The combination of physical activity with fruit and vegetable intake associated with life satisfaction among middle-aged and older adults: a 16-year population-based cohort study

BACKGROUND

Life satisfaction (LS) is part of a positive psychological feeling that protects individuals from a physical decline in old age. A healthy lifestyle, including physical activity (PA) and a healthy diet, such as the intake of fruits and vegetables (F&V), can lead to a better experience of LS in older adults. However, the association between PA and F&V intake habits when occurring together in older adults is still unclear for LS. The study aimed to investigate the combined association of PA and F&V intake on LS among a cohort of older Taiwanese adults.

METHODS

Five waves of population-based data gathered by the Taiwan Longitudinal Survey on Aging between 1999 and 2015 were analyzed. The year 1999 was set as the baseline, and the number of respondents was 4,440. The independent variables included the frequency, duration, and intensity of PA and the frequency of F&V intake. LS was assessed by using the Life Satisfaction Index. We performed generalized estimating equations (GEE) analysis with adjustment for covariates of health behaviors and health indicators.

RESULTS

After adjusting for confounders, model 1 showed that moderate and high-PA levels significantly correlated with LS (odds ratio [OR] = 1.41, 95% CI = 1.12-1.79) and OR = 1.74, 95% CI = 1.50-2.02). Moreover, high-F&V intake significantly correlated with LS (OR = 2.07, 95% CI = 1.69-2.53). Regarding the combined association shown in model 2, compared with both the low PA and F&V intake group, there were significantly higher LS in the both-high-group (OR = 4.69, 95% CI = 3.49-6.31), only-high-F&V intake (OR = 2.87, 95% CI = 2.14-3.85), only-high-PA (OR = 2.48, 95% CI = 1.74-3.52).

CONCLUSIONS

Our findings show the significant combined association of PA and F&V intake on LS among older adults. In addition, older adults who engaged in higher frequency, duration, and intensity of daily PA combined more than seven times a week of F&V intake had significantly higher LS than those who only engaged in low PA or only intake less F&V. Adopting multiple healthy behaviors in daily life is a safe and effective approach to promote LS among older adults.

Effect of Hand Hygiene Intervention in Community Kindergartens: A Quasi-Experimental Study

This study aimed to evaluate the effect of hand hygiene interventions on the overall hand hygiene (HH) status of teaching instruction of hand hygiene in kindergartens, given the vulnerability of kindergarten children and their high risk due to infectious diseases and the current COVID-19 epidemic. We investigated the HH status of teachers from two kindergartens in the same community. The participants were recruited from 28 classes in both kindergartens. After completing the baseline survey, the intervention program consisted of three components: lectures on infectious diseases, lectures on HH, and seven-step hand washing techniques conducted in two kindergartens. The intervention program effectively increased teachers' perceived disease susceptibility (p < 0.05), reduced the total bacterial colonization of children's hands (p < 0.001), and improved the HH environment (p < 0.01). We recommend that health authorities or kindergartens adopt this HH intervention program to effectively improve the HH status in kindergartens and allow for preventive responses to the COVID-19 epidemic or other emerging infectious diseases.

The combined effect of physical activity and fruit and vegetable intake on decreasing cognitive decline in older Taiwanese adults

The factors associated with cognitive decline among older adults include physical activity and fruit and vegetable intake. However, the long-term effects of concomitant physical activity and fruit and vegetable intake are unknown. This 16-year longitudinal study explored the joint effect of mitigating cognitive decline in a cohort of older Taiwanese individuals. Five population-based surveys (Taiwan Longitudinal Survey on Aging [1999–2015]) involving 4440 respondents over 53 years old in 1999 were conducted. Cognitive function was assessed using the Short Portable Mental Status Questionnaire (SPMSQ). The demographic, socioeconomic, health-related, behavioral, and disease status covariates were adjusted in the regression analysis. Trends in cognitive decline were observed over 16 years. The risk of cognitive decline decreased by 63% when high physical activity and high fruit and vegetable intake were combined (odds ratio 0.37; 95% confidence interval 0.23–0.59), indicating a potential combined effect of physical activity and fruit and vegetable intake on mitigating cognitive decline. These personal actions are safe, effective, and economical approaches to health promotion and disease prevention.

