Allison P Squires

Abstract

BACKGROUND: The US Preventive Services Task Force recommends screening for and treating obesity. However, there are many barriers to successfully treating obesity in primary care (PC). Technology-assisted weight loss interventions offer novel ways of improving treatment, but trials are overwhelmingly conducted outside of PC and may not translate well into this setting. We conducted a systematic review of technology-assisted weight loss interventions specifically tested in PC settings. METHODS: We searched the literature from January 2000 to March 2014. Inclusion criteria: (1) Randomized controlled trial; (2) trials that utilized the Internet, personal computer, and/or mobile device; and (3) occurred in an ambulatory PC setting. We applied the Cochrane Effective Practice and Organization of Care (EPOC) and Delphi criteria to assess bias and the Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) criteria to assess pragmatism (whether trials occurred in the real world versus under ideal circumstances). Given heterogeneity, results were not pooled quantitatively. RESULTS: Sixteen trials met inclusion criteria. Twelve (75 %) interventions achieved weight loss (range: 0.08 kg – 5.4 kg) compared to controls, while 5–45 % of patients lost at least 5 % of baseline weight. Trial duration and attrition ranged from 3–36 months and 6–80 %, respectively. Ten (63 %) studies reported results after at least 1 year of follow-up. Interventions used various forms of personnel, technology modalities, and behavior change elements; trials most frequently utilized medical doctors (MDs) (44 %), web-based applications (63 %), and self-monitoring (81 %), respectively. Interventions that included clinician-guiding software or feedback from personnel appeared to promote more weight loss than fully automated interventions. Only two (13 %) studies used publically available technologies. Many studies had fair pragmatism scores (mean: 2.8/4), despite occurring in primary care. DISCUSSION: Compared to usual care, technology-assisted interventions in the PC setting help patients achieve weight loss, offering evidence-based options to PC providers. However, best practices remain undetermined. Despite occurring in PC, studies often fall short in utilizing pragmatic methodology and rarely provide publically available technology. Longitudinal, pragmatic, interdisciplinary, and open-source interventions are needed.

Abstract

Background: Nursing faculty shortages threaten a country's ability to produce the amount of nurses necessary to sustain the delivery of healthcare services. Programs that "fast track" graduate education options for registered nurses are one solution to the problem. Objectives: To 1) evaluate admission criteria into PhD programs for direct entry from a bachelor's degree; 2) ascertain bachelors and masters degree nursing students' perspectives on pursuing a BSN to PhD course of study; 3) clarify factors that influence students' decision-making processes behind pursuing a PhD and identify characteristics of those who would be likely recruits for PhD study; 4) to test the survey questions to develop an instrument for future use. Design: A cross-sectional pilot study. Setting: A nursing program at a large urban university in the United States of America with an enrollment of over 1400 students. Participants: Currently enrolled bachelor's, master's, and doctor of nursing practice students. Methods: Students were sampled via a 10-question (including one open-ended question) electronic mail survey that included 1385 eligible subjects. Results: Among the 606 respondents (57% response rate), 63% were between ages 18 and 30 and 87% indicated that full tuition funding with a living stipend would make them more interested in pursuing a PhD. Current program track was a significant predictor of course of study and area of interest (p = .029). Analysis of the 427 respondents to the open-ended question revealed themes around "time" and "money" as the main barriers to study. The desire to gain clinical experience prior to PhD study was the third theme and an unanticipated finding. Conclusions: The questionnaire offered some predictive ability for gauging intent to study for a PhD among bachelor's and graduate degree prepared nurses. The results do offer some suggestions for nursing workforce development to help address faculty shortages.

