Therapeutic communities: diversity in treatment elements

This study addresses the need to describe the diversity of therapeutic community (TC) programs. The Survey of Essential Elements Questionnaire (SEEQ) was used to develop a typology of TC programs based on 19 programs that identified themselves as traditional or modified TCs in the Drug Abuse Treatment Outcome Studies (DATOS). These traditional and modified TCs differed in adherence to the elements of TC treatment, on operational characteristics, and in client mix. Differences in treatment philosophy and approach included the emphasis on self-reliance, and the use of work as a therapeutic agent for traditional TCs. There were also trends for traditional TC programs to utilize community-as-method, provide educational and vocational training, and include family members as part of therapy. Modified programs showed a greater tendency to rely on counselors. Implications of the findings for program quality, health care policy, and research are discussed.

Coronary revascularization of the circumflex system: different approaches and long-term outcome

BACKGROUND

Minimally invasive direct coronary artery bypass, without cardiopulmonary bypass, through a left lateral thoracotomy approach (lateral MIDCAB), is a safe alternative to coronary artery bypass surgery using cardiopulmonary bypass (on-pump CABG) of the circumflex system via median sternotomy. However, it is unknown whether lateral MIDCAB may yield an improved long-term outcome over the conventional on-pump median sternotomy approach.

METHODS

We compared the perioperative outcomes of patients undergoing lateral MIDCAB (n = 34) versus conventional on-pump CABG of the circumflex system (n = 16) from June 1996 to July 1999. The two groups were similar with respect to baseline characteristics and risk stratification. Patients who required only one or two grafts for complete revascularization were included.

RESULTS

Lateral MIDCAB patients had a lower need than on-pump CABG patients for intraoperative (12% MIDCAB vs 43% on-pump CABG, p = 0.03) and postoperative transfusions (29% vs 69%, p = 0.01), had fewer neuropsychologic changes (0% vs 19%, p = 0.03), and had a lower rate of postoperative atrial fibrillation (12% vs 44%, p = 0.02). Lateral MIDCAB was also associated with a significantly lower postoperative length of stay (5 +/- 2 vs 7 +/- 3 days, p = 0.02). Actuarial survival at a mean period of follow-up of 19 +/- 11 months was 97% for the lateral MIDCAB versus 88% for the on-pump CABG group (p = 0.6). Event-free survival was 88% for lateral MIDCAB versus 81% for on-pump CABG (p = 0.1).

CONCLUSIONS

Lateral MIDCAB may safely be performed in patients with isolated coronary artery disease of the circumflex system with improved early morbidity and an abbreviated hospital stay compared with conventional median sternotomy on-pump CABG.

[Ergotherapy assessment: field study of acceptance, practicability and process quality]

There is need for comprehensive assessment of patients suitable for occupational therapy. The "Ergotherapeutische Assessment" (EA) occupational therapy assessment instrument has been developed recently by a group of experts in the field. Its main purpose is to significantly support occupational therapists in diagnostics, planning, communication and evaluation of therapeutic outcome. In a first step, EA was tested in a field study with regard to practicability, acceptance, and its effects on process quality. The EA was applied in 329 patients by 22 occupational therapists (office, institution) who had been specially trained (handbook, instruction session) prior to the study. In addition, participants had to answer standardized evaluation forms with respect to the general therapeutic success, relevant functional changes possibly not covered by the EA, and professional benefit in the areas under investigation. In summary, the value for practicability as described using a 10-point scale was 5.8, and 7.6 for acceptance. With regard to process quality, the ratings were 7.3 for diagnostic effect, 6.0 for definition of therapeutic aims, and 6.8 for improvement of communication between members of the rehabilitation team. The internal consistency of the five individual modules of the instrument as calculated by Cronbachs alpha was between 0.72 and 0.95. Changes considered relevant by the participants and not reflected by the instrument accounted for 9% only. The correlation coefficient for the evaluated general success of the patients and category changes found on the basis of EA severity ratings was 0.48.

Factors influencing outcomes after delegation to unlicensed assistive personnel

The authors discuss a national survey of licensed nurses that describes factors associated with patient outcomes when nursing activities are delegated to unlicensed assistive personnel (UAP). Licensed nurses' overall experience and UAP's experience in the current work setting were associated with more positive events. When the outcome of the delegated activity was determined by routine observation, more positive events occurred. However, when there was no direct supervision of the UAP, more negative events occurred. Recognition of the importance of the supervisory process has implications for educational opportunities that focus on strengthening licensed nurses' delegation competencies.