Emotional Labor in Health Care: The Moderating Roles of Personality and the Mediating Role of Sleep on Job Performance and Satisfaction

The objective of this study is to investigate the effects of emotional labor on job performance and satisfaction, as well as to examine the mediating effect of sleep problems and the moderating effects of personality traits. A time-lagged study was conducted on 864 health professionals. Scales for emotional labor, sleep, personality traits, and job satisfaction were used and job performance data was obtained from records maintained by human resources. Structural equation modeling was performed to investigate the relations. Sleep problems only partially mediated the relationship between surface acting and job satisfaction but completely mediated the relationship between surface acting and job performance. Several personality traits were shown to moderate the relationship between surface acting and sleep problems. The effects were stronger for people with low agreeableness and high neuroticism. The relationship between high levels of deep acting and low levels of sleep problems was more pronounced in individuals with low extraversion. Supervisors should be conscious of emotional labor in the work context and provide necessary deep acting training to facilitate emotional regulation.

A Longitudinal Analysis of Total Pain Scores for a Panel of Patients Treated by Pain Clinics

Background:

There is a critical necessity to identify psychometric properties of the total pain score as a measurement of pain management effectiveness in the clinic.

Purpose:

In this article, we perform the analysis of the global pain scores from a panel of patients treated by 10 pain management physicians in a single group practice.

Basic Procedures:

The pain measurement consists of 4 pain subscales, namely physical pain, emotions, clinical outcome, and activities. A panel of 130 patients with 4 pain measurements is available to perform longitudinal analysis of the total pain scores. The analysis includes the following: (1) confirmatory factor analysis of the global pain scores with 4 related dimensions, (2) the stability of the pain scores between 2 clinical visits, (3) the change trajectories of pain scores in 4 waves of the pain measurement, and (4) the detection of physician variability in patients’ treatment outcomes measured by the reduction of total pain scores.

Main Findings:

The global pain scores were relatively stable between time 1 and time 2 clinical visits. The analysis indicated that there was a decrease in pain with longitudinal advancement in treatment. It also indicated that there was no significant change in this improvement with respect to difference in physicians involved in providing treatment.

Principal Conclusion:

While the results indicated a decrease in pain with an alleviation in treatment provided to the patient, the article delineates a well-thought scientific approach to the targeted problem.

Factors Influencing Variations in Hospitalization for Diabetes with Hypoglycemia

Many studies have explored risk factors associated with Hypoglycemia (HG) and examined the variation in healthcare utilization among HG patients. However, most of these studies failed to integrate a comprehensive list of personal risk factors in their investigations. This empirical study employed the Behavioral Model (BM) of health care utilization as a framework to investigate diabetes' hospitalizations with HG. The national inpatient sample with all non-pregnant adult patients admitted to hospitals' emergency departments and diagnosed with HG from 2012 to 2014 was used. Personal factors were grouped as predictors of the length of stay and the total charges incurred for hospitalization. High-risk profiles of hospitalized HG patients were identified. The analysis shows the need for care factors are the most influential predictors for lengthy hospitalization. The predisposing factors have a limited influence, while enabling factors influence the variation in hospital total charges. The presence of renal disease and diabetes mellitus (DM) complications played a key role in predicting hospital utilization. Furthermore, age, socio-economic status (SES), and the geographical location of the patients were also found to be vital factors in determining the variability in utilization among HG patients. Findings provide practical applications for targeting the high-risk HG patients for interventions.

Variations in Influenza and Pneumonia Immunizations for Medicare Beneficiaries Served by Rural Health Clinics

The availability of a rural health clinic (RHC) database over the period of 6 years (2008-2013) offers a unique opportunity to examine the trends and patterns of disparities in immunization for influenza and pneumonia among Medicare beneficiaries in the southeastern states. The purpose of this exploratory study was twofold. First, it examined the rural trends and patterns of immunization rates before (2008-2009) and after (2010-2013) the Affordable Care Act (ACA) enactment by state and year. Second, it investigated how contextual, organizational, and aggregate patient characteristics may influence the variations in immunization for influenza and pneumonia of Medicare beneficiaries served by RHCs. Four data sources from federal agencies were merged to perform a longitudinal analysis of the influences of contextual, organizational, and aggregate patient characteristics on the disparities in immunization rates of rural Medicare beneficiaries for influenza and pneumonia. We included both time-varying and time-constant predictors in a multivariate analysis using Generalized Estimating Equation. This study revealed the increased immunization rates for both influenza and pneumonia over a period of 6 years. The ACA had a positive effect on increased immunization rates for pneumonia, but not for influenza, in rural Medicare beneficiaries in the eight states. The RHCs that served more dually-eligible patients had higher immunization rates. For influenza immunization, provider-based RHCs had a higher rate than the independent RHCs. For pneumonia immunization, no organizational variables were relevant in the explanation of the variability. The results also showed that no single dominant factor influenced health care disparities. This investigation suggested further improvements in preventive care are needed to target poor and isolated rural beneficiaries. Furthermore, the integration of immunization data from multiple sources is critically needed for understanding health disparities.

