Publications

Abstract

Competency-based training approaches are being used more in healthcare to guide curriculum content and ensure accountability and outcomes in the educational process. This article provides an overview of the state of competency development in the field of behavioral health. Specifically, it identifies the groups and organizations that have conducted and supported this work, summarizes their progress in defining and assessing competencies, and discusses both the obstacles and future directions for such initiatives. A major purpose of this article is to provide a compendium of current competency efforts so that these might inform and enhance ongoing competency development in the varied behavioral health disciplines and specialties. These varied resources may also be useful in identifying the core competencies that are common to the multiple disciplines and specialties.

Abstract

Background: Care transitions are commonplace for ill older adults, but no studies to our knowledge have examined the occurrence of iatrogenic harm from medication changes during patient transfer. Objectives: To identify medication changes during transfer between hospital and nursing home and adverse drug events (ADEs) caused by these changes. Methods: Participants were residents of 4 nursing homes in the New York City metropolitan area admitted to 2 academic hospitals. Nursing home and hospital medical records were reviewed to identify changes in medication regimens between sites. Medications were matched and compared regarding dosage, route, and frequency of administration. Two physician investigators used structured implicit review to identify ADEs attributable to transfer-related medication changes. Results: During a total of 122 admissions, the mean numbers of medications altered during transfer from nursing home to hospital and hospital to nursing home were 3.1 and 1.4, respectively (P<.001 for comparison). Most changes in drug use were discontinuations, followed by dose changes and class substitutions. Of 71 bidirectional transfers that were reviewed by 2 physician investigators, ADEs attributable to medication changes occurred during 14 (20%). The overall risk of ADE per drug alteration (n = 320) was 4.4% (95% confidence interval, 2.5%-7.4%). Although most medication changes (8/14) implicated in causing ADEs occurred in the hospital, most ADEs (12/14) occurred in the nursing home after nursing home readmission. Conclusions: Medication changes are common during transfer between hospital and nursing home and are a cause of ADEs. Research is needed on interinstitutional patient care and systems interventions designed to prevent ADEs.

Abstract

Obesity and Type 2 diabetes have become major public health problems in the United States. Community health nurses, with expertise in preventive health care, have the potential to play a vital role in addressing these significant health issues. The purposes of this article are to identify current challenges related to obesity and Type 2 diabetes and to present the social ecological theory as a framework for the expansion of the reach of diabetes prevention and management that is relevant to community health nurses.

Abstract

OBJECTIVE: Previous studies reveal that many terminally ill patients never receive hospice care. Among those who do receive hospice, many enroll very close to the time of death. Nationally, between 1992 and 1998, the median length of stay at hospice declined 27%, from 26 to 19 days. In our prior study of 206 patients diagnosed with terminal cancer and using hospice, we found that one-third enrolled with hospice within 1 week prior to death. Late hospice enrollment can have deleterious effects on patients and their family members. The aim of the present study was to characterize common experiences of patients and primary family caregivers as they transition to hospice, focusing on caregiver perceptions of factors that might contribute to delays in hospice enrollment. METHODS: We conducted in-depth interviews with a purposive sample of 12 caregivers selected from a population of primary family caregivers of patients with terminal cancer who enrolled with hospice in Connecticut between September 2000 and September 2001. Respondents represented different ages, genders, and kinship relationships with patients. Respondents were asked about the patient's care trajectory, how they first learned about hospice, and their experiences as they transitioned to hospice. NUD*IST software was used for qualitative data coding and analysis. RESULTS: Constant comparative analysis identified three themes common to the experience of transitioning to hospice: (1) caregivers' acceptance of the impending death, (2) challenges in negotiating the health care system across the continuum of care, and (3) changing patient-family dynamics. SIGNIFICANCE OF RESULTS: Identification of these themes from the caregivers' perspective generates hypotheses about potential delays in hospice and may ultimately be useful in the design of interventions that are consistent with caregivers' needs.

