Nurse managed occupational health services: a primary care model in practice

1. Managed care focus on delivering health care which values prevention, early intervention, continuity of care, commitment to quality care, and outcomes, as well as client satisfaction. Occupational health nurses routinely integrate these values into their practice. 2. An on-site model of primary health care delivery, incorporating the fundamentals of occupational health nursing, can bring significant savings to the organization in health related costs. 3. Case management may provide the greatest potential for growth in occupational health nursing. It is a method that can be used together with managed care to maximize quality health care services. 4. Viewing health related costs as an investment as opposed to part of a benefit plan, influences employees to make positive choices. It also impacts the delivery of health care services on a systematic, global level, which affects total health care costs.     

Case management: integrating roles in the subacute setting

Nurses have great potential to advance the professional practice of nurse case management in the subacute care industry. This health care setting has created a new arena in which nursing may adapt and redefine the role of the case manager to meet the needs of an integrated system of outcomes based health care. Through cooperation and collaboration with a multidisciplinary team, the nurse case manager increases the cost effectiveness of care and enhances patient outcomes.     

Surgery on the crystalline lens. A plan of standardized care

In these days of concern for the growing costs of medical care it is an opportune moment to promote the importance of nurses as health care professionals and the roles that they play. This article presents a structural care plan for specific clinical situations regarding lens surgery with the goal of both guaranteeing quality nursing care and a method to evaluate costs. Lens surgery, a equently performed operation in the hospital, is used as an example to evaluate criteria of adequate service and efficiency. This method is based upon L.J. Caronito s bifocal model of clinical nursing.     

Evaluation of variances in patient outcomes

New knowledge and understanding about improving the quality and reducing the costs of care will come from careful scrutiny of the variations in the outcomes of nursing interventions. Nurses need to systematically identify and measure outcomes, understanding the probabilistic nature of these patient responses to the care received. Using a formative evaluation process, nurses should measure degrees of patient outcomes over time to ascertain the effects of nursing care and analyze the variances in these observed outcomes from what was expected. Critical pathways are valuable tools for guiding evaluations of nursing care along a timeline and can lead to improvements in nursing care.     

Cost-effectiveness of tissue plasminogen activator for acute ischemic stroke. NINDS rt-PA Stroke Study Group

Tissue plasminogen activator (tPA) has been shown to improve 3-month outcome in stroke patients treated within 3 hours of symptom onset. The costs associated with this new treatment will be a factor in determining the extent of its utilization. Data from the NINDS rt-PA Stroke Trial and the medical literature were used to estimate the health and economic outcomes associated with using tPA in acute stroke patients. A Markov model was developed to estimate the costs per 1,000 patients eligible for treatment with tPA compared with the costs per 1,000 untreated patients. One-way and multiway sensitivity analyses (using Monte Carlo simulation) were performed to estimate the overall uncertainty of the model results. In the NINDS rt-PA Stroke Trial, the average length of stay was significantly shorter in tPA-treated patients than in placebo-treated patients (10.9 versus 12.4 days; p = 0.02) and more tPA patients were discharged to home than to inpatient rehabilitation or a nursing home (48% versus 36%; p = 0.002). The Markov model estimated an increase in hospitalization costs of $1.7 million and a decrease in rehabilitation costs of $1.4 million and nursing home cost of $4.8 million per 1,000 eligible treated patients for a health care system that includes acute through long-term care facilities. Multiway sensitivity analysis revealed a greater than 90% probability of cost savings. The estimated impact on long-term health outcomes was 564 (3 to 850) quality-adjusted life-years saved over 30 years of the model per 1,000 patients. Treating acute ischemic stroke patients with tPA within 3 hours of symptom onset improves functional outcome at 3 months and is likely to result in a net cost savings to the health care system.     