Strategies to Modify the Risk of Heart Failure Readmission: A Systematic Review and Meta-Analysis

Background:

Human factors play an important role in health-care outcomes of heart failure (HF) patients. A systematic review and meta-analysis of clinical trial studies on HF hospitalization may yield positive proofs of the beneficial effect of specific care management strategies.

Purpose:

To investigate how the 8 guiding principles of choice, rest, environment, activity, trust, interpersonal relationships, outlook, and nutrition reduce HF readmissions.

Basic Procedures:

Appropriate keywords were identified related to the (1) independent variable of hospitalization and treatment, (2) the moderating variable of care management principles, (3) the dependent variable of readmission, and (4) the disease of HF to conduct searches in 9 databases. Databases searched included CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, ERIC, MEDLINE, PubMed, PsycInfo, Science Direct, and Web of Science. Only prospective studies associated with HF hospitalization and readmissions, published in English, Chinese, Spanish, and German journals between January 1, 1990, and August 31, 2015, were included in the systematic review. In the meta-analysis, data were collected from studies that measured HF readmission for individual patients.

Main Findings:

The results indicate that an intervention involving any human factor principles may nearly double an individual’s probability of not being readmitted. Participants in interventions that incorporated single or combined principles were 1.4 to 6.8 times less likely to be readmitted.

Principal Conclusions:

Interventions with human factor principles reduce readmissions among HF patients. Overall, this review may help reconfigure the design, implementation, and evaluation of clinical practice for reducing HF readmissions in the future.

KMAP-O framework for care management research of patients with type 2 diabetes

AIM

To review impacts of interventions involving self-management education, health coaching, and motivational interviewing for type 2 diabetes.

METHODS

A thorough review of the scientific literature on diabetes care and management was executed by a research team.

RESULTS

This article summarizes important findings in regard to the validity of developing a comprehensive behavioral system as a framework for empirical investigation. The behavioral system framework consists of patients’ knowledge (K), motivation (M), attitude (A), and practice (P) as predictor variables for diabetes care outcomes (O). Care management strategies or health education programs serve as the intervention variable that directly influences K, M, A, and P and then indirectly affects the variability in patient care outcomes of patients with type 2 diabetes.

CONCLUSION

This review contributes to the understanding of the KMAP-O framework and how it can guide the care management of patients with type 2 diabetes. It will allow the tailoring of interventions to be more effective through knowledge enhancement, increased motivation, attitudinal changes, and improved preventive practice to reduce the progression of type 2 diabetes and comorbidities. Furthermore, the use of health information technology for enhancing changes in KMAP and communications is advocated in health promotion and development.

Challenges in implementing mHealth interventions: a technical perspective

Over the years, the healthcare community has witnessed many improvements in methods and technologies used in healthcare delivery, including mHealth as an emerging area of healthcare applications to improve access to health services. However, challenges involved in implementing mHealth to optimal advantage do exist. In this article, we identify some of the most important challenges and propose feasible solutions.

A remote monitoring program evaluation: a retrospective study

OBJECTIVE

Using an integrated model, the Donabedian Quality and Logic Model, we examined a remote monitoring heart failure disease management program.

METHOD

This quantitative research used post-test only case matched design. The sample consisted of 210 participants from 23 home health care agencies.

RESULTS

Logistic regression results indicated statistical significance, there was an inverse relationship between caregiver support and the complexity of decision making; X² (3, n = 210) = 29.984, P = 0.012. The DTreg suggested that participants who were advised to go to the ER had a 1.00 probability of doing so, and those who were instructed otherwise had a 0.37 probability of going to the ER. Among participants who experienced a hospital readmission, there was 0.50 probability that patient education or other clinical intervention was implemented prior to the admission.