Abstract

Purpose To examine relationships among childhood adversity, attachment style (one's core beliefs regarding the self and others), and the following risk behaviors and contexts among young men who have sex with men (YMSM): homelessness, daily substance use, participation in sex work, involvement in the criminal justice system, and being out of school or work. Methods Using a targeted sampling approach, we recruited 569 YMSM aged 17-28 years from natural venues in New York City including bars, clubs, parks, and bus stations. Youth completed a structured interview assessing lifetime and current risk and protective contexts and behavior. Data were analyzed using univariate and multivariate statistical methods, including hierarchical logistic regression. Results After controlling for demographic characteristics and childhood adversity, YMSM with a fearful attachment style were more likely to have been homeless (OR 2.93, 95% CI 1.65-5.18), to have participated in sex work (OR 2.35, 95% CI 1.44-3.85), to use substances daily (OR 2.79, 95% CI 1.29-6.03), to have been involved in the criminal justice system (OR 2.04, 95% CI 1.38-3.01), and to be out of school/work (OR 2.47, 95% CI 1.47-4.15). Three subgroups were particularly vulnerable: YMSM who identified as heterosexual, or bisexual, and/or transgender. Conclusions A fearful attachment style contributes to some YMSM remaining outside of the protective systems of family, school, and work, and is associated with risky contexts where they are less likely to encounter prosocial peers and adults. Further, it is associated with risk behavior. Although gay-identified youth are generally found to have poor outcomes when compared with the general population of adolescents, in the present report, YMSM who identified as heterosexual were at particular risk. Attachment theory can guide interventions by informing how individuals experience relationships and manage developmental transitions.

Abstract

Introduction: The purpose of this study was to explore the attitudes and beliefs of pediatric nurse practitioners (PNPs) and pediatricians concerning collaborative practice relationships and to explore the themes that emerged to establish a definition of collaborative practice between PNPs and pediatricians as it applies to current practice trends. Methods: Twenty-four PNP and pediatrician dyads were identified through a random sampling technique from a list of names of certified PNPs obtained from the National Certification Board of Pediatric Nurse Practitioners and Nurses. Questionnaires were mailed to certified PNPs and the collaborating pediatrician. Data were collected and analyzed using both quantitative and qualitative methodology. Results: All PNPs and pediatricians were board certified and most had 6 or more years experience in a collaborative practice. The qualitative data revealed that open communication and a relationship built on mutual trust and respect, sharing of knowledge, and clinical expertise are essential components of a collaborative practice relationship if the shared goal of excellent patient care is to be achieved. Attitudes of importance in a collaborative practice relationship rated significantly higher by the PNPs included "respect for you as a professional" and "advocate for child health issues." Conclusion: The data revealed that the words "supervision" and "independence" should be changed to "consultation" when describing a contemporary collaborative practice relationship between a nurse practitioner and physician.

Abstract

Purpose To examine attitudinal and contextual factors associated with the occurrence of sexual health assessments during adolescent primary care visits. Methods A total of 313 primarily African-American youth aged 11-21 years from 16 community-based organizations in suburban Maryland and in New York City completed questionnaires focusing on sexually transmitted diseases (STD) and health care. The analysis examined the relationship of sexual activity, attitudes, and presence of the parent at the health care visit with discussion of three sexual health topics and testing for STD at the most recent health care visit. Data were analyzed using Chi-square tests and logistic regression. Results Overall, 74% of respondents reported that they had talked about at least one sexual health topic at their last health care visit but only 32% had discussed all three topics of sexual behavior, birth control, and STD. Females were more likely than males to discuss birth control although there were no gender differences in the overall likelihood of talking about a sexual health topic. Few adolescents initiated discussion of sexual issues. Positive attitudes toward discussing sexual issues with a provider and absence of a parent at the visit were independently associated with higher odds of discussing at least one sexuality topic and STD testing. Conclusions Although relatively large numbers of adolescents in the sample received sexual health assessments, the proportion was below recommended guidelines. The opportunity to speak privately with a clinician and having positive attitudes about discussing sex with a doctor appear to be important influences on the receipt of sexual health assessments. Improving the quality of adolescent preventive care will require creating a health care environment that facilitates discussion of sexual health issues.

