Exploring the Patient's Experience of Receiving Clinical Care Which Incorporates the Use of Mobile Technology at the Bedside.

OBJECTIVE: Research-based insight into patient's experiences of mobile technology at the bedside in the hospital setting remains limited. This research project aims to explore patient's experience. METHODS: This mixed method pre and post study aimed to explore the patient experience in relation to this and also test whether introducing further bedside technology (beyond the workstation on wheels) had an effect on the patient experience. Questionnaires and interviews were conducted among inpatient samples prior to and one year post introduction of a suite of new bedside technologies. RESULTS: Pre and post patient survey results (pre: n=82; post: n=98) suggested that mixed views and perceptions existed and that some of these were associated with primary demographics such as age. At post-test, attitudes about bedside technology were found to be more positive, and feedback about care quality was found to be unchanged, Baseline patient interview findings (n=15) highlight the social ubiquity of technology as a driver of positive attitude in the digital health context. CONCLUSION: The addition of new bedside technology is very well received by patients and was not perceived to impact on care quality.

Using and understanding consumer satisfaction to effect an improvement in mental health service delivery.

Consumer satisfaction is today, widely accepted as a measure of the level and quality of service received by consumers. The aim of this survey-based study is to explore consumer satisfaction with quality of care, staff, environment and discharge in a south eastern Sydney adult acute inpatient mental health unit. A cross-sectional analysis is pursued in order to identify aspects of the patient stay, which form an associative relationship with an overall rating of consumer satisfaction on a 10-point scale. During the survey period, there were 182 discharges. Seventy questionnaires (38.5%) were returned from this group. The survey results highlight a number of areas of identified need, enabling the service to prioritize organizational systems around meeting these needs. Multiple regression analysis identified three items in the survey, which were independently significant associates of overall consumer satisfaction. They included being happy with the service provided by the consumer support worker, having support for services on discharge and feeling safe and secure on the ward. The model containing these three items accounted for 50% of the variation in overall satisfaction. Two primary interventions have been developed because survey administration which, it is hoped, will address issues raised in the survey. The interventions were the development of an admission and discharge pathway and a ward-based psychosocial intervention programme, which includes the involvement of consumer support workers.

Health professionals' attitudes towards suicide prevention initiatives.

Preventing suicide can depend upon the ability of a range of different health professionals to make accurate suicide risk assessments and treatment plans. The attitudes that clinicians hold towards suicide prevention initiatives may influence their suicide risk assessment and management skills. This study measures a group of non-mental health professionals' attitude towards suicide prevention initiatives. Health professionals that had attended suicide prevention education showed significantly more positive attitudes towards suicide prevention initiatives. The findings in this study further support the effectiveness of educating non-mental health professionals in suicide risk awareness and management.

Patient characteristics and quality of life among a sample of Australian chronic pain clinic attendees.

BACKGROUND: Multidisciplinary chronic pain management programs have proliferated widely in recent decades. The clinical characteristics of patients attending these clinics are becoming the subject of increased research. Recent European data suggests that patients attending these clinics report very low quality of life. AIMS: The present study profiles an Australian population in terms of demographics, clinical characteristics and quality of life, as measured by the Short Form 36 Quality of Life Questionnaire (SF-36). METHODS: Data were collected prospectively from consecutive patients presenting to a multidisciplinary chronic pain clinic at a major Sydney metropolitan teaching-hospital. Cross-sectional analysis of demographic and clinical characteristics and quality of life were then undertaken. RESULTS: Descriptive analysis of demographics and clinical characteristics suggest a patient population group reporting significant pain severity and reduced quality of life. The comparison of SF-36 domain scores between clinic patients and Australian norm values indicates a greatly reduced score on all SF-36 domains for clinic patients. Pain clinic patients reported the most profound effect upon quality of life in the role physical, physical function and social function domains of the SF-36. Stepwise multiple regression indicated impaired coping ability and depressive disability as the most significant correlates of low quality of life. CONCLUSION: Patients who attend chronic pain clinics are likely to report low quality of life with an inability to cope. These findings suggest that future intervention research should explore the impacts of behavioural and self-management interventions. Psychological distress and ability to cope could be used as indices of improvement.