CONCLUSION

As home health care agencies consider disease management programs, it is important to gain a comprehensive understanding of the potential of innovative programs and the resources they require. While the agency invested the resources required by the remote monitoring program, the study demonstrated that caregiver support was a critical structural component of the program and may affect change in nurses' decision making to mitigate hospital utilization. We recommend that home health care agencies take greater consideration of the family and social support in implementing a remote monitoring system.

Thailand's universal coverage scheme and its impact on health-seeking behavior

BACKGROUND

Thailand's Universal Coverage Scheme (UCS) has improved healthcare access and utilization since its initial introduction in 2002. However, a substantial proportion of beneficiaries has utilized care outside the UCS boundaries. Because low utilization may be an indication of a policy gap between people's health needs and the services available to them, we investigated the patterns of health-seeking behavior and their social/contextual determinants among UCS beneficiaries in the year 2013.

RESULTS

The study findings from the outpatient analysis showed that the use of designated facilities for care was significantly higher in low-income, unemployed, and chronic status groups. The findings from the inpatient analysis showed that the use of designated facilities for care was significantly higher in the low-income, older, and female groups. Particularly, for the low-income group, we found that they (1) had greater health care needs, (2) received a larger number of services from designated facilities, and (3) paid the least for both inpatient and outpatient services.

CONCLUSIONS

This pro-poor impact indicated that the UCS could adequately respond to beneficiaries' needs in terms of vertical equity. However, we also found that a considerable proportion of beneficiaries utilized out-of-network services, which implied a lack of universal access to policy services from a horizontal equity point of view. Thus, the policy should continue expanding and diversifying its service benefits to strengthen horizontal equity. Particularly, private sector involvement for those who are employed as well as the increased unmet health needs of those in rural areas may be important policy priorities for that. Lastly, methodological issues such as severity adjustment and a detailed categorization of health-seeking behaviors need to be further considered for a better understanding of the policy impact.

Racial Disparities in Diabetes Hospitalization of Rural Medicare Beneficiaries in 8 Southeastern States

This study examined racial variability in diabetes hospitalizations attributable to contextual, organizational, and ecological factors controlling for patient variabilities treated at rural health clinics (RHCs). The pooled cross-sectional data for 2007 through 2013 for RHCs were aggregated from Medicare claim files of patients served by RHCs. Descriptive statistics were presented to illustrate the general characteristics of the RHCs in 8 southeastern states. Regression of the dependent variable on selected predictors was conducted using a generalized estimating equation method. The risk-adjusted diabetes mellitus (DM) hospitalization rates slightly declined in 7 years from 3.55% to 2.40%. The gap between the crude and adjusted rates became wider in the African American patient group but not in the non-Hispanic white patient group. The average DM disparity ratio increased 17.7% from the pre-Affordable Care Act (ACA; 1.47) to the post-ACA period (1.73) for the African American patient group. The results showed that DM disparity ratios did not vary significantly by contextual, organizational, and individual factors for African Americans. Non-Hispanic white patients residing in large and small rural areas had higher DM disparity ratios than other rural areas. The results of this study confirm racial disparities in DM hospitalizations. Future research is needed to identify the underlying reasons for such racial disparities to guide the formulation of effective and efficient changes in DM care management practices coupled with the emphasis of culturally competent, primary and preventive care.

A cost analysis of remote monitoring in a heart failure program

In this study, we examine the cost per outcomes of remote monitoring services in home health care. The methodology followed case matched design via retrospective chart reviews. Results of the chi-square test suggest that there were no significant associations between the intervention and hospital readmissions, χ² = (1, n = 210, p-value = .71, phi = .71). An independent t-test compared group means of the number of skilled nursing visits and agency costs, p-value of .002 and .000, respectively, favoring the standard of care group. Based on this data set, the home care agency lost $153.46 for each hospital readmission in the intervention group. The cost of care complicated the agency's resources through an increase in nursing visits without offsetting the agency's investment into technology; the cost did not support remote monitoring as a financially viable option to the standard of care.

