Promoting physician productivity through a variable compensation system

Integrated delivery systems must find ways to achieve optimal physician productivity and accountability, while fostering an entrepreneurial attitude among physicians. Lovelace Health Systems, Albuquerque, New Mexico, has implemented a variable compensation system designed for this purpose. An assessment of Lovelace's physician productivity had indicated performance well below national medians. To offer physicians a strong incentive to increase productivity, Lovelace developed a variable compensation system based on the resource-based relative value scale and relative value units. Lovelace also developed benchmark productivity targets.

Immunohistochemical study of endometrial microvascular basement membrane components in women using Norplant

The mechanisms responsible for progestogen-induced breakthrough bleeding remain unexplained. The aim of the present study was to examine the expression of three basement membrane components, collagen IV (CIV), laminin and heparan sulphate proteoglycan (HSPG), by immunohistochemistry in sections of endometrium from women receiving the subdermal levonorgestrel implant (Norplant) and normally cycling women. Control biopsies were obtained from 20 normal subjects from Melbourne, Australia, and pre- and post-Norplant-insertion biopsies were obtained from 11 women from Sydney, Australia, with between 3 and 6 months Norplant exposure. It was postulated that in Norplant users a decrease in the amount of basement membrane material present around endometrial vessels may be responsible for increased capillary fragility. The results, however, showed that for all three components, Norplant biopsies exhibited vascular basement membrane immunostaining at least as intense as that found in the mid-late secretory phase of the normal cycle. During the normal cycle, HSPG was only detected in approximately 40% of vessels with CIV and laminin immunoreactivity, and menstrual biopsies demonstrated reduced staining for all three components. Several biopsies exhibited a degree of regional variability in staining intensity, and Norplant biopsies exhibited areas of discrete, decidual-like stromal immunostaining for CIV and laminin. Although no differences were found in microvascular basement membranes in Norplant users that might explain capillary fragility, it is possible that other techniques could yield information on changes in the integrity of basement membrane components that might influence basement membrane strength.

Endometrial vasculature in Norplant users: preliminary results from a hysteroscopic study

Long-acting progestogenic contraceptives are frequently associated with disturbances of menstrual bleeding patterns. In particular, irregular, frequent and prolonged bleeding are commonly seen. The mechanism of this irregular bleeding is unknown, but changes in the endometrial vasculature are thought to be of importance. In endometrial biopsies from Norplant users, an increase in endometrial microvascular density has been observed after 3-12 months. Morphological changes in endometrial capillaries following progestogen exposure have suggested an increase in vascular fragility. Little is known about the structure and function of the endometrial vasculature in vivo following exposure to exogenous contraceptive steroids. This study has developed techniques for the assessment of vascular fragility by imposing a mechanical stress on the endometrium and observing subsequent bleeding under direct vision. The techniques were used in a preliminary examination between 1 and 9 months after Norplant insertion, and the study identified a number of morphological and functional characteristics of Norplant-exposed endometrium.

A comparison of mechanisms underlying disturbances of bleeding caused by spontaneous dysfunctional uterine bleeding or hormonal contraception

Recent research has not been able to demonstrate close endometrial morphological correlations with specific abnormalities of menstrual bleeding, but has pointed to an increasing number of molecular mechanisms that may be involved in the occurrence of certain forms of abnormal uterine bleeding. Ovulatory and anovulatory dysfunctional uterine bleeding (DUB) and progestogen-related breakthrough bleeding (BTB) are three conditions with quite different clinical characteristics. It is also probable that the local endometrial molecular mechanisms associated with these three menstrual disturbances are quite different. Ovulatory DUB is associated with a series of vascular and haemostatic disturbances that all appear to contribute to increased loss of blood and tissue fluid at menstruation. Anovulatory DUB is associated with obvious disturbances of endometrial histology, vascular morphology and fragility, with variable and increased blood flow. Progestogen-related BTB is associated with a multitude of morphological and functional endometrial changes that appear to relate predominantly to a patchy capillary origin for the bleeding. Many molecular and cellular changes have been observed in all three conditions. It is not yet known whether there is a single, but different, underlying mechanism responsible for these multiple abnormalities in each of the three clinical situations.