Comparing first and subsequent suprapubic catheter change: complications and costs.

Urologic and continence nursing advanced significantly during the 1990s. Today's health care environment emphasizes careful rationalizing of hospital-based resources. This trend is more or less responsible for the demise of medically managed suprapubic catheter (SPC) change. The results of this study indicate that first change of SPC, performed in the patient's home or outpatient clinic by appropriately skilled registered nurses, is a cost-effective practice with no increased risk of complication to the patient.

Management of postoperative epidural analgesia: a survey of Australian practice.

A sample of Australian hospitals was surveyed about their practice preferences in relation to the management of epidural analgesia for postoperative pain. Results indicated substantial variation in practice preference across institutions with respect to observation protocols, epidural analgesia duration, catheter removal where anticoagulant therapy is concurrent and management of catheter problems. Further research appears necessary to develop optimal epidural analgesia management practice.

Physician credentials and practices associated with childhood immunization rates: private practice pediatricians serving poor children in New York City.

Private practice physicians in New York City's poorest neighborhoods are typically foreign trained, have generally substandard clinical practices, and have been accused of rushing Medicaid patients through to turn a profit. However, they also represent a sizable share of physician capacity in medically underserved neighborhoods. This article documents the level of credentials, systems, and immunization-related procedures among these physicians. Furthermore, it assesses the relationship between such characteristics and childhood immunization rates. The analysis utilizes a cross-sectional comparison of immunization rates in 60 private practices that submitted 2,500 or more Medicaid claims for children. Immunization data were gathered from medical records for 2,948 randomly selected children under 3 years of age. Half of sampled physicians were board certified (55%), and half were accepted by the Medicaid Preferred Physicians and Children (PPAC) program (51.7%). Of physicians, 43% saw patients only on a walk-in basis, while only 17% scheduled the next appointment while the patient was still in the office. There were 75% of the physicians who reported usually immunizing at acute care visits. Immunization rates were higher among PPAC physicians compared to others (41% vs. 29% up to date for diphtheria and tetanus toxoids and pertussis [DTP]/Haemophilus influenzae type b [Hib], polio, and measles-mumps-rubella [MMR], P = .01), and board-certified physicians showed a trend toward better immunization rates (39% vs. 30%, P =.07). Physicians who reported usually immunizing at acute care visits also had higher rates than those who did not (38% vs. 27%, P = .05). Scheduling a date and time for the next immunization showed a trend toward association with immunization coverage (37% vs. 28%, P= .10). Private practice physicians who provide high volumes of care reimbursed by Medicaid have improved their credentials and affiliations over time, thereby expanding reimbursement options. Credentials and affiliations were at least as effective in distinguishing relatively high- and low-performing physicians, as were immunization-related practices, suggesting that they are useful markers for higher quality care. The relative success of the PPAC program should inform efforts to improve the capacity and quality of primary care for vulnerable children. Appointment and reminder systems that effectively manage the flow of children back into the office for immunizations and the vigilant use of acute care visits for immunizations go hand in hand. Opportunity exists for payers and plans to encourage and support these actions.

Impact of financial incentives on documented immunization rates in the inner city: results of a randomized controlled trial.

OBJECTIVE: This study determined the effect of 2 financial incentives---bonus and enhanced fee-for-service---on documented immunization rates during a second period of observation. METHODS: Incentives were given to 57 randomly selected inner-city physicians 4 times at 4-month intervals based on the performance of 50 randomly selected children. Coverage from linked records from all sources was determined for a subsample of children within physician offices. RESULTS: Up-to-date coverage rates documented in the charts increased significantly for children in the bonus group (49.7% to 55.6%; P <.05) and the enhanced fee-for-service group (50.8% to 58.2%; P <.01) compared with the control group. The number of immunizations given by these physicians did not change significantly, although the number of immunizations given by others and documented by physicians in the bonus group did increase (P <.05). Up-to-date coverage for all groups increased from 20 to 40 percentage points when immunizations from physician charts were combined with other sources. CONCLUSIONS: Both financial incentives produced a significant increase in coverage levels. Increases were primarily due to better documentation not to better immunizing practices. The financial incentives appeared to provide motivation to physicians but were not sufficient to overcome entrenched behavior patterns. However, true immunization coverage was substantially higher than that documented in the charts.