Major Role Losses and Social Participation of Older Males

This article examines the relative importance of major role losses experienced in widowhood and retirement, personal characteristics, and prior level of participation as predictors of formal and informal social participation in old age. Data obtained from the Longitudinal Retirement History Survey (LRHS) of a panel (N = 6603) of males in their sixties are analyzed. Stepwise regression analysis reveals that prior level of participation and personal characteristics explain more variance in participation than major role losses considered alone or in conjunction with related deteriorative changes such as income loss. When the effects of these variables are simultaneously controlled, persons with major role losses have lower levels of participation in formal organizations and in selected areas of informal activity than those without comparable losses. Examination of the cumulative effects of experiencing both major role losses exacerbated these results. Policy implications for preretirement education and programming are discussed.

Contextual, Ecological and Organizational Variations in Risk-Adjusted COPD and Asthma Hospitalization Rates of Rural Medicare Beneficiaries

The purpose of this study is to examine what factors contributing to the variability in chronic obstructive pulmonary disorder (COPD) and asthma hospitalization rates when the influence of patient characteristics is being simultaneously considered by applying a risk adjustment method. A longitudinal analysis of COPD and asthma hospitalization of rural Medicare beneficiaries in 427 rural health clinics (RHCs) was conducted utilizing administrative data and inpatient and outpatient claims from Region 4. The repeated measures of risk-adjusted COPD and asthma admission rate were analyzed by growth curve modeling. A generalized estimating equation (GEE) method was used to identify the relevance of selected predictors in accounting for the variability in risk-adjusted admission rates for COPD and asthma. Both adjusted and unadjusted rates of COPD admission showed a slight decline from 2010 to 2013. The growth curve modeling showed the annual rates of change were gradually accentuated through time. GEE revealed that a moderate amount of variance (marginal R² = 0.66) in the risk-adjusted hospital admission rates for COPD and asthma was accounted for by contextual, ecological, and organizational variables. The contextual, ecological, and organizational factors are those associated with RHCs, not hospitals. We cannot infer how the variability in hospital practices in RHC service areas may have contributed to the disparities in admissions. Identification of RHCs with substantially higher rates than an average rate can portray the need for further enhancement of needed ambulatory or primary care services for the specific groups of RHCs. Because the risk-adjusted rates of hospitalization do not very by classification of rural area, future research should address the variation in a specific COPD and asthma condition of RHC patients. Risk-adjusted admission rates for COPD and asthma are influenced by the synergism of multiple contextual, ecological, and organizational factors instead of a single factor.

Estimating the Net Career Income of a Geriatrician and a Nurse Practitioner: Still Want to Be a Doctor?

OBJECTIVES

With a continual shortage of geriatricians, adult-gerontology primary care nurse practitioners have assumed a greater role in the delivery of outpatient care for older adults. Given the long duration of physician training, the high cost of medical school, and the lower salaries compared with subspecialists, the financial advantage of a career as a geriatrician as opposed to a nurse practitioner is uncertain. This study compares the estimated career earnings of a geriatrician and an adult-gerontology primary care nurse practitioner.

METHODS

We used a synthetic model of estimated net earnings during a 43-year career span for a 22-year old person embarking on a career as a geriatrician versus a career as an adult-gerontology primary care nurse practitioner. We estimated annual net income and net retirement savings using different annual compound rates and calculated the financial impact of forgiving medical student loans, shortening the duration of physician training, and reinstituting the practice pathway for geriatric medicine certification.

RESULTS

Career net incomes for the geriatrician did not match the nurse practitioner until almost age 40. At 65 years of age, the difference between the geriatrician and nurse practitioner was 30.6%. A higher annual compound rate was associated with an even smaller percentage difference. Combining all three health policy interventions lowered the break-even age to 28 and more than doubled the difference in career earnings.

CONCLUSIONS

Small estimated differences in net career earnings exist between geriatricians and adult-gerontology primary care nurse practitioners. Health policy interventions had a dramatic positive effect on geriatricians' lifetime net earnings in calculated estimates.

Testing Measurement Equivalence in a Patient Satisfaction Instrument

The purpose of this methodological study was to examine five sources of measurement equivalence (configural invariance, metric invariance, scalar invariance, invariant uniquenesses, and invariant factor variances) in perceptions of patient satisfaction for two groups of patients, whose satisfaction was measured at different times, for men compared with women, and for minority populations compared with Whites. The sample consisted of a total sample of 1,897 patients of whom 1,070 were females, and 1,228 were White. Using confirmatory factor analysis and structural equation modeling, we found that the 10-item Likert-type scale performed well across time but required additional attention if it is to be used to compare satisfaction between genders and racial groups.