Abstract

The present study was undertaken to investigate the effects of bone morphogenetic protein-7 (BMP-7), also named osteogenic protein-1 (OP-1), on the progression of a striatal 6-hydroxydopamine (6-OHDA) lesion. BMP-7, a member of the transforming growth factor-β (TGF-β) superfamily of proteins, has been shown to have protective effects in other animal models of neuronal damage. In this study, male Fischer 344 rats received striatal 6-OHDA lesions followed 1 week later by an intraventricular dose of BMP-7. No significant effect of BMP-7 treatment on spontaneous locomotor activity was observed, however BMP-7 significantly increased the density of tyrosine hydroxylase (TH) immunoreactivity (TH-ir) in the substantia nigra (SN) pars compacta, in the lesioned hemisphere [31.7±5.2 (optical density (O.D.) arbitrary units) control vs. 50.2±4.3 O.D. BMP-7-treated; p<0.05]. Interestingly, BMP-7 significantly increased TH-ir in the SN of the non-lesioned hemisphere (pars reticulata: 14.8±1.19 O.D. control vs. 36±2.6 O.D. BMP-7-treated, p<0.05; pars compacta: 29.0±4.9 O.D. control vs. 64.4±6.9 O.D. BMP-7-treated, p<0.001). A significant increase in DA concentration in the contralateral, non-lesioned hemisphere was also noted (113.2 ng/g control vs. 198.2 ng/g BMP-7-treated, p<0.01). In contrast to other intraventricularly administered neurotrophic factors, BMP-7 was not associated with an increase in the sensitivity to pain. These results suggest that BMP-7 is able to act as a dopaminotrophic agent without unwanted side effects and as such may be a useful pharmacological tool in the treatment of Parkinson's disease in humans.

Abstract

This study estimated the value of contraceptives, through a random-digit-dialed survey of willingness to pay for health insurance coverage of contraceptives among 659 Washington State adults. People valued contraceptives at 5 times the actuarial cost; in general, women and reproductive-aged persons were willing to pay more, but low-income men highly valued contraceptives. Most respondents (85%) said that contraceptives should be covered by health insurance plans. The full benefit of contraceptives exceeds their cost.

Abstract

Microalbuminuria is a novel atherosclerotic risk factor in patients with type 2 diabetes mellitus (DM) and predicts future cardiovascular events. Endothelial dysfunction and systemic inflammation have been proposed as common links between microalbuminuria and cardiovascular disease. However, no study has assessed the relation between microalbuminuria and vascular dysfunction as measured by brachial artery reactivity (BAR) in DM. We evaluated 143 patients (85 men; mean age 60.0 ± 6.7 years) with DM (mean duration 8.2 ± 7.4 years) enrolled in the Detection of Ischemia in Asymptomatic Diabetics study. Subjects were categorized as those with microalbuminuria (ratio of urinary albumin to creatinine 30 to 299 μg/mg creatinine, n = 28) and those with normoalbuminuria (ratio of urinary albumin to creatinine 0 to 29.9 μg/mg creatinine, n = 115). High-resolution ultrasound BAR testing was used to measure endothelium-dependent and endothelium-independent vasodilations. C-reactive protein was measured as a marker of systemic inflammation. Patients with microalbuminuria and normoalbuminuria had similar baseline characteristics, with the exception that those with microalbuminuria had a longer duration of DM (p = 0.03). Endothelium-dependent vasodilation at 1 minute (p = 0.01) and endothelium-independent vasodilation at 3 minutes (p = 0.007) were significantly less in patients with microalbuminuria. In addition, 96% of patients with microalbuminuria and 76% of those with normoalbuminuria had impaired endothelium-dependent vasodilation (<8%, p = 0.01). Microalbuminuria was an independent predictor of endothelium-dependent vasodilation in the entire cohort (p = 0.045) and after excluding patients on hormone replacement therapy (p = 0.01). Levels of C-reactive protein were significantly higher in patients with microalbuminuria than in those with normoalbuminuria (p = 0.02). We conclude that in DM the presence of microalbuminuria is associated with impaired endothelium-dependent and endothelium-independent vasodilations of the brachial artery and a higher degree of systemic inflammation. In addition, microalbuminuria is an independent predictor of endothelial dysfunction in asymptomatic patients with DM, especially in the absence of hormone replacement therapy.