Cost-effectiveness model of adjunctive lamotrigine for the treatment of epilepsy

OBJECTIVE: To predict the cost-effectiveness of lamotrigine by evaluating the costs and health outcomes in treated patients. BACKGROUND: Lamotrigine adjunctive therapy has been found to be associated with decreased seizure frequency and severity in patients who are refractory to treatment with the older antiepileptic drugs (AEDs). METHODS: We used a cost-effectiveness clinical decision analysis framework to assess the impact of these clinical benefits on patient health care use. The measure of effectiveness was seizure-free days gained. The measures of health care resource use included hospitalizations, outpatient and emergency department visits, surgery, and AEDs. Medical care use and cost estimates were derived from clinical trial data and published sources. Costs and effectiveness (incremental costs per seizure-free days gained) of lamotrigine adjunctive therapy versus older AEDs were compared in patients refractory to previous treatment during three time periods: the start-up year, the second year when decisions about surgery were made, and all subsequent years. RESULTS AND CONCLUSIONS: The model predicts that use of lamotrigine would be associated with an overall reduction in use of other direct medical care resources (hospitalizations, outpatient visits, diagnostic and laboratory tests, and surgery). For a 10-year time horizon, the estimated cost-effectiveness ratio is $6.9 per seizure-free day gained. The model provides a flexible framework to analyze the effect of new antiepileptic drugs.     

Outcomes research: a review

PURPOSE: The purpose of this article is to review the history of the medical outcomes movement as well as the methodologies used in outcomes research. CONCEPT: Outcomes research refers to a genre of clinical investigation that emphasizes the measurement of patient health outcomes, including the patient's symptoms, functional status, quality of life, satisfaction with treatment, and health care costs. RATIONALE: Outcomes research evolved from studies that demonstrated the presence of wide geographic variations in the practice of medicine and surgery. Such differences in utilization were unaccompanied by any discernible difference in patient outcomes. With escalating health care costs, there has been a growing interest in measuring the outcomes of medical intervention to determine the quality and appropriateness of medical care. DISCUSSION: Outcomes may be measured both directly and indirectly, over differing periods of time, and with varying degrees of objectivity, reliability, and validity. Current research has focused on quality of life issues, which include the extent to which a patient's usual or expected physical, emotional, and social well-being have been affected by a medical condition or treatment. The true value of health care can be determined only by a systematic examination of patient outcomes. To accomplish this goal, methods are required that are relatively unfamiliar to many clinical researchers. Future clinical research should include patient-oriented outcome measures that would otherwise focus solely on physiological or anatomic outcomes. Such information will be essential in determining which medical and surgical treatment strategies should be abandoned and which will gain acceptance in the future.     

Moving behavioral medicine to the front line: A model for the integration of behavioral and medical sciences in primary care.

Psychologists have an unprecedented opportunity to influence primary medical care systems where chronic conditions, somatic symptoms, and health-threatening behaviors are prevalent. The authors developed a new model to incorporate behavioral medicine expertise into existing primary care practice with the purpose of delivering integrated, comprehensive, and efficient health care through physician training and direct patient care services. This model moves psychologists from isolated referral settings to the front line of medical care, where a broader impact on the outcomes and costs of health care can be achieved. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Education is the key to nurses' survival

Nurses must be prepared academically to survive in the current and future competitive world of health care. Bachelor's and master's degree programs enhance nurses' abilities to apply the nursing process in increasingly complex health care environments, to document patient outcomes, to study new ways of delivering quality nursing care, and to assume leadership roles that will guarantee nursing's position in a reformed health care system.     

Integrated care management: aligning medical call centers and nurse triage services

Successful integrated delivery systems must aggressively design new approaches to managing patient care. Implementing a comprehensive care management model to coordinate patient care across the continuum is essential to improving patient care and reducing costs. The practice of telephone nursing and the need for experienced registered nurses to staff medical call centers, nurse triage centers, and outbound telemanagement is expanding as the penetration of full-risk capitated managed care contracts are signed. As health systems design their new care delivery approaches and care management models, medical call centers will be an integral approach to managing demand for services, chronic illnesses, and prevention strategies.     

