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Purpose: To evaluate the influence of nurse staffing and work environment variables on patient outcomes by testing a conceptual model. Design: A prospective, correlational design with cross-sectional and longitudinal components was conducted in Canadian cardiac and cardiovascular care inpatient units. Methods: Data were collected from multiple sources. Hierarchical linear modeling was used to examine relationships among variables. Conclusions: The findings indicate that patient outcomes are influenced not only by patient and nurse characteristics, but also by organizational staffing practices. Organizations that manage the complexity of work conditions and target staffing utilization levels between 80% and 88% at the unit level can optimize patient outcomes. Clinical Relevance: Empirical validation of the model provides evidence to inform management decisions about hospital nurse staffing. Key words Nurse staffing, work environments, patient outcomes

Flexibility in health care design is typically addressed from an architectural perspective without a systematic understanding of its meaning from the end-user's viewpoint. Moreover, the architectural perspectives have been generally focused on expandability and convertibility. This study explored flexibility needs in adult medical-surgical inpatient care with the objective to understand its meaning from an end-user perspective and identify characteristics of the physical environment that promote or impede stakeholder' requirements. Semistructured interviews were conducted using a qualitative design with 48 stakeholders in nursing and nursing-support services at 6 hospitals across the United States. Data were collected during September-November 2006. Findings suggest that adaptability influences more aspects of unit operations than convertibility or expandability. Furthermore, physical design characteristics affect 9 critical operational issues where flexibility is required, spanning nursing, environmental services, materials management, dietary services, pharmacy, and respiratory therapy. Keywords: adaptability; convertibility; efficiency; expandability; flexibility; inpatient unit

A study to compare the outcomes of care of hospitalized patients throughout the U.S. by hospitalists, general internists and family physicians is conducted. Findings show hospitalist care modestly less expensive than that provided by general internists, but it offers no significant savings as compared with the care provided by family physicians.

Purpose: The purpose of this study was to determine the relationship between nursing home staffing level, care received by individual residents, and resident quality-related care processes and functional outcomes. Design and Methods: Nurses recorded resident care time for 5,314 residents on 156 units in 105 facilities in four states (Colorado, Indiana, Minnesota, and Mississippi). We linked residents' care times to their measures of health and functioning from Minimum Data Set assessments. Major variables were unit- and resident-specific minutes of care per day, process measures (physical restraints, range of motion, toileting program, and training in activities of daily living [ADLs]), outcome measures (ADL decline, mobility decline, and worsening behavior between the time study and 90-day follow-up), and covariates such as unit type and resident health status. We used multilevel analysis to examine staffing and quality relationships. Results: Residents with toileting programs, range of motion or ADL training, and restraints received significantly more care from unlicensed but not from licensed staff. However, functional outcomes were not significantly related to care received from licensed or unlicensed staff, except for ADL decline, which was greatest for residents receiving more unlicensed minutes of care. Unit staffing level (licensed and unlicensed) was unrelated to any of the care processes or outcome measures, although higher overall staffing was associated with more time devoted to direct resident care. Implications: Future research into nursing home quality should focus on organization and delivery rather than simply the amount of care available. Key Words: Nursing home, Quality, Nurse staffing, Outcomes, Multilevel model

A study analyzed claims in order to describe typical care delivery patterns in fee-for-service Medicare, to evaluate the extent to which a beneficiary's care could be assigned to a single physician or practice, and to determine the extent to which physicians can be held accountable for Medicare patients. Results demonstrated that the dispersion of patients' care among multiple physicians limits the effectiveness of pay-for-performance initiatives that rely on a single retrospective method of assigning responsibility for patient care.

Objectives. We conducted a 3-year cohort study of 407 youths aged 9 to 18 years to develop multivariable risk prediction models of agriculture-related injuries. Methods. Data were obtained via participant event monitoring, with youths self-reporting injuries and exposures in daily diaries over a 13-week period. We evaluated data quality by comparing injury self-reports with other injury data. Results. Semilogarithmic plots of rates of all unintentional injuries combined (US data from 2000) as well as of agriculture-related injuries (US and Canadian data from 19 previous studies) graphed as a function of injury severity exhibited linearity, as did plots based on the present results. Severity-specific unintentional injury rates were 1.4- to 4.3-times higher than national rates, suggesting that our methodology can significantly reduce injury underreporting. In addition, at each severity level, estimated agriculture-related injury rates were 5.8- to 9.3-times higher than rates from previous national, regional, and state-based studies. Conclusions. Our approach to participant event monitoring can be implemented with youths aged 9 to 18 years and will yield reliable daily data on unintentional injuries. (Am J Public Health. 2007;97:283-290. doi:10.2105/AJPH.2005.077172)

There is an argument for the collaboration among payers, purchasers, patients and providers in the development system of public accountability. Patients are given potential report cards with illnesses, which often gives inconsistent results.