Comparison of preventive care in Medicaid managed care and Medicaid fee for service in institutions and private practices.

OBJECTIVE: To compare preventive screening for children in Medicaid managed care (MMC) with children in Medicaid fee for service (M-FFS) in private and institutional settings. METHODS: The sample included randomly selected institutions and private practice physicians in New York City. Within setting, children in MMC and M-FFS were sampled randomly and charts reviewed for immunizations and lead and anemia screening. RESULTS: In both institutions and private practices, children enrolled in MMC appeared more likely to be up-to-date than their M-FFS counterparts for immunizations (institution, P <.01; private practice, P <.05), lead screening (institution, P <.01; private practice, P <.01), and anemia screening (institution, P <.01; private practice, P <.01). However, children in MMC had more visits (P <.01) and were followed up for a longer time (P <.01). After controlling for these variables, effects of MMC diminished and only remained significant for screening among private physicians. When considering 10 different attributes of managed care plans, no clear pattern of association with better preventive care services was observed. CONCLUSION: The positive effect of managed care on preventive care services was largely explained by more visits and longer follow-up time; however, there were differences between institutions and private practices, with enrollment in MMC associated with some positive effect on screenings in private practices.

Findings from case studies of state and local immunization programs.

BACKGROUND: As part of its examination of federal support for immunization services during the past decade, the Institute of Medicine (IOM) Committee on Immunization Finance Policies and Practices (IFPP) commissioned eight case studies of the states of Alabama, Maine, Michigan, New Jersey, North Carolina, Texas, and Washington; and a two-county study of Los Angeles and San Diego in California. Specifically, the IOM Committee and these studies reviewed the use of Section 317 grants by the states. Section 317 is a discretionary grant program that supports vaccine purchase and other immunization-related program activities. These studies afforded the Committee an in-depth look at local policy choices, the performance of immunization programs, and federal and state spending for immunization during the past decade. METHODS: The case-study reports were developed through interviews with state and local health department officials, including immunization program directors, Medicaid agency staff, budget analysts, and Centers for Disease Control and Prevention public health advisors to the jurisdiction. Other sources included state and federal administrative records and secondary sources on background factors and state-level trends. The case studies were supplemented by site visits to Detroit, Houston, Los Angeles, Newark, and San Diego. OBSERVATIONS: The nature of immunization "infrastructure" supported by the Section 317 program is shifting from primarily service delivery to a broader set of roles that puts the public effort at the head of a broad immunization partnership among public health, health financing, and other entities in both the public and private sectors. The rate and intensity of transition vary across the case-study areas. In the emerging pattern, service delivery increasingly takes place in the private sector and is related to managed care. "Infrastructure" is moving beyond supporting a core state staff and local health department service delivery to include such activities as immunization registries, quality improvement, and coordination with programs outside public health agencies. At the same time, the recent decline in federal Section 317 support is forcing difficult choices between old and new activities at the state and local levels. CONCLUSIONS: Immunization programs function as an organic component of the local health care financing and delivery systems of which they are a part. Immunization efforts are organized and conducted within distinctive state and local fiscal, economic, and health care contexts. Section 317 Financial Assistance grants, while playing a vital role in supporting immunization "infrastructure," have been too unstable and unpredictable to elicit the strategic planning, programming, and own-source spending that would be optimal for state and local programs. The predominant immunization function of state and local public health agencies is becoming assurance of age-appropriate immunization throughout the lifespan. To be successful in this emerging role, the health agencies must be supported with appropriate staffing, interagency collaboration, and clearly articulated authority.

Measuring immunization coverage.