Microvascular density in conditions of endometrial atrophy

Irregular menstrual bleeding in users of hormonal contraception represents the single major reason for discontinuation of these contraceptive methods. The mechanisms which underlie these bleeding disturbances are poorly understood, but appear to be associated with changes in the endometrial microvasculature following abnormal patterns of sex steroid exposure. Endometrial microvascular density is known to be increased in users of the low-dose levonorgestrel contraceptive implant, Norplant. This study explores microvascular density in other conditions of spontaneous (post-menopausal) and induced (danazol and goserelin) endometrial atrophy. Endometrial biopsies were fixed, paraffin-embedded and sections were immunostained using anti-CD34 antibody to identify vascular endothelial cells. The mean microvascular density (+/-SEM) for control samples was 186 +/- 8 vessels/mm2. There were no statistically significant changes in vascular density observed across the menstrual cycle. Mean microvascular density in spontaneous and induced endometrial atrophy did not differ significantly from that observed in the control population. The mean microvascular density was 230 +/- 17 vessels/mm2 in 31 postmenopausal women, 269 +/- 67 vessels/mm2 in 25 subjects treated with danazol was and 191 +/- 45 vessels/mm2 in nine subjects treated with goserelin. These findings suggest that the mechanisms controlling microvascular density in conditions of endometrial atrophy may vary according to the nature of the atrophic stimulus.

Patient satisfaction in the ambulatory setting. Influence of data collection methods and sociodemographic factors

To evaluate the impact of patient characteristics and method of data collection on satisfaction results used for the comparison of practice locations, questionnaires were distributed to 1,208 adult outpatients at five medicine clinics, either on-site or by mail. Patient dissatisfaction with three service domains was measured: communication with the provider, courtesy of the office staff, and timeliness of care. Practice location, survey methodology, and patient characteristics were significant predictors of dissatisfaction, and adjustment for the latter two factors affected the rankings of practices by dissatisfaction rates for all three domains. Further study of the impact of patient characteristics and method of data collection should be conducted before the comparison of unadjusted satisfaction results becomes the accepted standard.

Energetic consequences of flight speeds of foraging red and hoary bats (Lasiurus borealis and Lasiurus cinereus; Chiroptera: Vespertilionidae)

We used Doppler radar readings of the flight speeds of foraging, lactating female Lasiurus borealis (N=826) and Lasiurus cinereus (N=544) to test morphologically based predictions about their flight performance. Both species flew at speeds (V=6.7 and 7.7 m s-1, respectively) that differed significantly from predicted minimum power speed (Vmp; 4.0 and 5.08 m s-1, respectively) or predicted maximum range speed (Vmr; 5.25 and 6.69 m s-1, respectively), perhaps reflecting the active pursuit of moths performing evasive manoeuvres. Estimates of costs of flight and lactation are combined with data on prey size together with encounter and capture rates to illustrate the energetic benefits accruing to these species when they forage in concentrations of insects.

Appointment, promotion, and tenure criteria to meet changing perspectives in healthcare

With anticipated changes in healthcare delivery systems, nursing faculty members need to redefine the faculty role and scholarship as a product of that role. The authors describe the development of appointment, promotion, and tenure criteria that value scholarly outcomes generated from both practice and research within the educational model.

Vero cytotoxin-producing Escherichia coli O157 in beefburgers linked to an outbreak of diarrhoea, haemorrhagic colitis and haemolytic uraemic syndrome in Britain

Vero cytotoxin (VT)-producing Escherichia coli O157 (O157 VTEC) were isolated from a raw beefburger obtained from a retail source linked to a small community outbreak of O157 VTEC infection in Wales. Strains from the meat and from seven of eight patients belonged to phage type 49 and were indistinguishable by their VT-type, plasmid content and hybridization with DNA of a VT-encoding phage from an O157 VTEC strain. This first report of the isolation of O157 VTEC from a beef product in Britain supports the view that there is a bovine reservoir for this organism.

Aerobic dance injuries

Aerobic dance has taken the spotlight as one of the most popular forms of exercise in America. The benefits of a well developed, comprehensive program include an increase in strength, flexibility, and endurance while promoting a healthy cardiovascular system. Orthopaedic nurse clinicians frequently come in contact with aerobic dance participants before and after injury occurs. This article discusses the occurrence of aerobic dance injuries, treatment, and prevention.