Byline: L. Perez-Edo (1), M. Ciria Recasens (1), C. Castelo-Branco (2), P. Orozco Lopez (3), A. Gimeno Marques (4), C. Perez (1), J. Manasanch Dalmau (5) Keywords: Bone densitometry; General practice; Knowledge; Medical education; Osteoporosis; Osteoporosis investigations; Primary care physician Abstract: A cross-sectional survey was conducted to determine the current situation in Spain regarding diagnosis and care of patients with osteoporosis in the primary care setting. A total of 2,500 primary care physicians who were homogeneously grouped in autonomous communities throughout the country received a postal 30-item anonymous self-administered questionnaire. The questionnaire covered demographics and personal characteristics of the physicians, conditions in everyday consultation, and degree of knowledge with regard to risk factors, diagnosis, treatment, and follow-up of the disease. The overall response was 850 (34%). The mean age of physicians surveyed was 43 years (range 23-66 years). The percentage of physicians specialized in community and family medicine was 46.7%. In 55.2% of cases, years of practice ranged between 11 and 20, and 55.7% of physicians visited between 31 and 50 patients per day. Age and years of practice were not associated with daily number of visits. Only 4% of physicians stated that there were specific programs for osteoporosis implemented in their primary care center. Diagnostic complementary investigations that could be ordered included plain radiographs in 96.2% of cases and bone densitometry in 27.8%. Laboratory tests included serum hormones in 61.6% of cases, PTH in 50.2%, and bone alkaline phosphatase in 33.4%. The diagnosis of osteoporosis was made always personally in 25.2% of cases. Personal diagnosis and follow-up, as well as actions directed to detection of osteoporosis were significantly higher among physicians working in centers with specific programs for osteoporosis. With regard to knowledge about osteoporosis, the mean percentage of correct responses was 63%. The percentage of correct responses was inversely associated with age and years of practice, and positively associated with speciality of community and family medicine. Primary care providers are in a good position to assess risk factors and recommend prevention strategies, as well as to play an active role in the diagnosis, care, and follow-up of patients with osteoporosis. Practitioners of younger age and relatively few years of practice were those with more up-to-date information regarding the disease, and the existence of a specific program for osteoporosis seems to improve the management of this condition. Author Affiliation: (1) Service of Rheumatology, Hospital de la Esperanca, Sant Josep de la Muntanya 12, 08024, Barcelona, Spain (2) Hospital Clinic, Clinical Institute of Obstetrics and Gynaecology, Barcelona, Spain (3) Area Basica de Salut (ABS) Gotic, Barcelona, Spain (4) Health Care Center l'Alcudia, Valencia, Spain (5) Pierre Fabre Iberica, Barcelona, Spain Article History: Registration Date: 04/12/2003 Received Date: 17/03/2003 Accepted Date: 04/12/2003 Online Date: 27/01/2004

Background: Most clinicians rely on clinical scales such as the unified Parkinson's disease rating scale (UDPRS) for evaluating parkinsonian patients and assessing their response to levodopa. Gait analysis is not [...]

Byline: Gillian Hawker (1), Rowena Ridout (1), Maria Ricupero (1), Susan Jaglal (1), Earl Bogoch (4) Keywords: Fracture clinic intervention Fragility fractures Osteoporosis Pre-post study Abstract: We examined the effect of a fracture clinic intervention in reducing previously documented undertreatment of osteoporosis (OP) in individuals with fragility fractures. Fragility fracture patients presenting to five community fracture clinics with no prior diagnosis of, or treatment for OP, and whose radiographic appearance was consistent with fragility fracture, were included. These individuals (intervention group) were informed of their OP risk, and advised to follow up with their physician for assessment. A standardized letter, intended for the physician and outlining the same was provided. Three months later, a telephone interview determined whether a physician visit had occurred, and if so, what investigation and treatment recommendations were made. These outcomes were compared with those for an equal number of age- and sex-matched fragility fracture 'controls,' selected from among fracture clinic attendees in the 6--9 months preceding the intervention. Logistic regression was used to examine the effect of having received the intervention on physician follow-up, bone density testing, and OP treatment recommendations. The mean age of the 278 participants (139 per group) was 66.0 years 74% were female. Adjusting for age, sex, hospital, and perceived diagnosis of OP, those who received the intervention were more likely to follow up with a physician (adjusted OR 1.85, p=0.02) and to be recommended bone density testing (adjusted OR 5.22, p&lt 0.0001), but were not more likely to receive an OP treatment recommendation (adjusted OR 2.07, p=0.07). It is concluded that a simple fracture clinic intervention increased follow-up and investigation, but not treatment for OP, in fragility fracture patients. Individuals recommended treatment for OP were more likely to perceive themselves as having OP and to have had a previous fragility fracture. Our findings suggest that future interventions should incorporate assessment of patients' OP health beliefs and education about risk factors for fracture, and should be coupled with physician education to achieve optimal results. Author Affiliation: (1) Osteoporosis Research Program, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada (2) Division of Endocrinology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada (3) Department of Rehabilitation Science, Women's College Ambulatory Care Centre, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada (4) The Mobility Program and the Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada (5) Department of Health Policy, Management and Evaluation, Women's College Ambulatory Care Centre, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Canada (6) Division of Rheumatology, Department of Medicine, Women's College Ambulatory Care Centre, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, 76 Grenville Street, 10th floor, Room 1010, M5S 1B2, Toronto, Canada Article History: Received Date: 13/08/2002 Accepted Date: 17/12/2002 Article note: Electronic Publication