OBJECTIVE: Information about immunization coverage comes from five major sources: the National Immunization Survey, the National Health Interview Survey, retrospective school-entry surveys, the Health Plan Employer Data and Information Set (HEDIS) measures reported by managed care plans, and assessments performed on clinics and private practices. In this article, we describe the methodology of the major surveys, discuss technical and policy issues in measuring immunization coverage, and identify issues that must be addressed to harmonize immunization rates calculated from different sources. METHODS AND TOPICS: We describe the (1) design and methodology of the five major sources of immunization coverage assessments, (2) issues and controversies in measuring immunization coverage, and (3) preliminary efforts to harmonize calculation of immunization coverage. Technical and policy issues involve dose and interval requirements, which vaccines are included in the series-completion calculations, and who is excluded from each method of calculation. CONCLUSIONS: The purpose of measuring up-to-date immunization coverage determines the way that it is measured. The tension between measuring immunization coverage to monitor population protection against disease and measuring immunization coverage to determine how well the health care delivery system is working leads to different ways of selecting a sample and reporting coverage. These differences create confusion for the public policymakers who try to identify problems and to set priorities for immunization efforts. Although some unavoidable differences may occur because of differences in purpose of the measurement, greater harmonization is possible.

EQuIP accreditation: feedback from a Sydney teaching hospital.

The Australian Council on Healthcare Standards' new Evaluation and Quality Improvement Program (EQuIP) accreditation model reflects the worldwide trend towards incorporating continuous quality improvement and patient-focused care goals into hospital/health service accreditation. We conducted a post-EQuIP feedback survey among senior clinical and managerial staff at a Sydney teaching hospital and identified significant levels of negative feedback among respondents. Principal concerns were related to perceptions that the process was unnecessarily unwieldy and that it offered little value in terms of patient care delivery for the significant amount of human resources it consumed.

Problems with quality monitoring for Medicaid managed care: perceptions of institutional and private providers in New York City.

The study objective was to examine quality oversight efforts by Medicaid managed care organizations (MCOs) for children in a sample of ambulatory care institutions and private practices in New York City. This was a cross-sectional study of quality assurance priorities and strategies of MCOs and their impact date in institutions in New York City. Data were from structured interviews administered in 1997 to medical directors in the eight largest MCOs; and medical directors, heads of ambulatory pediatrics, and institutional pediatricians in a random sample of 15 institutions and 20 private office-based providers. Medical directors in MCOs reported that their main priority areas were the preventive care measures (e.g., immunization and lead screening) that they must report to the state. Knowledge of these MCO priority areas and monitoring activities was high for medical directors in the random sample, but decreased from these medical directors to heads of ambulatory pediatrics to institutional pediatricians, with the differences between the medical directors and institutional pediatricians significant (P < .05). However, 96% of the institutional pediatricians reported knowing their own institution's priorities and monitoring activities. In contrast, most private pediatricians reported they knew MCO priorities and monitoring activities (80%). Less than 33% of any group reported activities as "very effective" or felt any incentive to improve performance. There was a high level of overlap in provider networks, with institutions and private providers having children in many MCOs, and MCOs having children in many sites. Conclusions. The current model of quality oversight is producing reports for the state, but is not translating into effective strategies at the provider level. The need to work through the leadership in institutions to influence quality is highlighted. The level of overlap in provider networks suggests the need for collaboration among MCOs in quality monitoring.

The relative influence of personal and workplace descriptors on stress.

A survey canvassing self-reported workplace stress levels and personal/workplace demographics was conducted among a sample of Australian nurses. Stress ratings and demographics were cross-sectionally analysed. Quantitative and qualitative analyses of survey responses suggest that excessive workload is the likely dominant predictor of workplace stress. Personal and workplace demographics are shown to be relatively unimportant in comparison with workload-related factors. Regular exercise habit was shown to be correlated with reduced workplace stress ratings. The findings support a previously unreported view that nurses are unlikely to bring their personal stress with them to the workplace--rather the workload characteristics of the workplace itself are the principle stress determinants.

Substance-use assessment for hospital inpatients.

Many patients are not assessed for substance use and few are assessed comprehensively. Nurses are more likely than doctors to take a comprehensive substance-use history. A substance-use history assessment tool can be used hospital-wide.

The impact of physician bonuses, enhanced fees, and feedback on childhood immunization coverage rates.

