Publications

Abstract

This article examines the recent controversy in health care delivery about whether it should be conceptualized as a business. The current debate implicitly appeals to a common understanding of business and business practices that is no longer very useful. This common notion, which the authors call "cowboy capitalism," conceptualizes business as a competitive jungle resting on self-interest and an urge for competition in order to survive. The authors suggest that stakeholder capitalism offers a more useful framework for the dialogue about health care reform.

Abstract

• OBJECTIVES: To examine the association between (1) comorbid conditions related to diabetes mellitus, clinical findings on arrival at the hospital, and characteristics of the myocardial infarction and (2) risk of heart failure, recurrent myocardial infarction, and mortality in the year after myocardial infarction in elderly 30-day survivors of myocardial infarction who had non-insulin-or insulin-treated diabetes. • METHODS: Medical records for June 1, 1992, through February 28, 1993, of Medicare beneficiaries (n = 1698), 65 years or older, hospitalized for acute myocardial infarction in Connecticut were reviewed by trained abstractors. • RESULTS: One year after myocardial infarction, elderly patients with non-insulin- and insulin-treated diabetes mellitus had significantly greater risk for readmission for heart failure and recurrent myocardial infarction than did patients without diabetes mellitus, and risk was greater in patients treated with insulin than in patients not treated with insulin. Diabetes mellitus, comorbid conditions related to diabetes mellitus, clinical findings on arrival, and characteristics of the myocardial infarction, specifically measures of ventricular function, were important predictors of these outcomes. Mortality was greater in patients not treated with insulin than in patients treated with insulin; the increased risk was mostly due to comorbid conditions related to diabetes mellitus and poorer ventricular function. • CONCLUSIONS: Risk of heart failure, recurrent myocardial infarction, and mortality is elevated in elderly patients who have non-insulin-or insulin-treated diabetes mellitus. Comorbid conditions related to diabetes mellitus and ventricular function at the time of the index myocardial infarction are important contributors to poorer outcomes in patients with diabetes mellitus.

Abstract

A Chinese Dementia Specialist Education Program (CDSEP) was launched in the Greater Boston Area to educate Chinese American health care providers who lacked adequate dementia education and services. This program trained bilingual health care providers to identify, assess and serve people with dementia and their families, and raised dementia awareness in Chinese American communities. The ten-month follow-up survey documented that the sixteen graduates helped over 70 families and held 76 workshops and formal and informal discussions, reaching over 400 people. The CDSEP demonstrates that a “Train the Trainer” model is an effective approach for building dementia care capacity in community-based agencies, increasing outreach to people with dementia and their families, and for raising dementia awareness in bilingual and minority communities.

Abstract

Hispanics in the United States have disproportionately high rates of HIV. The existence of ethnically and culturally diverse Hispanic communities indicate that qualitative research on HIV-related attitudes and behaviors within subgroups is needed to develop successful interventions. Findings from interviews with 20 Dominicans involved with drug-related or sex work-related activities in New York City are presented in terms of predominant cultural influences and specific issues regarding sex work, drug use, and HIV/AIDS. Several directions for interventions in the Dominican community are indicated, e.g., outreach efforts sensitive to the stigmatization of behaviors such as needle use and homosexuality, and the encouragement of sex workers to use condoms with their partners as well as clients. Additional information regarding such areas as contraception, family planning, and drug treatment services is needed within this community. A knowledge of cultural norms can serve as a foundation for these intervention and education efforts.

Abstract

Community interventions are rare in the field of sexually transmitted disease (STD) control and prevention. The goals of the Gonorrhea Community Action Project are to design and implement interventions for the reduction of gonorrhea in high-prevalence areas and to increase the appropriateness and effectiveness of STD care in the participating communities. Key to conducting the formative research and developing the interventions was the creation of a community-academic-health department collaborative partnership. Using a staged model, this article presents a case study of collaboration development in the community of Harlem, New York.

Abstract

Objectives. This study assessed the effectiveness of a sexually transmitted disease (STD)/HIV behavior change intervention in increasing women's use of the female condom. Methods. A total of 604 women at high risk for STDs and HIV in New York City, Baltimore, Md, and Seattle, Wash, enrolled in a randomized controlled trial of a small-group, skills-training intervention that included information and skills training in the use of the female condom. Results. In a logistic regression, the strongest predictors of use were exposure to the intervention (odds ratio [OR] = 5.5; 95% confidence interval [CI] = 2.8, 10.7), intention to use the female condom in the future (OR= 4.5; 95% CI = 2.4, 8.5), having asked a partner to use a condom in the past 30 days (OR= 2.3; 95% CI = 1.3, 3.9), and confidence in asking a partner to use a condom (OR = 1.9; 95% CI= 1.1, 3.5). Conclusions. Clinicians counseling women in the use of the female condom need to provide information, demonstrate its correct use with their clients, and provide an opportunity for their clients to practice skills themselves.

Abstract

Objectives. This study determined the effects of nurse staffing and nursing organization on the likelihood of needlestick injuries in hospital nurses, Methods. We analyzed retrospective data from 732 and prospective data from 960 nurses on needlestick exposures and near misses over different 1-month periods in 1990 and 1991. Staffing levels and survey data about working climate and risk factors for needlestick injuries were collected on 40 units in 20 hospitals. Results. Nurses from units with low staffing and poor organizational climates were generally twice as likely as nurses on well-staffed and better-organized units to report risk factors, needlestick injuries, and near misses. Conclusions. Staffing and organizational climate influence hospital nurses' likelihood of sustaining needlestick injuries. Remedying problems with understaffing, inadequate administrative support, and poor morale could reduce needlestick injuries.