Comparative study of perioperative management of hepatic resection

In an attempt to identify the factors that influence outcome after hepatic resection, patient background was reviewed and operative morbidity and mortality rates were assessed during two periods: 1985-1988 (group I: N = 96) and 1995-1998 (group II: N = 109). There were no differences in patient background factors between the two groups, but intraoperative blood loss, operative morbidity, and mortality were significantly reduced in group II compared to group I. There has been a significant reduction in postoperative complications, even in cases complicated by liver cirrhosis or obstructive jaundice. As a result of appropriate surgical procedures, postoperative complications in cirrhosis have been markedly decreased. After preoperative percutaneous biliary drainage in obstructive jaundice, attempts have been made to reduce the volume of blood loss even in extensive hepatectomy, the extent of liver resection in poor risk cases has been reduced without sacrificing radicality, and, by minimizing surgical stress, perioperative management has been greatly improved.

Placement matching: challenges and technical progress

Although it is highly desirable, standardized placement matching for substance use disorders poses challenges due to variability in settings, services, and syndromes; multidimensionality of clinical problems; multiplicity of outcome constructs; and temporal phenomena in the course of recovery. Despite these obstacles, progress is being made in developing patient placement criteria that are comprehensive with adequate reliability, feasibility, and resolution. With these methodological advances, it has been possible to initiate controlled research with placement criteria. The first such studies provide early evidence supporting such criteria and indicate areas for refinement.

Framing the work: development of a renal nursing professional practice model

In 1997, a nursing care model task group was formed to develop a framework to guide the development of the nursing care delivery system in a newly merged hospital corporation. A collective group of experienced and motivated nurses in the renal program met to develop an integrated renal nursing professional practice model. In addition it was recognized that a city-wide model involving the two acute care renal centres would be advantageous. The challenge was to clearly articulate the professional roles and relationships of nurses and nurse practitioner/clinical nurse specialists in a constantly changing environment. This process provided the opportunity to identify key trends influencing renal care and possibilities for changing practice. Networking across the corporations was enhanced, partnerships were formed, and a sense of value for the work that was being undertaken developed. The group's endeavours resulted in an integrated nursing professional practice model that emphasizes accountability and continuity and places value on therapeutic relationships. Another strength of the model is the acknowledgement of the collaborative nature of the multidisciplinary team. After two years of development, the model was implemented. A city-wide Renal Nursing Professional Practice Council has been established in order to provide leadership in evaluating the model. This will include assessing the success of implementation, impact on patient/family care, and collaborative rewards experienced by staff. Future planning will address the potential need for a multidisciplinary focus within the practice council.

Development of a "treatment program" descriptor: the addiction treatment inventory

This paper reviews the current literature on the definition and classification of drug and alcohol user treatment "programs," and provides a rationale for our approach to measuring the treatment programs in the Drug Evaluation Network System (DENS). The DENS gathers extensive background and recent status data on patients' drug, alcohol, psychiatric, medical, employment, legal, and family problems as they enter a sample of treatment programs throughout the country. The DENS recognized the need for descriptive information on important structural, organizational, and service delivery aspects of the programs in which those patients were treated. To this end, we present our efforts thus far in characterizing and monitoring "service delivery units" or "programs" that are sampled in the DENS system. Specifically, we present development of the Addiction Treatment Inventory (ATI), a standardized measurement instrument to characterize these service delivery units and their services.

Evaluations of correctional treatment programs in Germany: a review and meta-analysis

This study presents a review and meta-analyses of research on the recidivism-reducing impact of correctionally based treatment programs in Germany. The data are part of the Correctional Drug Abuse Treatment Effectiveness (CDATE) project meta-analytic database (covering 1968-1996) of evaluation research studies of correctional interventions. Overall, the five studies of educational programs show no practical impact of these programs in reducing recidivism. Four studies of programs to counsel driving-under-the-influence (DUI) offenders fall in an intermediate area (not statistically significant, but promising enough to warrant further research). The eight studies of Social Therapy programs did show, on the average, a statistically significant practical impact in reducing recidivism.

