Genetic discrimination: the clinician perspective.

Clinicians attending continuing education sessions in California were surveyed about their beliefs and attitudes regarding genetic discrimination and their knowledge of protective legislation. Two hundred seventy-one surveys were collected from physicians (n = 191) and nurses (n = 80). Most respondents lacked information or were misinformed about the existence of protective legislation (58.3%) or published cases of insurance discrimination (85.2%); 52.4% believed that mutation carriers have difficulty obtaining health insurance; 13% would not encourage genetic testing, despite a family history of cancer. Clinician concerns about potential genetic discrimination, and lack of information regarding protective legislation, may influence access to care.

Effects of a cancer genetics education programme on clinician knowledge and practice.

BACKGROUND: Many clinicians lack adequate knowledge about emerging standards of care related to genetic cancer risk assessment and the features of hereditary cancer needed to identify patients at risk. OBJECTIVE: To determine how a clinical cancer genetics education programme for community based clinicians affected participant knowledge and changed clinical practice. METHODS: The effects of the programme on participant knowledge and changes in clinical practice were measured through pre and post session knowledge questionnaires completed by 710 participants and practice impact surveys completed after one year by 69 out of 114 eligible annual conference participants sampled. RESULTS: Respondents showed a 40% average increase in specific cancer genetics knowledge. Respondents to the post course survey reported that they used course information and materials to counsel and refer patients for hereditary cancer risk assessment (77%), shared course information with other clinicians (83%), and wanted additional cancer genetics education (80%). CONCLUSIONS: There was a significant immediate gain in cancer genetics knowledge among participants in a targeted outreach programme, and subset analysis indicated a positive long term effect on clinical practice. Clinician education that incorporates evidence based content and case based learning should lead to better identification and care of individuals with increased cancer risk.

Urinary incontinence treatment preferences in long-term care.

OBJECTIVE: To elicit preferences for different urinary incontinence (UI) treatments in long-term care (LTC) from groups likely to serve as proxy decision makers for LTC residents. DESIGN: A descriptive, comparative study of preference for UI treatments of frail older adults, family members of nursing home (NH) residents, and LTC nursing staff. Surveys were mailed to families and self-administered by staff. Older adults were interviewed. SETTING: Four LTC facilities and two residential-care facilities in Los Angeles. PARTICIPANTS: Four hundred and three family members of incontinent NH residents were mailed surveys. Sixty-six nursing staff caring for these incontinent residents and 79 older adult residents of care facilities (nine cognitively intact NH respondents and 70 residential care residents) answered surveys. MEASUREMENTS: Preference rankings between seven paired combinations of five different UI treatments were measured on an 11-point visual analog scale, with the verbal anchors "definitely prefer" this treatment, "probably prefer" this treatment, and "uncertain." Respondents gave open-ended comments as well. RESULTS: Forty-two percent of family members (171/ 403) returned the mailed survey. Of all respondents, 85% "definitely" or "probably" preferred diapers, and 77% "definitely" or "probably" preferred prompted voiding (PV) to indwelling catheterization. Respondent groups occasionally differed significantly in their preferences. In choosing between treatment pairs using a visual analogue scale, nurses preferred PV to diapers significantly more than did older adults or families (both of whom preferred diapers) (F (2,295) = 13.11, P < .0001). Older adults, compared with family and nurse respondents, showed a significantly stronger preference for medications over diapers (F (2,296) = 41.54, P < .0001). In open-ended responses, older adults stated that they would choose a UI treatment based in part upon criteria of feeling dry, being natural, not causing embarrassment, being easy, and not resulting in dependence. Nurses said that they would base their choice of UI treatment upon increasing self-esteem and avoiding infection. CONCLUSIONS: Although there was wide variation within and between groups about preferred UI treatment, most respondents preferred noninvasive strategies (diapers and PV) to invasive strategies (indwelling catheters and electrical stimulation). Older adults preferred to a greater degree medications and electrical stimulation, therapies directed at the underlying cause of UI. Despite data documenting that diapering is a less time intensive way to manage UI and that toileting programs are difficult to maintain in LTC, nurses viewed PV as "natural" and strongly preferred it to diapering. Several family members and older adults viewed PV as "embarrassing" and "fostering dependence." These data highlight the need to elicit preferences for UI treatment among LTC residents and their families.

Can hospital structural and financial characteristics explain variations in mortality caused by acute myocardial infarction?

Each year 1 in 160 people in the United States suffers from acute myocardial infarction (AMI). Of these more than 1.5 million cases annually, 500,000 end in fatalities. This study's purpose was to describe and evaluate the role hospital characteristics play in rates of mortality caused by AMI in acute-care California hospitals. Characteristics evaluated include structural characteristics--i.e., teaching status, percentage of board-certified physicians, registered nurse hours per patient day (RN hours/patient day), volume of cases, technological resource availability, and urban density; and financial characteristics--profit status and total operating expenses per patient day. Although part of a larger investigation correlating mortality and length of stay, this article reports only the results for significant influences on mortality.

Predictive power of clinical indicators for self-care deficit.

PURPOSE: To describe the predictive power of a set of the best clinical indicators for the nursing diagnostic labels self-care deficit (SCD) and impaired physical mobility. METHODS: Patient assessment data (physical examination and interview) were obtained from 414 hospitalized patients. FINDINGS: Patients with the diagnostic label of self-care deficit were significantly older in age, had a greater number of nursing diagnoses, required greater assistance in activities of daily living, and were less mobile than those without the diagnostic label. While 18 of 32 clinical indicators were positively related to self-care deficit, five clinical indicators were sufficient to diagnose SCD. CONCLUSIONS: Further development of the method may be useful in improving diagnostic accuracy and efficiency of nursing diagnoses.