Abstract

Objective. To compare the incidence of hepatic decompensation in patients who are co-infected with HIV and hepatitis C (HCV) and who underwent antiretroviral treatment and patients who are HCV-monoinfected. Design. Retrospective cohort study. Participants and setting. This study used the Veterans Aging Cohort Study Virtual Cohort (VACS-VC), which includes electronic medical record data from patients who are HIV-infected and are receiving care at Veterans Affairs (VA) medical facilities in the United States. Inclusion criteria for patients who were co-infected were: detectable HCV RNA, recently initiated antiretroviral therapy (ART), defined as use of ≥ 3 antiretroviral drugs from 2 classes or ≥ 3 nucleoside analogues within the VA system, HIV RNA level > 500 copies/mL within 180 days before starting ART, and were seen in the VACS-VC for at least 12 months after initiating ART. Inclusion criteria for patients who were monoinfected with HCV were detectable HCV RNA, no HIV diagnosis or antiretroviral prescriptions, and seen in the VACS-VC for at least 12 months prior to inclusion into the study. Exclusion criteria were hepatic decompensation, hepatocellular carcinoma, and liver transplant during the 12-month baseline period or receipt of interferon-based HCV therapy. Main outcome measure. The primary outcome was incident hepatic decompensation, defined as diagnosis of ascites, spontaneous bacterial peritonitis, or esophageal variceal hemorrhage at hospital discharge or 2 such outpatient diagnoses.

Abstract

Objective. To investigate the clinical effectiveness and costs of nurses working as substitutes for physicians in primary care. Design. Systematic review and meta-analysis of published randomized controlled trials (RCTs) and 2 economic studies that compared nurse-led care with care by primary care physicians on numerous variables, including satisfaction, hospital admission, mortality, and costs of health care. Settings and participants. The 24 RCTs were drawn from 5 different countries (UK, Netherlands, USA, Russia, and South Africa). In total, there were 38, 974 participants. Eleven of the studies had less than 200 participants and 13 studies had more than 200 (median, 1624). Mean age was reported in 20 trials and ranged from 10 to 83 years. Analysis. The authors assessed risk of bias in the studies, calculated the study-specific and pooled relative risks (RR) or standardized mean differences (SMD), and performed fixed-effects meta-analyses. Main results. Nurse-led care was effective at reducing the overall risk of hospital admission (RR 0.76, 95% CI 0.64-0.91) and mortality (RR 0.89, 95% CI 0.84-0.96) in RCTs of ongoing or non-urgent care, longer (at least 12 months) follow-up episodes, and in in larger (n > 200) RCTs. Pooled analysis showed higher overall scores of patient satisfaction with nurse led care (SMD 0.18, 95% Cl 0.13-0.23). Higher-quality RCTs (with better allocation concealment and less attrition) showed higher rates of hospital admissions and mortality with nurse-led care, but the difference was not significant. Subgroup analysis showed that RNs had a stronger effect than nurse practitioners (NPs) on patient satisfaction. The results of cost-effectiveness and improved quality of care analysis with nurses were inconclusive. Conclusion. Nurse-led care appears to have a positive effect on patient care and outcomes but more rigorous research is needed to confirm these findings.