Effect of Organizational and Environmental Factors on Service Differentiation Strategy of Integrated Healthcare Networks

During the past decade, the missions/goals of medical providers of healthcare services in the United States have shifted — from emphasizing individual, independent illness treatments to focusing on the continuum of care, population-based wellness, and providing the appropriate care in the most efficient way. Integrated healthcare networks (IHNs) — or integrated healthcare delivery systems — have been focusing heavily on their level of various partnership integration (i.e. service differentiation strategy) in order to offer a full continuum of care. The aim of this study, using the individual IHN as the unit of analysis, was to identify organizational and environmental factors that influence IHN administrators to focus on their service differentiation of market lines, including the establishment of third-party payers' contracts, the affiliation of managed-care organizations, and the alliances of various nonhospital medical providers, to provide a continuum of care. The study findings show that tax status of an IHN, its age, and market competition affect its service differentiation strategy in the provision of a full continuum of care.

The Influence of Remote Monitoring on Clinical Decision Making

The aim of this study was to examine the meaningful use of remote monitoring. In partnership with a home health care agency, we examined the degree to which the information obtained from remote monitoring influenced change in decisions that affect readmission rates among patients diagnosed with heart failure. Hospital utilization was highly associated with nurses’ clinical decisions to go to the hospital; the additional data provided by technology did not modify decisions. The role of nurses in heart failure management is critical to quality outcomes. Investments into remote monitoring technology should accompany strategies to enhance decision making and align clinical decision making with quality goals.

Variations in Colorectal Cancer Screening of Medicare Beneficiaries Served by Rural Health Clinics

This study aims (1) to examine the trends and patterns of colorectal cancer screening (CCS) of Medicare beneficiaries in rural areas by state and year (before and after Affordable Care Act [ACA] enactment) and (2) to investigate the contextual, organizational, and aggregated patient characteristics influencing variations in care received by patients of rural health clinics (RHCs). The following 2 hypotheses were formulated: (1) CCS rates are higher in the post-ACA period than in the pre-ACA period, irrespective of the factors rurality, poverty, dually eligible status, and the organizational characteristics of RHCs and (2) the contextual and organizational factors of RHCs exert more influence on the variation in CCS rates of RHC patients than do aggregated personal factors. We used administrative data on CCS rates (2007 through 2012) for rural Medicare beneficiaries. Autoregressive growth curve modeling of the CCS rates was performed. A generalized estimating equation of selected predictors was analyzed. Of the 9 predictors, 5 were statistically significant: The ACA and the percentage of female patients had a positive effect on the CCS rate, whereas regional location, years of RHC certification, and average age of patients had a negative effect on the CCS rate. The predictors accounted for 40.2% of the total variance in CCS. Results show that in rural areas of 9 states, the enactment of ACA improved CCS rates, contextual, organizational, and patient characteristics being considered. Improvement in preventive care will be expected, as the ACA is implemented in the United States.

The Impact of State Nursing Home Staffing Standards on Nurse Staffing Levels

This study investigated the impact of state nursing home staffing standards on nurse staffing levels for the year 2011. Specifically, the study attempted to measure state staffing standards at facility level (i.e., nurse staffing levels that each individual nursing home must retain by its state staffing standards) and analyzed the policy impact. The study findings indicated that state staffing standards for the categories of registered nurse, licensed nurse, or total nurse are positively related to registered nurse, licensed nurse, or total nurse staffing levels, respectively. Nursing homes more actively responded to licensed staffing requirements than total staffing requirements. However, nursing homes did not increase their staffing levels as much as those required by state staffing standards. It is possibly because the quality-oriented inspection allows flexibility in nursing homes’ control of nurse staffing levels.

INFRASTRUCTURAL MECHANISMS LEADING TOWARD PRO-ACCOUNTABLE CARE ORGANISATION ORIENTATION: A SURVEY OF HOSPITAL MANAGERS

Organisations across the country are transforming the way they deliver care, in ways similar to the accountable care organisation (ACO) model supported by Medicare. ACOs modalities are varying in size, type, and financing structure. Little is known about how specific infrastructural mechanisms influence hospital managers' pro-ACO orientation. Using an electronic-survey of hospital managers, this study explores how pro-ACO orientation, as a latent construct, is captured from the perceptions of hospital managers; and identify infrastructural mechanisms leading to the formation of pro-ACO orientation. Of the total hospital respondents, 58% are moving toward the establishment of ACOs; 56% are planning to join in the next two years; 48% are considering joining ACOs; while 25% had already participated in ACOs during 2012. Urban hospitals are more likely than rural hospitals to be engaged in ACO development. The health provider network size is one of the strongest indicators in predicting pro-ACO orientation.

