Allison P Squires

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NEEDS AND OBJECTIVES: Treating obesity is a complex task and barriers to effective counseling include lack of adequate time during clinical encounters and insufficient provider training. Further, providers become frustrated when they perceive that obese patients are not motivated to change their lifestyles. Implementation of obesity curricula within graduate health professions education programs to address these barriers is important. Use of a curriculum that incorporates an interprofessional approach may foster and facilitate collaborative efforts among health professionals; a multi-disciplinary approach to the treatment of obesity is considered to be especially effective.We sought to design an interprofessional curriculum in obesity counseling that could be individualized based on learner needs and would be appropriate for use across the lifespan and which focused on acquisition of skills related to two domains: 1) motivational interviewing (MI) and 2) health literacy. SETTING AND PARTICIPANTS: The curriculum was piloted in the Department of Pediatrics in an urban academic hospital with three residents and two nurse practitioner students. It is scheduled to be piloted with Ob/GYN and internal medicine residents. DESCRIPTION: The curriculum included 3 one-hour interactive sessions followed by an evaluative OSCE. Materials for the sessions were compiled by adapting existing curricula that had been developed separately for pediatrics and internal medicine residents. To this curriculum we included additional items based on a needs assessment obtained from the program director and trainees. The first session included discussion about perceived barriers to obesity treatment and a review of health literacy principles and obesity counseling as well as a brief introduction to MI. The second session focused on challenges in the assessment of the literacy levels of patients and an introduction to specific MI skills, such as change talk and goal setting. The third session was reserved for role playing using the skills learned in the first two sessions. Each session concluded with plans for skills practice within the clinical setting. EVALUATION: We evaluated the curriculum with a 10-minute OSCE station counseling a resistant adolescent on weight reduction. Participants were assessed on use of counseling techniques, including MI skills. Following the OSCE, qualitative feedback was obtained from the trainees via a written survey and audio-taped debriefing session. DISCUSSION/REFLECTION/LESSONS LEARNED: Learners had strong feelings of frustration and resignation about their experiences with obesity counseling and were initially resistant to using MI. To address this, we strove to create an environment where learners could be honest about their perceptions and attitudes. Feedback from participants indicated that there was increasing acceptance of MI over the sessions. Learners highly valued the opportunity to learn in an interprofessional setting, identifying areas of similarity and difference in approach to obesity counseling.

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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.

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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.

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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.

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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.

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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.