Two-leaflet artificial heart valve with the common turn axis for leaflets

Quality improvement, measurement, and accountability pervade all health care, including the agendas of nursing, other care providers, and consumer groups. One new face of quality is unequivocal: data will be more equitably shared among all groups for data-based quality judgments. This will emphasize quality more than cost with greater involvement of the citizens compared to health care providers, payers, and health care product suppliers. Emphasis on quality will allow patients to have a voice heard and amplified through the implementation of patient-centered outcomes in the computerized patient care record. This article describes the implications of the Nursing Outcomes Classification (NOC) for nursing information systems and the computer-based patient record.     

Home health care

Home health care is the fastest-growing expense in the Medicare program because of the aging population, the increasing prevalence of chronic disease and increasing hospital costs. Patients and families are choosing the option of home care more frequently. Medicare's regulations are often considered the standard of care for all home health agency interactions, even when a patient does not have Medicare insurance. These regulations require patients who receive home health care services to be under the care of a physician and to be homebound. The patient must have a documented need for skilled nursing care or physical, occupational or speech therapy. The care must be part time (28 hours or less per week, eight hours or less per day) and occur at least every 60 days except in special cases. A detailed referral and specific care plan maximize the care to the patient and the reimbursement received by the physician.     

Quality of life after cardiac surgery

Tremendous strides have been made in the surgical treatment of cardiac disease. Research has documented many physical and psychologic benefits for the patient, but many questions remain unanswered. The change in quality of life may be the single most important outcome of cardiac surgery. This issue has received considerable attention in professional literature in recent years, particularly in the midst of rapidly expanding technology and soaring health care costs. This article reviews the literature related to the quality of life of cardiac surgical patients. Specific topics, such as physiologic and psychologic outcomes, return to work, family responses, and issues related to transplant patients, are discussed. The article includes a discussion of nursing implications.     

Informing the policy process: from efficacy to effectiveness data on pharmacotherapy

Health care delivery is rapidly changing, but are the right data available to inform the policy process? This article illustrates the use of observational data on quality and effectiveness of treatment for anticipating the consequences of alternative forms of health care delivery, with psychotropic medications used as the example. The data are from the Medical Outcomes Study. Patients in each specialty sector (general medical provider, psychiatrist, psychologist or master's-level therapist) have unique profiles of use of appropriate psychotropics, and there is less appropriate and less efficient medication management in prepaid than fee-for-service care, especially within psychiatry. Overall, effective psychotropic medications are underused, reducing the cost-effectiveness of care. Improving the quality of psychotropic medication management would improve patient functioning outcomes and cost effectiveness of care, but in the absence of compensating strategies, it would also raise treatment costs.     

Measuring organizational readiness for nursing research programs

Nursing research programs are important innovations for health services organizations (HSOs). Evidence supports the positive impact that successful programs have on both clinical practice and patient outcomes. In the current era of scarce health care resources, decision makers must be able to accurately judge HSO readiness for nursing research programs to facilitate their success. Judging innovation readiness is an important and complex process for decision makers. An Innovation Readiness Scale (IRS) was developed from research-based HSO contextual cues identified by nurse researchers as supportive of successful hospital-based nursing research programs. The IRS provides decision makers with a measure by which to judge HSO readiness for nursing research programs. Psychometric results are reported from a pilot and actual test of the IRS in two urban acute care settings involved in nursing research program innovation.     