Innovative generalist programs: academic health care centers respond to the shortage of generalist physicians

Academic health care centers increasingly are exploring innovative ways to increase the supply of generalist physicians. The authors review successful innovations at representative academic health centers in the areas of recruitment and admissions, undergraduate medical education, residency training, and practice support. Lessons learned focus on those areas that have demonstrated improvements in the number and quality of physicians trained in family practice, general pediatrics, and general internal medicine. Successful recruitment of generalism-oriented applicants requires identification and tracking of rural, minority, and other special groups of students at the high school and college levels. Academic health care centers that provide early, sustained, community-based, ambulatory experiences for medical students and residents encourage trainees to maintain and choose generalist careers. Finally, academic health care centers that link with community providers and with state government encourage the retention of generalist physicians through continuing education and teaching networks.

Energy as a central factor in the self-assessment of health

This article explores the role of energy in conceptualization of health, based on self-reported health ratings in 310 women (master's-prepared nurses) ages 50 to 70 years. The health self-assessment instrument consists of 1 global and 10 specific items. The item energy level emerged as central--loading on both the psychosocial health and physiologic health factors and accounting for 48% of variance of Global Health Self-Assessment. These findings build on the World Health Organization definition of health as a synthesis of psychosocial and physiologic well-being; energy level is key to an integrated view of health.

Competence statements for differentiated nursing practice in critical care

The demand for high-quality patient care in the current complex health care environment and the variety of today's available nursing education programs dictate a need to differentiate nursing practice into technical and professional roles. These roles are based on competencies acquired in ADN and BSN degree programs and implemented in practice settings where the contributions of all nurses are valued. To create a preferred future, AACN has developed a model for differentiated nursing practice in critical care. The model is a guideline for those nurses and institutions who may be or will be involved in changing practice patterns. The model does not support or encourage the elimination or disenfranchisement of any individual or groups of nurses. These statements were developed to address specific behavior that reflects the valuable contributions of each category of nurses within critical care nursing. The statements provide a model for creating efficient and effective practice patterns that may contribute to high-quality outcomes for critically ill patients and their families.

Maintaining Clinical Excellence in a Weekend Alternative Program: The Role of the Divisional Clinical Manager

Many innovative management changes designed to promote clinical excellence and scholarship were undertaken by the nursing executive team at our 821-bed tertiary care teaching hospital. Included in these changes was the creation of the divisional clinical manager (DCM). The purpose of this article is to describe how these weekend managers employees contribute to the overall objectives of providing consistent supervision, clinical support and a rich continuing education program.

The changing epidemiology of diabetes mellitus among Navajo Indians

Although early descriptions of diabetes mellitus among Navajo Indians characterized the disease as an infrequent and "benign chemical abnormality," the prevalence of diabetes and its complications among Navajos appears to have increased substantially in this century. We reviewed recent Indian Health Service inpatient and ambulatory care data and compared these data with previous reports. Of the estimated Navajo population aged 45 years or older, 4,331 (16.9%) had an ambulatory care visit for diabetes between October 1, 1986, and September 30, 1987. Diabetes was coded for 1,041 (7.0%) of hospital admissions of persons aged 20 and older. Of 377 lower-extremity amputations done from 1978 to 1987, diabetes was involved in 245 (66%). The 1986 age-adjusted mortality rate from diabetes was 30.3 per 100,000, approximately twice that for the general US population. The explanation for the increased prevalence of diabetes mellitus among Navajos probably relates to an increasing prevalence of obesity.

What are the needs of families of critically ill patients? A review of the literature since 1976

The research conducted on families' needs in critical care was reviewed to summarize the findings for practice and recommend future directions for research on this topic. A literature search yielded eight articles in which replicable primary research on the needs of families of critically ill patients was reported. These reports, although individually limited by small sample size, presented similar findings. Families rated information needs most important, followed by needs for reassurance and convenience. Strategies to enhance information to families, such as written information, daily contact with physician or nurse or both, and establishing a nurse contact person for families and a family contact person who can be called about changes in patient status, are presented. Recommendations for future research include the study of elderly and male family members and tests of interventions aimed at meeting families' needs.