participated in this study. The participants reported that CLOSE was applicable to older community-dwelling adults and the training program was useful for increasing facilitator competency. We suggest some lessons from this pilot study that can be used to improve the ACP program and encourage community health nurses to participate in ACP as facilitators.

Advance Practice Provider Transformational Leadership Structure: A Model for Change.

BACKGROUND: The role of the advanced practice provider (APP) is rapidly expanding in healthcare, whereas infrastructure to support it is not keeping pace. A large academic healthcare organization implemented the role of a director of APPs; supported by the C-suite, one who understands scope of practice, revenue models, and compliance and addresses engagement and retention to meet this challenge. This article chronicles the implementation of innovative success strategies, supporting APPs across a large academic health system, employing more than 1000 APPs, which has led to improvements in APP-generated revenue, patient access, engagement, and alignment. METHODS: Emory Healthcare rapidly expanded the number of APPs (nurse practitioners and physician assistants) over the past 10 years. APPs reported to administration or nursing leadership leading to APP dissatisfaction, questions on return on investment (ROI) and productivity, and poor utilization due to lack of role clarity. An APP leadership structure was created so that every APP reported to an APP leader. In alignment with the goals and plan for Emory Healthcare, standardized service line productivity and accountability expectations were developed and implemented, as well as a vision and strategic plan to support APPs. RESULTS: Improvement in productivity was seen across service lines, supported by the increase in full-time equivalent numbers, while improving the ROI for the organization. A roadmap to aligning an APP and organizational strategic plan has been created and implemented. Improvement in APP engagement was realized. CONCLUSIONS: An APP director and leadership structure are vital to the creation of infrastructure to support APPs in this healthcare. Optimization and standardization of APP practice resulted in role clarity and allowed for support of practice development.

Advanced Practice Provider Clinics: Expediting Care For Children Undergoing Tympanostomy Tube Placement.

OBJECTIVE/HYPOTHESIS: Advanced practice provider (APP) employment is becoming common in pediatric otolaryngology practices, though few studies have evaluated the consequences that APP-led clinics have on access to care. The objectives of this study were: 1) to investigate whether access to bilateral myringotomy with tympanostomy tube placement (BMT) for recurrent acute otitis media (RAOM) differed between patients seen in otolaryngologist and APP-led clinics 2) to compare clinical characteristics of patients seen by provider type. METHODS: Retrospective cohort study at an academic, tertiary care pediatric otolaryngology practice. All children were <18 years old and underwent evaluation for RAOM followed by BMT. We compared time in days from scheduling pre-operative appointment to appointment date and time from appointment to BMT between patients seen by APPs and otolaryngologists using Mann-Whitney U tests and multivariate linear regression models. We compared clinical characteristics by provider type using Mann-Whitney U tests and Fisher exact tests. RESULTS: A total of 957 children were included. Children seen by APPs had significantly shorter wait times for appointments (median 19 vs. 39 days, P < .001) and shorter times from preoperative appointment to BMT (median 25 vs. 37 days, P < .001). Patients seen by otolaryngologists had increased prevalence of craniofacial abnormalities, Down Syndrome, hearing loss, history of otologic surgery, and higher ASA physical status classification. CONCLUSIONS: Children seen by APPs received care more quickly than those seen by otolaryngologists. Patients seen by otolaryngologists tended to be more medically complex. Implementation of independent APP clinics may expedite and improve access to BMT for children with RAOM. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2133-2140, 2021.

A preliminary evaluation of full practice authority of advance practice registered nurses in the Veterans Health Administration.

BACKGROUND: Responding to National Academy of Medicine and National Council of State Boards of Nursing recommendations, the Department of Veterans Health Affairs (VHA) implemented full practice authority (FPA) for Advanced Practice Registered Nurses in VHA medical centers (VAMCs) in 2017. PURPOSE: To evaluate FPA policy implementation's impact on quality indicators including access to care as measured by new patient appointments in primary, specialty and mental health services. METHODS: Linear growth models compared early (n = 85) vs. late (n = 55) FPA implementing VAMCs on the trajectories of each of the three quality indicators. FINDINGS: Early FPA implementing VAMCs showed greater rates of improvement over time in new patient appointments completed within 30 days of preferred date for primary care (p = .003), specialty care (p = 0.05), and mental health (p = 0.001). DISCUSSION: VAMCs that started implementation of FPA policy early showed greater improvement in access to care for Veterans over time than VAMCs that did not.

Étude exploratoire de la perception des parties prenantes hospitalières vis-à-vis de l'implantation des infirmiers en pratique avancée.