A TRANSDISCIPLINARY APPROACH TO HEALTH POLICY RESEARCH AND EVALUATION

An integrated perspective consists of macro- and micro-level approaches to health policy research and evaluation is presented. Analytical strategies are suggested for policy analysis, targeting on health disparities at individual and population levels. This systems approach enables investigators to view how scientific public policy analysis can be implemented to assess policy impacts. In this special issue, five papers are introduced.

Gaps in nurse staffng and nursing home resident needs

Trends in nurse staffing levels in nursing homes from 1997 to 2011 varied across the category of nurse and the type of nursing home. The gaps found in this study are important to consider because nurses may become overworked and this may negatively affect the quality of services and jeopardize resident safety. Nursing home administrators should consider improving staffing strategically. Staffing should be based not only on the number of resident days, but also allocated according to particular resident needs. As the demand for nursing home care grows, bridging the gap between nurse staffing and resident nursing care needs will be especially important in light of the evidence linking nurse staffing to the quality of nursing home care. Until more efficient nursing care delivery exits, there may be no other way to safeguard quality except to increase nurse staffing in nursing homes.

Transitional care: looking for the right shoes to fit older adult patients

Potentially avoidable hospitalizations are associated with high costs and an increased risk for iatrogenic conditions in older adult patients. Although care managers may be aware of the common potential pitfalls that may arise in the transfer of patients to and from the hospital defining best practice models has been difficult. Many current models of geriatric care have had little or no impact on lowering the rates of hospitalizations and rehospitalizations when formally studied. Health care reform legislation mandates initiatives involving new models of coordinated or guided care such as the medical home model and the accountable care organization. These new models too will face significant challenges in their attempt to provide the financial incentives and systematic changes needed to successfully address transitional care in older adults.

Relationships of hospital-based emergency department culture to work satisfaction and intent to leave of emergency physicians and nurses

Given the limited studies on emergency care management, this study aimed to explore the relationships of emergency department (ED) culture values to certain dimensions of ED physicians' and nurses' work satisfaction and intent to leave. Four hundred and forty-two emergency medical professionals completed the employee satisfaction questionnaire across 119 hospital-based EDs, which had culture value evaluations filed, were used as unit of analysis in this study. Adjusting the personal and employment backgrounds, and the surrounded EDs' unit characteristics and environmental factors, multiple regression analyses revealed that clan and market cultures were related to emergency physicians' work satisfaction and intent to leave. On the other hand, adhocracy, market and hierarchical cultures were related to emergency nurses' work satisfaction. There do exist different patterns among various culture types on various work satisfaction dimensions and intent to leave of emergency physicians and nurses. The findings could offer hospital and ED leaders insights for changes or for building a better atmosphere to enhance the work life of emergency physicians and nurses.

The impact of health literacy on a patient's decision to adopt a personal health record

Health literacy is a concept that describes a patient's ability to understand materials provided by physicians or other providers. Several factors, including education level, income, and age, can influence health literacy. Research conducted at one medical practice in Florida indicated that in spite of the patients' relatively low education level, the majority indicated a broad acceptance of personal health record (PHR) technology. The key variable explaining patient willingness to adopt a PHR was the patient's health literacy as measured by the eHealth Literacy Scale (eHEALS). Adoption and use rates may also depend on the availability of office staff for hands-on training as well as assistance with interpretation of medical information. It is hoped that technology barriers will disappear over time, and usefulness of the information will promote increased utilization of PHRs. Patient understanding of the information remains a challenge that must be overcome to realize the full potential of PHRs.

Behavioral cues to expand a pain model of the cognitively impaired elderly in long-term care

BACKGROUND

The purpose of this study was to determine the relationship between hypothesized pain behaviors in the elderly and a measurement model of pain derived from the Minimum Data Set-Resident Assessment Instrument (MDS-RAI) 2.0 items.