EPR evidence for the involvement of free radicals in the iron-catalysed decomposition of qinghaosu (artemisinin) and some derivatives; antimalarial action of some polycyclic endoperoxides

The role of pharmacies that specialize in the treatment of specific chronic diseases in the alternate-site health care setting is discussed. The optimal use of medications through disease management programs can improve patient outcomes and lower overall health care costs. The increase in disease management programs has spawned the growth of disease-specific pharmacies in the home care and other alternate-site health care settings. These pharmacies usually operate from a single location or are regionalized operations that deliver pharmaceutical products to patients throughout the United States. The pharmacies employ clinicians who specialize in a particular disease. These clinicians conduct comprehensive patient education programs, drug-use review, and compliance monitoring. Disease management pharmacies focus on chronic, expensive diseases; costs related to inventory, equipment, and storage can be very high. Many disease management pharmacies are involved in preferred-distribution or closed-distribution arrangements with pharmaceutical manufacturers. Pharmacists involved in disease management programs routinely send compliance information about their patients to pharmaceutical companies, managed care organizations, or prescribing physicians. Disease management pharmacies act as advocates for patients with particular chronic diseases. Various foundations and patient advocacy and research groups have created their own disease management pharmacies. Disease management has also reached the community pharmacy practice setting. Pharmacies specializing in the treatment of specific chronic diseases in the alternate-site health care setting can improve health care and promote efficient use of health care dollars.     

Community-based leg ulcer clinics: organisation and cost-effectiveness

To establish the cost effectiveness of community leg ulcer clinics using four-layer compression bandaging and the care provided by district nurses, a randomised controlled trial was set up in eight community-based research clinics in four trusts, funded by Trent Regional Health Authority. The main outcomes monitored were the amount of time needed to complete ulcer healing, patient health status, and recurrence. Satisfaction with care, use of services and personal costs were also monitored.     

Using economics to assess the place of screening

To an economist the place of screening is, in principle, no different from that of any other medical intervention. Any screening activity should be evaluated in terms of the costs it incurs and the benefits it produces. The reasoning for this is based on one fundamental principle of economics: that of opportunity cost. Resources are scarce, requiring choices to be made about what health care to provide and what not to provide. Sacrifices will be made through not taking up some opportunities, and the benefits of these sacrifices are known as opportunity costs. The place of economics is to assist decision making to promote efficiency and equity in the health care sector. To do this it is necessary to relate the benefits of any screening activity to its costs. Of course, the practicalities of applying economics to assessment of screening activities may be different than for other areas of health care. For instance, screening has a broader range of outcomes than most types of health care, including investment in knowledge as well as health gain. This does have implications for the way in which these outcomes are valued in an economic analysis. This means that economics can be applied to a wide range of policy questions about screening. In this paper examples from applications of economics are used to consider the following issues: How should we set out and estimate costs and benefits (using the example of cholesterol screening)? What is benefit and how should it be measured (using an example from cystic fibrosis carrier screening)? How can economics be used to examine equity issues in screening (using an example from bone mineral density screening)? Together, these case studies highlight the range of screening issues to which economics can be usefully applied.     

Peer review among rural clinics

One goal of nursing has always been to improve the quality of health care. This goal has resulted in myriad attempts to evaluate both nurses and nursing care, determine outcomes and goals, establish criteria, and develop measurement tools. Since Derryberry first documented the evaluation of nursing care in 1939, evaluations have focused on the provider, the consumer, the outcomes, and the process of providing care; but all have had as their central purpose the benefit of the client through the improvement of health care. The importance of quality assurance is reflected not only in nursing literature, but also in the recent development of PSROs, Medicaid/Medicare regulations, certification, and mandatory continuing education for health professionals. At the 1978 American Nurses' Association Convention, the House of Delegates pledged "to work aggressively on improving the quality of health care, and that of nursing care in particular, through peer review."     

New therapies for cytomegalovirus retinitis

Advocates of inpatient managed care employing clinical pathways are confident that this patient management strategy reduces cost while promoting optimal patient outcomes. Other health care professionals are concerned that cost reductions place patients at higher risk for adverse health events. Research is needed to demonstrate the true impact of cost-containment strategies on clinical outcomes. The article describes a study in progress comparing patients conventionally managed by their physicians with similar patients whose overall management involved a nurse case manager. This study explores the issue of resource costs that can be linked to clinical and financial outcome measures.