Introduction : One solution proposed by the authorities to address public health issues is to deploy a new category of professionals with a greater range of skills : advanced practice nurses (APNs). The literature identifies the complexity of the deployment projects of these professionals. The PEPPA model approved by the International Council of Nurses is the reference model for the introduction of APNs. The objectives of this study were to explore various stakeholders' perceptions on the introduction of APNs into health institutions, in order to propose recommendations to support the institutions.Method : A multicenter qualitative study was conducted in France's Provence-Alpes-Côte d'Azur region with physicians, managers, nurses, patients, and advanced practice students.Results : APNs are beneficial for patients and the health system, but their introduction into health institutions brings with it risks, primarily linked to their integration. APN introduction projects need to be well planned and should prioritize their integration.Discussion : Results consistent with the PEPPA model identified seven recommendations to facilitate the successful introduction of APNs into hospitals.Conclusion : This work needs to be continued with studies related to the out-of-hospital setting and the evaluation of the successfulness of APNs' introduction.

Advanced Practice Provider-Led Strategies to Improve Patient Discharge Timeliness.

Hospitals are under increased pressure to address both financial and capacity constraints to improve their clinical operations. Effective capacity management programs have become a key driver of clinical operations for managing the flow of patients into and out of the hospital. Many high-functioning medical centers have developed capacity management programs to strategically address patient throughput. Discharging patients from the hospital is one fundamental, but complex, patient flow initiative for efficient patient throughput. Despite advances in optimizing patient flow, there is a lack of understanding associated with the structure and processes to efficiently discharge patients. This article outlines a discharge timeliness project where advanced practice providers are principal leaders of designing a safe and efficient patient discharge prototype. Design thinking was used to develop a patient discharge prototype that included 6 key areas that led to improved discharge times on a cardiac surgery step-down unit. High tech solutions were incorporated into the electronic medical record system to enhance communication across phases of care and inform the interdisciplinary team of patient progress.

Cálculo del riesgo aterogénico en pacientes con enfermedad renal crónica. Una valoración complementaria en el riesgo cardiovascular / Estimating the atherogenic risk in patients with chronic kidney disease: a complementary evaluation in cardiovascular risk

OBJETIVO: con enfermedad renal crónica (ERC) así como explorar la influencia del sexo y la diabetes mellitus (DM) en dicho riesgo. MÉTODO: estudio descriptivo transversal en pacientes con ERC del Área Básica de Salud Balaguer (n= 1.852). Variables analizadas: sexo, DM, cHDL-cLDL-triglicéridos (cTG)-colesterol total (CT), índices: CT/cHDL, cLDL/cHDL, TG/cHDL, No-cHDL. Análisis estadístico mediante Chi cuadrado/U-Mann-Whitney con el programa SPSS. RESULTADOS: un total de 1.834 pacientes cumplían los criterios de inclusión. Se observaron valores óptimos de control lipídico (62,6% con CT< 200 mg/dl), aunque prevalencias elevadas de RA alto (73,3% según cociente CT/cHDL). Las mujeres (con o sin DM) presentaron valores lipídicos más altos que los hombres: CT 190 mg/dL (DE: 41,3) con DM y 198 mg/dl (DE: 39,1) sin DM, frente a 175 mg/dl (DE: 37,2) con DM y 183 mg/dl (DE: 38,9) sin DM (p< 0,001). El cálculo del RA para las mujeres fue superior en todos los cocientes excepto cTG/cHDL. Las personas no diabéticas presentaron una mayor prevalencia de RA elevado en comparación con las diabéticas; fue superior en cLDL/cHDL (44,4% sin DM frente a 39,8% con DM) y No-cHDL (68,0% sin DM frente a 59,3% con DM), pero inferior en cTG/cHDL (57,7% sin DM frente a 76,6% con DM) y CT/cHDL (72,7% sin DM frente a 74,4% con DM). CONCLUSIONES: parece que tanto los valores de RA como el control lipídico (CT, cLDL) son mejores en personas con DM (posible intensidad terapéutica) y peores en mujeres. Destaca el No-cHDL como mejor predictor entre todos los índices de cálculo del RA