Effective technology transfer in alcoholism treatment

Alcoholism treatment services in the United States continue to be characterized by a lack of evidence-based care. Problems establishing effective research-practice knowledge transfer stem, in part, from the strong allegiance of scientists and practitioners to contrasting treatment models. Four underlying assumptions of the Minnesota model that continue to guide the delivery of alcohol services in the United States are identified and related research is reviewed. Findings indicate little support for these assumptions. However, support for superiority of alternative science-based treatments to replace current practices varies. To facilitate effective technology transfer, research practitioner collaboration must be promoted. Research paradigms are needed that possess high salience to practitioners while preserving scientific rigor. Two examples of studies involving research-practitioner collaboration are described.

Substance dependency treatment for adolescents: practice and research

This paper reviews the more common treatment approaches that address adolescent substance abuse and the spectrum of problems which often attend involvement with drugs. The most common outpatient treatment approaches for adolescents are 12-step based programs and family-based therapies which may be used separately or in conjunction with each other. The therapeutic community is a residential approach, characterized by the use of the peer community itself to facilitate social and psychological change in individuals. Both outpatient and residential modalities have demonstrated effectiveness in working with adolescents. Ideally, the type of intervention will depend upon the young person's needs, in particular the extent and effects of his/her drug use, as well as the level of other problems. Overall, treatment must address a range of concerns of special relevance to adolescents because of their age and dependency status; for example, developmental stage, cultural issues, and gender issues.

Institutionalization of quality improvement programs in Korean hospitals

OBJECTIVE

To investigate the institutionalization of quality improvement (QI) programs in Korean hospitals, in which organizational efforts to improve the quality of care have been made only recently.

DESIGN

A cross-sectional study based upon an initial telephone contact and follow-up mail survey.

STUDY PARTICIPANTS

All hospitals with 400 beds or more, 100 as of 1997, were contacted in the initial telephone survey. The survey questionnaire was then sent to all of 28 hospitals found to have a QI department; 26 hospitals returned the completed questionnaire.

RESULTS

Hospitals that had larger bed capacities, that provided tertiary levels of care or that were in urban areas were found to have a higher tendency to establish QI departments. These QI departments most frequently cited improvement of patient satisfaction as one of their overall missions. They also reported that their most important responsibilities were monitoring performance and preparing for the two national Korean hospital assessment programs. Participating in these hospital assessment programs helped them to initiate and develop their QI activities. The main difficulties they had in performing their QI programs stemmed from lack of knowledge and resources. These survey findings indicate that hospital assessment programs significantly aided Korean hospitals to institutionalize their QI programs. At the same time, the survey data indicate that the hospital assessment programs may emphasize short-term benefits from QI activities at the expense of long-term QI institutionalization.

CONCLUSION

QI programs have not as yet been fully institutionalized in Korean hospitals. More support for QI structure and organizational preparation at both the national and organizational levels will be needed.

Home phototherapy for neonatal jaundice--technology and teamwork meeting consumer and service need

32 babies with uncomplicated physiological jaundice received home phototherapy from a hospital/community team in southern Brisbane. All babies showed acceptable reductions in their serum bilirubin on home therapy, and none required hospital re-admission for phototherapy. Their families were highly satisfied with the home program, and recorded high levels of confidence in their therapeutic responsibilities. Community providers were able to deliver a high quality 24-hour service, integrated with appropriate neonatology support. The cost of delivering the home program was significantly less than a comparable hospital stay.

Radiotherapy outpatient review: a nurse-led clinic

The aim of this project was to improve the quality of the delivery of care to patients undergoing outpatient fractionated radiotherapy, in terms of effectiveness and efficiency. This article provides a descriptive account of the activities that took place within a traditional doctor-held radiotherapy review (floor) clinic (71 individual clinic episodes from 71 patients) and compares them with a nurse-led clinic (299 clinic episodes from 141 patients). The outcome measures encompassed the number and type of activities in both clinics, including the number of interventions that occurred, consultation time, waiting time, degree of involvement with other support services, reasons for doctor contact, and perceptions of patients, doctors, nurses and therapy radiographers. Nurse consultations lasted longer than doctor consultations. Waiting times were reduced. Of 299 nurse-led clinic episodes, only 21 contacts were made with the doctor. More interactions and activities occurred during nurse consultations. A greater number of referrals and liaisons with other support services occurred, resulting in the establishment of continuity of care. The results from this small sequential observational study require prospective confirmation, but they suggest that specialist nursing staff, given appropriate medical support, may provide more effective care for patients who are undergoing outpatient radiotherapy.