Byline: A. G. Juby (1), C. M. De Geus-Wenceslau (2) Keywords: Key words:Elderly -- Hip fracture -- Osteoporosis Abstract: A retrospective chart review was carried out on all consecutive patients over 65 years of age admitted to a tertiary care teaching hospital with a diagnosis of a new hip fracture. A further chart review occurred after discharge from post-surgery rehabilitation. The primary objective was to evaluate the prevalence of osteoporosis diagnosis and treatment in both phases of the study. Secondary objectives included evaluation of the mortality rates, length of stay, prevalence of osteoporosis investigation, and prevalence of osteoporosis diagnosis based on the clinical subspecialty involved. There were 311 patients evaluated in the initial phase, and 226 after rehabilitation. The mortality rate was 5.8% (10% for men, 4% for women p&lt 0.005) in the acute care hospital and 9.3% (8% men, 10% women) during rehabilitation. Previous hip fracture occurred in 17.4%, and 1.5% were readmitted during the study period with fracture of the opposite hip. Osteoporosis was diagnosed in the acute care hospital on admission in 11.9% and on discharge in 15.4%. In the rehabilitation hospital it was diagnosed in 9.7% on admission and 11.2% on discharge (p=NS). Osteoporosis treatment (including calcium or vitamin D therapy) was instituted in 13% on admission to acute care and in 9.7% at the time of discharge. For the rehabilitation hospital, treatment occurred in 12.8% on admission and 10.2% on discharge. The diagnosis of osteoporosis significantly increased the prevalence of treatment (p&lt 0.001). Use of specific agents (hormone replacement therapy, bisphosphonates or calcitonin) occurred in &lt 6% of all patients. Osteoporosis is under-diagnosed and under-treated in this group of elderly hip fracture patients. It is associated with significant mortality and morbidity and every effort should be made to prevent future fractures. Physicians in the 'front line' of hip fracture treatment are missing this key aspect of management in their patients. Education of these physicians, as well as the public, may be the key to addressing this care gap. Author Affiliation: (1) Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada , CA (2) Av. Nossa Senhora da Luz, ap 17, Bacacheri, Curitiba Parana, Brazil, BR Article note: Received: 12 March 2001 / Accepted: 23 July 2001

Byline: N. F. de Keizer (1), C. P. Stoutenbeek (2), L. A. J. B. W. Hanneman (2), E. de Jonge (2) Keywords: Key words Patient Data Management System; Information needs; Intensive care Abstract: Objective: To assess the agreement between the functions of seven configurations of Patient Data Management Systems (PDMS) and the Dutch specifications prepared by the users prior to use. Design: An observational descriptive study with hospital visits of seven configurations of five different PDMS systems including three commercial systems and two locally developed systems. Setting: Seven Dutch level I intensive care units in university and teaching hospitals. Measurements and results: A substantial disagreement was found between the Dutch specifications and the actual functions of the PDMS configurations tested. Between the PDMS configurations, major differences in key features, including 'automated charting', 'information and care planning', and 'management information', were observed. Automated charting is adequately supported by the three commercial systems. All configurations tested had limited functions supporting care planning. In none of the configurations tested was the required function present to support unit management with reports on resource utilisation and outcome performance. The automatic calculation of prognostic scores was either absent or incorrect. The implementation, the (continuous) configuration and the training required a substantial investment in costs and human resources. Conclusion: Today, none of the PDMSs tested satisfy the Dutch specifications. This can be explained by technical impossibilities of the systems and shortcomings in the actual configuration or in the unit organisation. The PDMS might become a valuable tool in improving the quality of ICU practice, but full implementation of these systems according to the specifications still has a long way to go. Author Affiliation: (1) Department of Medical Informatics, Academic Medical Center, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands Fax: + 31 (20) 6 91 24 32 email: n.f.keizer@amc.uva.nl, NL (2) Department of Intensive Care, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands, NL Article note: Received: 20 May 1997 Accepted: 21 November 1997