Abstract

The objective of this article is to study a barrier for breastfeeding women working full-time outside the home: breast milk expression in the workplace. Data are from a large corporation that provides employee benefits. Mothers express breast milk about twice a day when infants are 4 months old (x = 2.2 ± 0.8) and 6 months old (x = 1.9 ± 0.6), with a significant decline in frequency (P < .05 comparing the 2 age groups. Most mothers spend 1 hour or less expressing breast milk when infants are 3 (82%) or 6 months old (96%), with a significant difference (P < .05) between the 2 age groups. Mothers of younger infants were no more likely to work fewer days per week than were mothers of older infants. Most women can express breast milk for 3- and 6-month-old infants in less than an hour, distributed in about 2 separate portions, in an employment environment supportive of breastfeeding.

Abstract

OBJECTIVE - The goal of this study was to determine whether treatment with an aldose reductase inhibitor (ARI) has beneficial effects on asymptomatic cardiac abnormalities in diabetic patients with neuropathy. RESEARCH DESIGN AND METHODS - Diabetic subjects with neuropathy (n = 81) with either a low diastolic peak filling rate or impaired augmentation of left ventricular (LV) ejection fraction (LVEF) during maximal bicycle exercise were identified by gated radionuclide ventriculography. Coronary artery disease, left ventricular hypertrophy, and valvular heart disease were excluded by clinical evaluation, myocardial perfusion imaging, and echocardiography. Subjects were randomized to receive blinded treatment with either the placebo or the ARI zopolrestat 500 or 1,000 mg daily for 1 year. RESULTS - After 1 year of ARI treatment, there were increases in resting LVEF (P < 0.02), cardiac output (P < 0.03), LV stroke volume (P < 0.004), and exercise LVEF (P < 0.001). In placebo-treated subjects, there were decreases in exercise cardiac output (P < 0.03), stroke volume (P < 0.02), and end diastolic volume (P < 0.04). Exercise LVEF increased with ARI treatment independent of blood pressure, insulin use, or the presence of baseline abnormal heart rate variability. There was no change in resting diastolic filling rates in either group. CONCLUSIONS - Diabetic patients with neuropathy have LV abnormalities that can be stabilized and partially reversed by ARI treatment.

Abstract

Objectives: The purpose of the study is to explore the unique effects of various chronic illnesses on depression in a sample of Chinese immigrant elders. Methods: The data were collected in the Greater Boston area at various social service agencies, social, and religious institutions. A self-administered sample of 177 Chinese-speaking immigrant elders was included in the study. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure depressive symptoms in the study. Regression analysis was performed for three measures of depression: 7-selected CES-D scale, its subscale somatic symptoms, and depressive symptoms. Results: Chronic illnesses have various effects on the selected CES-D score, and its subscales under the total sample and the samples of male and female respondents. Conclusions: The findings suggest that medical, psychological, and social work treatments or interventions for depression should take the impact of chronic illnesses into consideration.