A synthesis of a vocational assessment system and an information system of technical aids

PURPOSE

In vocational rehabilitation, the selection and tailoring of the work place is tightly bound with the integration or reintegration of people with disabilities into the work environment. Instruments which ease this task are assessment systems as well as information systems of technical aids. To date, these instruments are separated from one another in practice. They also necessitate a broad transfer capacity between the results of an assessment system and the selection of technical aids for a work place design suited for people with disabilities.

METHOD/RESULTS

Therefore, when employing assessment system, immediate access to information concerning technical aids would ease the work of experts in the area of vocational rehabilitation. This information should also provide a commentary concerning which aids have been utilized to date in concrete cases of suitably designing work places for people with disabilities.

CONCLUSIONS

This article describes the synthesis of a vocational assessment system with an information system of technical aids from the aspect of frequency of use.

[Differences in hip prosthesis implantation in a non-urban region]

AIM

The aim of the study was to analyse differences of early results after total hip replacement performed at various hospitals.

METHOD

A total of 37 consecutive patients submitted for postoperative rehabilitation were examined. These patients were referred from 18 different hospitals. In an assessment sheet, personal data, age, indication, operating department (surgical or orthopedic), side, length of skin incision and early X-ray presentation with regard to cup angle, position of greater trochanter in relation to head of prosthesis, varus/valgus angle of femoral prosthesis, and cementation were recorded.

RESULTS

Of the 37 patients, 26 were female, 11 male. Average age was 62.9 +/- 10.4 years. Degenerative osteoarthritis was present in 23 cases, fractures in 6 cases, there were 6 patients with osteoarthritis following hip dysplasia, 1 pathological fracture, and 1 aseptic necrosis of the femoral head. The skin incision length varied from 8 to 31 cm, averaging to 16.8 +/- 5.3 cm. Implantations were cementless in 20 cases, cemented in 12, and partly cemented in 5 cases. Using a THR-Early-Result-Score of 25 points maximum, # 7 implantations were scored as normal, 16 subnormal, 10 atypical, and 4 highly atypical.

CONCLUSION

The data presented show an incidence of 81% non-ideal implantations which is considered surprisingly high. Potential reasons are discussed. It is suggested that efforts to improve the quality of total hip replacements should be made.

Renal growth in children with severe vesicoureteral reflux: 10-year prospective study of medical and surgical treatment: the International Reflux Study in Children (European branch)

PURPOSE

To determine whether medical or surgical treatment better promotes renal growth in children with severe vesicoureteric reflux (VUR) and to examine factors influencing renal growth.

MATERIALS AND METHODS

Three hundred two children younger than 11 years with urinary tract infection and grade III or IV VUR were randomly assigned to surgical (n = 149) or medical (n = 153) treatment and were followed up at serial intravenous urography for up to 5 years; 223, for up to 10 years (surgical, n = 110; medical, n = 113). Renal size was measured planimetrically on serial intravenous urograms and was related to the virtual height of L1 through L3 by expressing it as an SD score.

RESULTS

There was no significant difference in mean renal growth between patients treated surgically or those treated medically after 5- or 10-year follow-up. Bilateral renal size of 80 surgical and 75 medical patients remained within 1 SD score. In patients entering the study at 2 years of age or younger and in those with grade IV VUR, bilateral VUR, or renal scars, there was a trend toward improved renal growth in those treated medically, but this finding was not statistically significant. When renal scarring or thin parenchyma was unilateral, the affected kidney grew less well, irrespective of treatment. Bilateral renal scarring was usually asymmetrical, with a corresponding effect on renal growth.

CONCLUSION

There was no significant difference in renal growth during 10 years between surgical and medical treatment in patients with severe reflux.

Poor outcome with round spermatid injection in azoospermic patients with maturation arrest

OBJECTIVE

To compare the outcome of intracytoplasmic sperm injection (ICSI) and round spermatid injection (ROSI), both obtained by testicular sperm extraction (TESE), and to compare the results of fresh versus frozen ROSI.