Abstract

Objective. To determine if there is an association between self-reported English language ability and glycemic control in Latinos with type 2 diabetes. Design. Descriptive correlational study using data from a larger cross-sectional study. Setting and participants. 167 adults with diabetes who selfidentified as Latino or Hispanic recruited at clinics in the Chicago area from May 2004 to May 2006. The dataset was collected using face-to-face interviews with diabetic patients aged ≥ 18 years. All participants attended clinics affiliated with an academic medical center or physician offices affiliated with a suburban hospital. Patients with type 1 diabetes and those with < 17 points on the Mini-Mental State Examination were excluded. English speaking ability was categorized as speaking English "not at all," "not well," "well," or "very well" based on patient self-report. A multivariable logistic regression model was used to examine the predictive relationship between English language skills and HbA1c levels, with covariates selected if they were significantly correlated with English language ability. The final regression model accounted for age, sex, education, annual income, health insurance status, duration of diabetes, birth in the United States, and years in the United States. Main outcome measure. HbA1c ≥ 7.0% as captured by chart review. Main results. Of the 167 patients, 38% reported speaking English very well, 21% reported speaking well, 26% reported speaking not very well, and 14% did not speak English at all. Reflecting immigration-sensitive patterns, patients who spoke English very well were younger and more likely to have graduated high school and have an annual income over $25,000 per year. Comorbidities and complications did not differ by English speaking ability except for diabetic eye disease, which was was more prevalent among those who did not speak English at all (42%, p = 0.04). Whether speaking ability was treated as a continuous or dichotomous variable, HbA1c levels formed a U-shaped curve: those who spoke English very well (odds ratio [OR] 2.32, 95% CI, 1.00-5.41) or not at all (OR 4.11, 95% CI 1.35-12.54) had higher odds of having an elevated HbA1c than those who spoke English well, although this was only statistically significant for those who spoke no English. In adjusted analyses, the U-shaped curve persisted with the highest odds among those who spoke English very well (OR 3.20, 95% CI 1.05-9.79) or not at all (OR 4.95, 95% CI 1.29-18.92). Conclusion. The relationship between English speaking ability and diabetes management is more complex than previously described. Interventions aimed at improving diabetes outcomes may need to be tailored to specific subgroups within the Latino population.

Abstract

Objective. To evaluate the usefulness of the Frailty Index (FI) as a prognostic indicator of adverse outcomes in geriatric trauma patients,. Design. Prospective cohort study. Setting and participants. Geriatric (aged 65 and over) trauma patients admitted to inpatient units at a Level 1 trauma center in Arizona were enrolled. Patients were excluded if they were intubated/nonresponsive with no family members present or transferred from another institution (eg, skilled nursing facility). The following categories of data were collected: (a) patient demographics, (b) type and mechanism of injury, (c) vital signs (eg, Glasgow coma scale score, systolic blood pressure, heart rate, body temperature), (d) need for operative intervention, (e) in-hospital complications, (f) hospital and intensive care unit (ICU) lengths of stay, and (g) discharge disposition. Patients or, in the case of nonresponsive patients, their closest relative, responded to the 50-item Frailty Index questionnaire, which includes questions regarding age, comorbid conditions, medications, activities of daily living (ADLs), social activities, mood, and nutrition. FI score ranges from 0 (non-frail) to 1 (frail), with an FI of 0.25 or more indicative of frailty based on established guidelines. Patients were categorized as frail or non-frail according to their FI scores and were followed during the course of their hospitalization. Main outcome measure. The primary outcome measure was in-hospital complications. In-hospital complications included myocardial infarction, cardiopulmonary arrest, pneumonia, pulmonary embolism, sepsis, urinary tract infection, deep venous thrombosis, disseminated intravascular coagulation, renal insufficiency, and reoperation. The secondary outcome measure was adverse discharge disposition, which was defined as death during the course of hospitalization or discharge to a skilled nursing facility. Main results. The sample consisted of 250 patients with a mean age of 77.9 years. Among these, 44.0% were considered frail. Patients with frailty were more likely to have a higher Injury Severity Score (P = 0.04) and a higher mean FI (P = 0.01) than those without frailty. There were no statistically significant differences with respect to age (P = 0.21), mechanism of injury (P = 0.09), systolic blood pressure (P = 0.30), or Glasgow Coma Scale score (P = 0.91) between the groups. Patients with frailty were more likely to develop in-hospital complications (37.3% vs 21.4%, P = 0.001) than those without frailty. Among these complications, pneumonia and urinary tract infection were the most common. There were no differences in the rate of reoperation (P = 0.54) between the 2 groups. An FI of 0.25 or higher was associated with the development of in-hospital complications (P = 0.001) even after adjusting for age, systolic blood pressure, heart rate, and Injury Severity Score. Frail patients had longer hospital length of stay (P = 0.01) and ICU length of stay (P = 0.01), and were more likely to have adverse discharge disposition (37.3% vs. 12.9%, P = 0.001). All patients who died during the course of hospitalization (n = 5) were considered frail. Frailty was also found to be a predictor of adverse discharge disposition (P = 0.001) after adjustment for age, male sex, Injury Severity Score, and mechanism of injury. Conclusion. The FI is effective in identifying geriatric trauma patients, who are vulnerable to poor health outcomes.