Abstract

Objective: The objective of this study was to compare reporting between audio computer-assisted self-interview (ACASI) and clinician-administered sexual histories. Goal: The goal of this study was to explore the usefulness of ACASI in sexually transmitted disease (STD) clinics. Study: The authors conducted a cross-sectional study of ACASI followed by a clinician history (CH) among 609 patients (52% male, 59% white) in an urban, public STD clinic. We assessed completeness of data, item prevalence, and report concordance for sexual history and patient characteristic variables classified as socially neutral (n = 5), sensitive (n = 11), or rewarded (n = 4). Results: Women more often reported by ACASI than during CH same-sex behavior (19.6% vs. 11.5%), oral sex (67.3% vs. 50.0%), transactional sex (20.7% vs. 9.8%), and amphetamine use (4.9% vs. 0.7%) but were less likely to report STD symptoms (55.4% vs. 63.7%; all McNemar chi-squared P values <0.003). Men's reporting was similar between interviews, except for ever having had sex with another man (36.9% ACASI vs. 28.7% CH, P <0.001). Reporting agreement as measured by kappas and intraclass correlation coefficients was only moderate for socially sensitive and rewarded variables but was substantial or almost perfect for socially neutral variables. ACASI data tended to be more complete. ACASI was acceptable to 89% of participants. Conclusions: ACASI sexual histories may help to identify persons at risk for STDs.

Abstract

Drug treatment programs are uniquely situated to screen patients for antibodies for hepatitis C virus (HCV), an infectious disease that has reached epidemic proportions among drug users. This paper compares the accessibility and patients' use of opportunities for HCV antibody testing in a large sample of methadone and drug-free treatment programs (N=256) in the US, and reports programs' recent changes and future plans concerning it. Results indicate that almost all methadone and about two-thirds of drug-free programs in the sample provided HCV antibody screening to at least some patients in 2001. While about two-thirds of the methadone and close to one-third of the drug-free programs offered this service to all patients, these programs report that only about 3/5 of their patients actually provided specimens for testing for HCV antibodies. Some drug treatment programs were planning to increase the availability and accessibility of HCV antibody screening, but others were planning to cut back on these services, primarily due to limited resources. These results can inform policymakers who advocate for increased HCV antibody screening in drug treatment programs about the current level and future plans for implementing these services, illuminating where resources and motivational efforts need to be targeted.

Abstract

Background: Retesting 3 to 4 months after treatment for those infected with chlamydia and/or gonorrhea has been recommended. Goal: We compared various methods of encouraging return for retesting 3 months after treatment for chlamydia or gonorrhea. Study: In study 1, participants were randomly assigned to: 1) brief recommendation to return, 2) intervention 1 plus $20 incentive paid at return visit, or 3) intervention 1 plus motivational counseling at the first visit and a phone reminder at 3 months. In study 2, participants at 1 clinic were randomly assigned to 4) intervention 1,5) intervention 1 plus phone reminder, or 6) intervention 1 plus motivational counseling but no telephone reminder. Results: Using multiple logistic regression, the odds ratios for interventions 2 and 3, respectively, compared with intervention 1 were 1.2 (95% confidence interval [CI], 0.6-2.5) and 2.6 (95% CI, 1.3-5.0). The odds ratios for interventions 5 and 6 compared with intervention 4 were 18.1 (95% CI, 1.7-193.5) and 4.6 (95% CI, 0.4-58.0). Conclusions: A monetary incentive did not increase return rates compared with a brief recommendation. A reminder phone call seemed to be the most effective method to increase return.

Abstract

This report presents data on computer access, Internet use, and factors associated with health information seeking on the Internet among a sample of youths aged 15 to 30 years in New York City. Findings from street intercept surveys indicate substantial computer access at home (62%) and frequent (everyday or a few times a week) Internet use (66%). Fifty-five percent of the sample reported seeking health information on the Internet, which was associated with positive beliefs about getting a health checkup and frequent Internet use.