OBJECTIVES: The purpose of this study was to examine the effects on immunization coverage of 3 incentives for physicians--a cash bonus for practice--wide increases, enhanced fee for service, and feedback. METHODS: Incentives were applied at 4-month intervals over 1 year among 60 inner-city office-based pediatricians. At each interval, charts of 50 randomly selected children between 3 and 35 months of age were reviewed per physician. RESULTS: The percentage of children who were up to date for diphtheria, tetanus, and pertussis and Haemophilus influenzae type b; polio; and measles-mumps-rubella immunization in the study's bonus group improved by 25.3 percentage points (P < .01). No significant changes occurred in the other groups. However, percentage of immunizations received outside the participating practice also increased significantly in the bonus group (P < .01). Levels of missed opportunities to immunize were high in all groups and did not change over time. Physicians' knowledge of contraindications was low. CONCLUSIONS: Bonuses sharply and rapidly increased immunization cover-age in medical records. However, much of the increase was the result of better documentation. A bonus is a powerful incentive, but more structure or education may be necessary to achieve the desired results.

Experiences of families that applied for government-sponsored child health insurance: report of a follow-up study in New York City.

CONTEXT: This study followed up on a summer 1997 advocacy project by the Children's Defense Fund--New York, which assisted families in New York City in enrolling their children in government-sponsored health insurance programs (Medicaid and Child Health Plus). OBJECTIVE: To determine how many participants from the 1997 project acquired insurance, to document their experiences during the application process, and to solicit their suggestions on improving the application process. DESIGN: Guided telephone interviews in summer 1998 with all families from the 1997 program that could be located. PARTICIPANTS: Fifty-five families from New York City that, with the assistance of the Children's Defense Fund--New York, applied for Medicaid or Child Health Plus in summer 1997. RESULTS: Of the 55 families, 46 acquired insurance for their children at some point during the year. A number of families changed insurance status several times during the year, and some insured originally through government-sponsored programs later acquired private insurance. The families experienced many difficulties in dealing with the health insurance bureaucracies. CONCLUSION: The process of applying for Medicaid and Child Health Plus is more difficult and time consuming than may be realized, and many families may go through the application repeatedly. Current efforts to decrease the number of uninsured children in the US must take into account the bureaucratic barriers faced by families that are eligible for these programs and must consider ways to make the application process less formidable.

Evaluation of "Hope for a Million Kids Immunization Event: "process, outcome, and costs.

This study evaluates the Hope For A Million Kids Immunization Event in East Harlem, New York, in 1996. The methodology: (1) Documented planning and implementation processes. (2) Analyzed numbers of children reached through the outreach initiative and those actually immunized due to the Event. (3) Assessed associated costs. The Event reached and educated 120,000 children through door-to-door canvassing. Substantially fewer children, 562, registered at the Health and Human Services Fair, and 211 children were immunized at a cost of about $594 per immunized child. Immunization registries may be more effective in increasing childhood immunization rates.

A comparison of dressings in the management of surgical abdominal wounds.

This prospective randomised trial compared the performance of three dressing protocols in the management of 36 dehisced surgical abdominal wounds: a standard alginate; a gauze moistened with sodium hypochlorite (0.05%); and a combine dressing pad. Outcomes assessed were: healing time (cm2 per day and cm3 per day), patient comfort (pain and satisfaction) and cost. There were no statistically significant differences in healing rates between the three groups but there was a trend for the combine dressing pad protocol to produce a greater reduction in wound area. The combine dressing pad protocol performed well when compared with the calcium alginate in terms of healing time, patient comfort and cost. Maximum pain was significantly greater (p = 0.011) and satisfaction significantly lower among patients who received the sodium hypochlorite protocol. Costs during the in-patient phase were also substantially higher for the sodium hypochlorite protocol. Trial results support the view that sodium hypochlorite dressing protocols for surgical wounds should be abandoned.

Prostate disease patients: planning services to meet their coping needs.

A committee comprising hospital and community-based urology and oncology nurses and social workers planned, organized, implemented, and evaluated an educational public seminar on prostate cancer (PC). Data relating to satisfaction with the seminar, reasons for attendance, perceived needs for further support/education, and demographics were collected using a feedback questionnaire. Results suggested a need for education and a significant interest in support groups and further educational forums for patients with PC or symptoms and their caregivers.