OBJECTIVE: to determine the atherogenic risk in patients with chronic kidney disease (CKD), as well as to explore the influence of gender and diabetes mellitus (DM) in said risk. METHOD: a descriptive cross-sectional study in CKD patients from the Balaguer Basic Health Area (n= 1.852). Variables analyzed: gender, DM, HDLc-LDLc-triglycerides (TGc)-total cholesterol (TC); indexes: TC/HDLc, LDLc/HDLc, TG/HDLc, No-HDLc. Statistical analysis through Chi square-Mann-Whitney U with the SPSS program. RESULTS: in total, 1,834 patients met the inclusion criteria. Optimal values of lipid control were observed (62.6% with TC< 200 mg/dl), though there was a high prevalence of elevated AR (73.3% according to the TC/HDLc ratio). Women (with or without DM) presented higher lipid values than men: TC 190 mg/dL (SD: 41.3) with DM and 198 mg/dl (SD: 39.1) without DM, vs. 175 mg/dl (SD: 37.2) with DM and 183 mg/dl (SD: 38.9) without DM (p< 0.001). The estimation of AR for women was superior in all ratios except for TGc/HDLc. Non-diabetic persons presented a higher prevalence of high AR vs. diabetic persons; it was higher in LDLc/HDLc (44.4% without DM vs. 39.8% with DM), and No-HDLc (68.0% without DM vs. 59.3% with DM), but lower in TGc/HDLc (57.7% without DM vs. 76.6% with DM) and TC/HDLc (72.7% without DM vs. 74.4% with DM). CONCLUSIONS: it seems that both AR values and lipid control (TC, LDLc) are better in persons with DM (potential treatment intensity), and worse in women. No-HDLc stands out as the best predictor among all indexes for calculating AR

Sustaining the quality of midwifery practice in Belgium: Challenges and opportunities for advanced midwife practitioners.

BACKGROUND: Midwifery practice is essential in achieving high-quality maternal and newborn care in all settings and countries. However, midwifery practice has become more complex over the past decades. Considerable demands are being placed on midwives to meet increasing epidemiological, socio-economic, and technological challenges. These require a well-trained midwifery workforce ready to shape the care in the near and long-term future. OBJECTIVE: To discuss advanced midwife practitioner role implementation in Belgium as a possible answer to healthcare-related challenges that impact midwifery practice. Furthermore, to stimulate a debate within the profession at all levels in Belgium and in countries considering advanced midwife practitioner roles. METHOD: The framework by De Geest et al. (2008) served as a basis for discussing the drivers for advanced midwife practitioner role implementation: the legal, policy and economic context, workforce issues, education, practice patterns, and healthcare needs of the population. FINDINGS: A legal basis for advanced midwife practitioner role implementation is lacking in Belgium. Remuneration opportunities for the non-clinical part of these roles (e.g. leadership and innovation activities) are missing. It might be challenging for healthcare organisations to support the implementation of such roles, as immediate revenues of non-clinical activities are absent. However, sufficient potential resources are available to fill in future advanced midwife practitioner positions. Additionally, advanced midwife practitioner specific master programmes are being planned in the near future. CONCLUSIONS: Although several barriers for the implementation of advanced midwife practitioner roles were identified, a discussion should be held on the opportunities of implementing these roles to facilitate the development of new models of care that meet current and future challenges in midwifery practice and healthcare. After initial discussions amongst midwives in academic, managerial, and policy positions, stakeholders such as obstetricians, general practitioners, associations representing healthcare organisations, and policy makers should be involved as a next step.

Driving high-functioning clinical teams: An advanced practice registered nurse and physician assistant optimization initiative.

BACKGROUND: Rapid changes in the health care marketplace are driving health care systems to modify operations by which the advanced practice registered nurse (APRN) and physician assistant (PA) clinicians serve patients. By identifying more effective and efficient utilization workflows, organizations can meet these demands resulting in high-functioning clinical teams. LOCAL PROBLEM: With the growing number of APRNs and PAs within a large academic medical center, there was a recognized need to establish effective and efficient utilization practices for these health care providers. METHODS: Directors of the Advanced Practice Provider Best Practice Center developed an internal nurse practitioner (NP)/certified nurse midwife (CNM)/clinical nurse specialist (CNS)/PA assessment service in which evaluations were conducted to optimize APRN and PA practice at the clinical/department level. This assessment excluded certified registered nurse anesthetists. INTERVENTIONS: Thirty-two clinical areas were evaluated between September 2016 and May 2019. This included an NP/CNM/CNS/PA survey and over 200 individual NP/CNM/CNS and PA provider interviews. Assessments addressed utilization, billing practices, professional development, and communication among team members. RESULTS: Qualitative and quantitative reports were compiled. Many common themes were identified. These were broken down into three major categories: productivity, clinical operations, and professional development/support. CONCLUSIONS: Several recommendations were presented to department leaders regarding NP/CNM/CNS/PA practice. Those departments who implemented several of the recommendations showed positive outcomes. This was evidenced by increased financial gain (increased relative value units, increase in revenue generated), increased patient access (increased clinic densities), and overall NP/CNM/CNS/PA satisfaction.