Abstract

Although drug users are at elevated risk for hepatitis C virus (HCV) infection, many are uniformed or misinformed about the virus. Drug treatment programs are uniquely situated to provide comprehensive risk-modifying educational programs for decreasing HCV transmission, a strategy advocated in the most recent National Institutes of Health Consensus Development Conference Statement on the Management of Hepatitis C. Given the large proportion of patients that inject drugs in methadone maintenance treatment programs and the high prevalence of HCV among drug injectors, we compared a nationwide sample (N=246) of methadone maintenance treatment programs and drug-free programs regarding the content and comprehensiveness of HCV education. All of these programs provide HCV education to at least some of their patients. Results indicated that, compared to drug-free programs, methadone maintenance treatment programs cover a significantly greater number of HCV-related topics, and that a significantly greater proportion of the methadone programs cover specific topics (e.g., bow to avoid transmitting HCV, the importance of testing for HCV, treatment options if HCV positive). Of special concern is that fewer than three quarters of the drug-free programs address what to do if co-infected with human immunodeficiency virus (HIV) and HCV and bow to maintain health if HCV positive, and only about half of the drug-free and methadone maintenance treatment programs educate HCV-positive patients about the importance of obtaining vaccinations for hepatitis A and B. Drug treatment programs need to educate patients about the proactive steps these individuals can take to deal with HCV, provide critically needed HCV services, and encourage patients to make full use of these services.

Abstract

This article examines the behavioral practices and health risks associated with preparing crack cocaine for injection. Using an ethno-epidemiological approach, injection drug users (n=38) were recruited between 1999 and 2000 from public settings in New York City and Bridgeport, Connecticut and responded to a semistructured interview focusing on crack injection initiation and their most recent crack injection. Study findings indicate that methods of preparing crack for injection were impacted by a transforming agent, heat applied to the "cooker," heroin use, age of the injector, and geographic location of the injector. The findings suggest that crack injectors use a variety of methods to prepare crack, which may carry different risks for the transmission of bloodborne pathogens. In particular, crack injection may be an important factor in the current HIV epidemic.

Abstract

This article reports on the development and pilot feasibility testing of a culturally competent intervention of education and care for black women with type 2 diabetes mellitus (T2DM). Using a one group, pretest posttest quasi-experimental design, the intervention was tested with a convenience sample of 25 community black women with T2DM. The conceptual basis, process, and content of the intervention as well as the feasibility and acceptability of study materials and methods are described. Significant improvements from baseline to 3 months were observed in measures of glycemic control, weight, body mass index, and diabetes-related emotional distress. The findings suggest that a culturally sensitive intervention of nurse practitioner diabetes care and education is beneficial for black women with T2DM, resulting in program attendance, kept appointments, improved glycemic control and weight, and decreased diabetes-related emotional distress.

Abstract

OBJECTIVE - To assess the prevalence and clinical predictors of silent myocardial ischemia in asymptomatic patients with type 2 diabetes and to test the effectiveness of current American Diabetes Association screening guidelines. RESEARCH DESIGN AND METHODS - In the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study, 1,123 patients with type 2 diabetes, aged 50-75 years, with no known or suspected coronary artery disease, were randomly assigned to either stress testing and 5-year clinical follow-up or to follow-up only. The prevalence of ischemia in 522 patients randomized to stress testing was assessed by adenosine technetium-99m sestamibi single-photon emission-computed tomography myocardial perfusion imaging. RESULTS - A total of 113 patients (22%) had silent ischemia, including 83 with regional myocardial perfusion abnormalities and 30 with normal perfusion but other abnormalities (i.e., adenosine-induced ST-segment depression, ventricular dilation, or rest ventricular dysfunction). Moderate or large perfusion defects were present in 33 patients. The strongest predictors for abnormal tests were abnormal Valsalva (odds ratio [OR] 5.6), male sex (2.5), and diabetes duration (5.2). Other traditional cardiac risk factors or inflammatory and prothrombotic markers were not predictive. Ischemic adenosine-induced ST-segment depression with normal perfusion (n = 21) was associated with women (OR 3.4). Selecting only patients who met American Diabetes Association guidelines would have failed to identify 41% of patients with silent ischemia. CONCLUSIONS - Silent myocardial ischemia occurs in greater than one in five asymptomatic patients with type 2 diabetes. Traditional and emerging cardiac risk factors were not associated with abnormal stress tests, although cardiac autonomic dysfunction was a strong predictor of ischemia.