DESIGN

Retrospective study.

SETTING

An IVF unit at a university hospitalPatient(s): Eighteen infertile couples with nonobstructive azoospermia.

INTERVENTION(S)

TESE with ROSI or ICSI of mature spermatozoa into metaphase II oocytes was performed. The resulting embryos were transferred to female partners. The spare round spermatids were frozen.

MAIN OUTCOME MEASURE(S)

Fertilization and cleavage rates, embryo quality, and clinical pregnancy rates.

RESULT(S)

Seventeen ROSI cycles and six ICSI cycles were compared. Fertilization rate following ROSI (44.9%) was significantly lower than with ICSI (69%). A significantly higher rate of cleavage arrest occurred following ROSI (40.8%) as compared to ICSI (8.2%). The morphology of embryos resulting from ROSI was significantly poorer. No pregnancies were achieved following ROSI as compared to a 50% clinical pregnancy rate in the ICSI group. The fertilization and cleavage rates following ROSI with fresh versus frozen-thawed spermatids were comparable.

CONCLUSION(S)

In azoospermic patients with maturation arrest at the stage of round spermatids the efficiency of ROSI appears to be extremely poor. The role of ROSI in the treatment of nonobstructive azoospermia should be reevaluated.

Variation between and within drug treatment modalities: data from the National Treatment Outcome Research Study (UK)

This paper describes treatment practices in 54 drug treatment programmes taking part in the National Treatment Outcome Research Study (NTORS). Programmes were representative of the 4 main treatment modalities in the UK: in-patient, residential rehabilitation, methadone maintenance and methadone reduction. Distinguishing features of these forms of treatment were identified. Substantial variations in treatment practices were also observed within each modality, particularly for detoxification and prescribing arrangements, counselling and non-drug treatment services, and planned duration of treatment. Many programmes reported extensive waiting lists. These findings are discussed in the context of the growing international evidence of the association between patient outcome and the manner in which programme services are delivered.

The Australian National Workplace Health Project: design and baseline findings

BACKGROUND

This paper describes the study design, recruitment, measurement, and initial recruitment outcomes of Australia's largest workplace intervention trial, the National Workplace Health Project.

METHODS

This was a cluster-randomized trial of socio-behavioral and environmental interventions focusing on key behaviors of physical activity, healthy food choices, cigarette smoking, and alcohol consumption, as well as motivational readiness for change. Twenty worksites were randomized separately for each intervention using a two-by-two factorial design. All participants underwent a health risk appraisal and measurements were made at baseline and at 1 and 2 years.

RESULTS

The overall response rate for the baseline survey was 73% with 61% attending the health risk appraisal. The sample was predominantly male, English-speaking, married, blue-collar workers. Overall, 12% reported unsafe alcohol consumption, 26% were current smokers, 44% were physically inactive, 74% ate at most one piece of fruit per day, and 26% ate at most one serving of vegetables per day. Intervention and control conditions were similar at baseline for the primary outcomes, except that a higher proportion of the sociobehavioral intervention condition was more physically active (59%) than the corresponding control condition (53%).

CONCLUSIONS

This study will permit the rigorous evaluation of the efficacy of sociobehavioral and environ mental intervention approaches to workplace health promotion. Although participants were randomized by worksite, intervention and control conditions were similar at baseline; any differences in the primary out come variables will be controlled for in the analysis.

Experiencing transitions: an emerging middle-range theory

Changes in health and illness of individuals create a process of transition, and clients in transition tend to be more vulnerable to risks that may in turn affect their health. Uncovering these risks may be enhanced by understanding the transition process. As a central concept of nursing, transition has been analyzed, its components identified, and a framework to articulate and to reflect the relationship between these components has been defined. In this article, the previous conceptual analysis of transitions is extended and refined by drawing on the results of five different research studies that have examined transitions using an integrative approach to theory development. The emerging middle-range theory of transitions consists of types and patterns of transitions, properties of transition experiences, facilitating and inhibiting conditions, process indicators, outcome indicators, and nursing therapeutics. The diversity, complexity, and multiple dimensionality of transition experiences need to be further explored and incorporated in future research and nursing practice related to transitions.