Abstract

Obesity disproportionately affects Latina adults, and goal-setting is a technique often used to promote lifestyle behavior change and weight loss. To explore the meanings and dimensions of goal-setting in immigrant Latinas, we conducted four focus groups arranged by language ability and country of origin in an urban, public, primary care clinic. We used a narrative analytic approach to identify the following themes: the immigrant experience, family dynamics, and health care. Support was a common sub-theme that threaded throughout, with participants relying on the immigrant community, family, and the health care system to support their goals. Participants derived satisfaction from setting and achieving goals and emphasized personal willpower as crucial for success. These findings should inform future research on how goal-setting can be used to foster lifestyle behavior change and illustrate the importance of exploring the needs of Latino sub-groups in order to improve lifestyle behaviors in diverse Latino populations.

Abstract

This review seeks to understand the role of remittances in international nurse migration within the context of three theories of international migration: equilibrium approaches, social networks, and globalization. To analyze the phenomenon, an integrative review of the literature was conducted. Search terms sought articles discussing, either directly or indirectly, remittances and international nurse migration. The initial search returned 369 articles, and further screening decreased the total to 65. Full text screening reduced the final number for the analysis to 48. A directed content analysis structured the analytic approach by examining how authors discussed remittances in the content and context of the paper. The final analysis showed the majority of papers were policy analyses (five); opinion papers, reviews, or editori-als that indirectly discussed remittances (27); or were qualitative and quantitative studies (16), either with primary data collection (14) or secondary data analyses (two). Overall, a nurse's individual motivation for sending remittances home stemmed from familial factors but was never a primary driver of migration. Domestic labor market factors were more likely to drive nurses to migrate. The nurse's country of origin also was a factor in the remittance dynamic. The identity of the author of the paper played a role in how they discussed remittances in the context of international nurse migration. The three theories of migration helped explain vari-ous aspects of the role of remittances in international nursing migration. While the phenom-enon has changed since the 2008 global economic crisis and the passing of the World Health Organization's Global Code of Practice on the International Recruitment of Health Personnel in 2010, future research around the role of remittances needs to consider the confluence of gender, social, political, labor market, and economic dynamics, and not just view the phenomenon from an individual lens.

Abstract

Background: Obesity disproportionately affects Latinas living in the United States, and cultural food patterns contribute to this health concern. Objective: The aim of this study was to synthesize the qualitative results of research regarding Latina food patterns in order to (a) identify common patterns across Latino culture and within Latino subcultures and (b) inform future research by determining gaps in the literature. Methods: A systematic search of three databases produced 13 studies (15 manuscripts) that met the inclusion criteria for review. The Critical Appraisal Skills Program tool and the recommendations of Squires for evaluating translation methods in qualitative research were applied to appraise study quality. Authors coded through directed content analysis and an adaptation of the Joanna Briggs Institute Qualitative Assessment and Review Instrument coding template to extract themes. Coding focused on food patterns, obesity, population breakdown, immigration, acculturation, and barriers and facilitators to healthy eating. Other themes and categories emerged from this process to complement this approach. Results: Major findings included the following: (a) Immigration driven changes in scheduling, food choice, socioeconomic status, and family dynamics shape the complex psychology behind healthy food choices for Latina women; (b) in Latina populations, barriers and facilitators to healthy lifestyle choices around food are complex; and (c) there is a clear need to differentiate Latino populations by country of origin in future qualitative studies on eating behavior. Discussion: Healthcare providers need to recognize the complex influences behind eating behaviors among immigrant Latinas in order to design effective behavior change and goal-setting programs to support healthy lifestyles.