Selecting nursing home residents for satisfaction surveys.

Many cognitively impaired nursing home (NH) residents are excluded from interviews measuring quality of life or care based on the belief that these residents cannot accurately answer questions. These exclusions are based on subjective criteria and ignore individual differences among cognitively impaired NH residents. This study describes a screening rule based on four minimum data set (MDS) indicators that provides an objective method for identifying residents capable of accurate report. Sixty percent of a sample of 83 NH residents who could answer yes or no questions about their care could do so accurately. Eighty-one percent of the sample was correctly classified by the MDS indicators.

Longitudinal effects of an HIV testing and counseling programme for low-income Latina women.

OBJECTIVES: The purpose of this study was to assess the effects of an HIV antibody testing, counseling and education programme on the knowledge and practices of low-income Los Angeles Latina women. METHODS: The study design was prospective and longitudinal involving pre-test, post-test and retest measures over a 2-year period. The study employed an experimental group and a comparison group which did not receive the intervention. The study group was comprised of a convenience sample of 508 low-income Latina women who were recruited from the Public Health Service nutrition programme for women, infants and children (WIC). The comparison group (n = 51) was recruited from the same setting. A battery of instruments was selected to measure HIV knowledge and practices, the social support received, self-esteem, the level of acculturation and sociodemographic characteristics. The instruments were administered at pre-test, 2 weeks post-test and 1 year retest. The HIV antibody serostatus was assessed at pre-test and retest. An intervention protocol based on cultural competence, women as traditional health care givers and the major transmission categories was provided after the pre-test and was reinforced post-test. Finally, qualitative data were collected from the focus group participants (n = 55) to evaluate the intervention protocol. RESULTS: The participants in the study made significant improvements in HIV knowledge and reported condom use practices from pre-test to post-test that were retained on retest. The comparison group subjects did not make significant pre-test-post-test improvements on these measures. CONCLUSIONS: It should be noted that the changes in practices made by the study group did not necessarily reduce their risk of HIV infection or transmission and were not related to the demonstrated knowledge and skills improvement. Of special significance to programme planners, educators and researchers, both the quantitative and qualitative data revealed problem areas with the intervention protocol related to cultural norms and the possible fragmentation of information based on the behavioral transmission categories.

Incontinence among nursing home patients: clinical and functional correlates.

This study was undertaken to examine the association of specific medical and genitourinary conditions, medications, and functional disabilities with urinary incontinence (UI) in a nursing home (NH) population. Seventy-six incontinent and 38 continent patients in a Veterans Administration NH were studied. Incontinence was highly associated with each of the physical and mental functional disabilities we examined. However, with the exception of recurrent urinary tract infections and dementia, no specific clinical factors were significantly more common among incontinent than continent patients. Although precise causes for the UI were not determined, these data highlight the potential role of impairments of physical and/or mental function in the pathogenesis of UI among NH patients, and emphasize the need to address these impairments in future research on the assessment and treatment of UI in this population.

Development and testing of an incontinence monitoring record.

Bladder records can play an important role in the assessment and treatment of incontinence. Many records currently used in long-term care settings are difficult to read and interpret, and they do not provide for the recording of information that can be of value in the assessment and treatment process. Two versions of an incontinence monitoring record (IMR), one using black and white symbols and the other using colored circles, were developed and tested in a quasiexperimental design in three proprietary nonacademically affiliated nursing homes. The IMRs were well accepted by the nursing staff in these homes. Recordings were made more frequently and interrater reliability was highest with the color version of the IMR. Results of this initial study are promising and suggest that the IMR, or a similarly designed record, will be helpful in nursing homes to assess the bladder and bowel status of new admissions, determine patterns of and factors associated with incontinence, design individualized bladder training programs, and monitor the results of these programs and other treatment modalities. In addition, the IMR can provide an opportunity for nurses' aides to meaningfully participate in the assessment and treatment of a condition they manage on a daily basis.

Information needs in office practice: are they being met?

We studied the self-reported information needs of 47 physicians during a half day of typical office practice. The physicians raised 269 questions about patient management. Questions related to all medical specialties and were highly specific to the individual patient's problem. Subspecialists most frequently asked questions related to other subspecialties. Only 30% of physicians' information needs were met during the patient visit, usually by another physician or other health professional. Reasons print sources were not used included the age of textbooks in the office, poor organization of journal articles, inadequate indexing of books and drug information sources, lack of knowledge of an appropriate source, and the time required to find the desired information. Better methods are needed to provide answers to questions that arise in office practice.

Adherence to health care regimens among elderly women.

This study examined selected components of nurse practitioners' care to determine which contributed most to the intent to adhere to the care plan. High and low levels of components of care (technical quality, psychosocial, and patient participation) were depicted by videotapes of a patient visit to a nurse practitioner. The videotapes were randomly selected and shown in 26 senior citizen nutrition centers in a metropolitan area. Elderly women indicated how likely they would be to adhere if they had been the patient in the tape. High psychosocial care was the only component significantly related to intent to adhere; however, the significance did not hold in an analysis of covariance when individual characteristics were controlled. Individual characteristics related to high intent to adhere were widowed marital status, religion, perceived importance of the examination, social network, and preexisting satisfaction with health care.