Abstract

Continuing its commitment to patient care quality, the American Nurses Association appointed a committee in 1997 to expand nursing-sensitive quality indicators beyond acute care. This article is the final report describing the processes used to identify a core set of community-based quality indicators relevant to nurses across the care continuum and identifies next steps. The indicator categories are (a) change in symptom severity, (b) strength of the therapeutic alliance, (c) utilization of services, (d) client satisfaction, (e) risk reduction, (f) increase in protective factors, and (g) level of function/functional status. Potential indicators requiring further research and development are also described.

Abstract

Many HIV positive drug users are unaware that they have the virus, either because they never obtained testing for HIV or because they submitted a biological specimen for testing but never returned to obtain the result of the test. Using data collected from a large multi-site sample of out-of-treatment HIV positive drug users (N=1, 544), we identify a variety of socio-demographic characteristics and drug use and sexual risk behaviors that differentiate HIV-positive individuals who had obtained HIV testing in the past and those who had not and, among those who had been tested, what differentiates individuals who had returned to obtain their HIV test results and those who had failed to return. Results of the analyses suggest that there is a need to target different subgroups of high risk drug users for interventions to obtain HIV testing as compared with those that need encouragement to obtain the results of this testing.

Abstract

Context The worsening hospital nurse shortage and recent California legislation mandating minimum hospital patient-to-nurse ratios demand an understanding of how nurse staffing levels affect patient outcomes and nurse retention in hospital practice. Objective To determine the association between the patient-to-nurse ratio and patient mortality, failure-to-rescue (deaths following complications) among surgical patients, and factors related to nurse retention. Design, Setting, and Participants Cross-sectional analyses of linked data from 10184 staff nurses surveyed, 232342 general, orthopedic, and vascular surgery patients discharged from the hospital between April 1, 1998, and November 30, 1999, and administrative data from 168 nonfederal adult general hospitals in Pennsylvania. Main Outcome Measures Risk-adjusted patient mortality and failure-to-rescue within 30 days of admission, and nurse-reported job dissatisfaction and job-related burnout. Results After adjusting for patient and hospital characteristics (size, teaching status, and technology), each additional patient per nurse was associated with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12) increase in the likelihood of dying within 30 days of admission and a 7% (OR, 1.07; 95% CI, 1.02-1.11) increase in the odds of failure-to-rescue. After adjusting for nurse and hospital characteristics, each additional patient per nurse was associated with a 23% (OR, 1.23; 95% CI, 1.13-1.34) increase in the odds of burnout and a 15% (OR, 1.15; 95% CI, 1.07-1.25) increase in the odds of job dissatisfaction. Conclusions In hospitals with high patient-to-nurse ratios, surgical patients experience higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses are more likely to experience burnout and job dissatisfaction.

Abstract

OBJECTIVE: To examine the effects of nurse staffing and organizational support for nursing care on nurses' dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals. DESIGN: Multisite cross-sectional survey SETTING: Adult acute-care hospitals in the U.S. (Pennsylvania), Canada (Ontario and British Columbia), England and Scotland. Study Participants: 10319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions. INTERVENTIONS: None Main outcome measures: Nurse job dissatisfaction, burnout, and nurse-rated quality of care. RESULTS: Dissatisfaction, burnout and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support. CONCLUSION: Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.

Abstract

Objective. To examine the effects of nurse staffing and organizational support for nursing care on nurses' dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals. Design. Multisite cross-sectional survey. Setting. Adult acute-care hospitals in the United States (Pennsylvania), Canada (Ontario and British Columbia), England, and Scotland. Study participants. 10 319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions. Interventions. None. Main outcome measures. Nurse job dissatisfaction, burnout, and nurse-rated quality of care. Results. Dissatisfaction, burnout, and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support. Conclusion. Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.

Abstract

An exploratory assessment of the impact of the September 11th attacks in New York City on drug users, including their perceptions of changes in drug use, drug availability, police activities, and access to services, was undertaken. Methods included focus groups with drug users and acquired immunodeficiency syndrome (AIDS) outreach worker supervisors and surveys of service providers. Results indicated that, while there was some immediate concern about the potential impact on drug availability, there was no perceived scarcity, although some drug users did report a decrease in drug purity. Responses included increased use of drugs and increased demand for drug treatment. The wide range of responses indicates that continued monitoring of the impact may be needed to assess long-term effects.

Abstract

The left ventricular ejection fraction (LVEF) test rate is increasingly used as a quality of care indicator for patients with heart failure. Our study produced benchmark LVEF test rates in a Medicare fee-for-service population for consideration by a clinical panel assembled by the Health Care Financing Administration. Our sample consisted of 46,583 beneficiaries admitted to the hospital for heart failure and with a complete set of Medicare fee-for-service bills dated 1996 or 1997. The national 2-year LVEF test rate was 79% for Medicare fee-for-service beneficiaries hospitalized for heart failure. Except for 1 state, the test rate ranged from 61% to 89% across states. Our analysis demonstrates the feasibility of using billing data to compute LVEF test rates. Using a 2-year time window and measuring tests performed in outpatient as well as inpatient settings, we find a higher LVEF test rate than has been reported by most previous studies.

Abstract

Ethnographic mapping plays an important role in learning more about the geographic location and temporal movement of hidden populations; it also aids in the exploration of drug use patterns and the social infrastructure of drug users. This paper presents a narrative account of the development and implementation of a mapping process for the ARIBBA project, a dual-site study of the HIV risk behaviors of Puerto Rican drug injectors and crack smokers. The overall goals of the project are to understand the differences in influences on HIV-related risk behaviors. Mapping provided the environmental context for data analysis and led to new insights on both the differences and the similarities between field locations and target populations. Mapping substantively enhanced the ability to make meaningful comparisons in the analysis of both qualitative and quantitative data.