METHODS

This work included a longitudinal cohort recruited from Medicare-certified longterm care facilities across the United States. MDS data were collected from 52,996 residents (mean age 83.7 years). Structural equation modeling was used to build a measurement model of pain to test correlations between indicators and the fit of the model by cognitive status. The model evaluates the theoretical constructs of pain to improve how pain is assessed and detected within cognitive levels.

RESULTS

Using pain frequency and intensity as the only indicators of pain, the overall prevalence of pain was 31.2%; however, analysis by cognitive status showed that 47.7% of the intact group was in pain, while only 18.2% of the severely, 29.4% of the moderately, and 39.6% of the mildly cognitively impaired groups were experiencing pain. This finding supports previous research indicating that pain is potentially under-reported in severely cognitively impaired elderly nursing home residents. With adjustments to the measurement model, a revised format containing affective, behavioral, and inferred pain indicates a better fit of the data to include these domains, as a more complete measure of the pain construct.

CONCLUSION

Pain has a significant effect on quality of life and long-term health outcomes in nursing home residents. Patients most at risk are those with mild to severe cognitive decline, or those unable to report pain verbally. Nursing homes are under great scrutiny to maintain standards of care and provide uniform high-quality care outcomes. Existing data from federally required resident surveys can serve as a valuable tool to identify indicators of pain and trends in care. Great responsibility lies in ensuring pain is included and monitored as a quality measure in long-term care, especially for residents unable to communicate their pain verbally.

Nursing home research in Jinan, China: a focus group approach

This qualitative research using the focus group approach has gathered pertinent perceptions from the stakeholders in Chinese elderly care environment, including community-based and institutionalised elderly, medical providers, administrators and governmental officials. The study found that the elderly are willing to live in nursing homes when they are not in good physical condition and are dependent on others for their activities of daily living. The utilisation of nursing home care has gained acceptance in the community as more elders recognise its advantages. The elderly study subjects expressed interest in the service environment, as well as the cultural and recreational activities in nursing homes. Most participants were satisfied with the quality of nursing care. Administrators and providers in the nursing homes agreed that skilled nursing facilities appear to be more competitive because they require more licensed providers and other professional staff members. A majority of nursing homes face serious financial difficulties.

Organizational and Environmental Correlates to Preventive Quality of Care in US Rural Health Clinics

PURPOSE

To identify organizational and environmental correlates to rural health clinics' preventive quality of care in the United States.

DESIGN

A retrospective observational cohort study design was applied under Donabedian's Structure-Process-Outcome framework. Three structure measures of care (proportion of nonphysicians, absence of physicians, and provider affiliation) and three measures of process (total clinical visits, prevention use for congestive heart failure and diabetes) were used as explanatory variables. Five environmental correlates were included. The Centers for Medicare and Medicaid Services National Medicare Chronic Care Condition Data Warehouse for 2007 was used to obtain clinical data. Preventive quality of care outcomes were measured through Agency for Healthcare Research and Quality prevention quality indicators. The indicators were risk adjusted for age, sex, race, severity, and comorbidity of patients.

METHODS

Structural equation modeling with maximum likelihood estimation was used.

FINDINGS

Provider affiliation (P = .03), absence of physicians (P = .007), and higher proportion of nonphysicians (P = .007) were negatively related to preventive quality of care. Lower cause-specific mortality rate at the county level as compared to the United States average (P = .05) and rural location (P = .001) were positively related to quality of care.

IMPLICATIONS

The results of the study showed the need to attract and retain physicians in rural health clinics. The positive relationship between rural location and quality of care reflects more on the limited access to hospitals in remote areas.

The importance of mental health to the experience of job strain: an evidence-guided approach to improve retention

AIMS

The purpose of this study was to evaluate the causal relationships between job strain, the practice environment and the use of coping skills in order to assist in the prediction of nurses who are at risk for voluntary turnover and identify potential intervention strategies.

BACKGROUND

Analysis of the US nurse workforce indicates that it will be necessary to identify new strategies that will promote a healthy workforce and retain nurses in the workplace.

METHODS

Exploratory cross-sectional survey of 1235 staff nurses resulted in 308 usable surveys (25%). Data were analysed using multivariate statistical techniques (SEM).

RESULTS

It was determined that diminished mental health status as a component of job strain was predictive of propensity to leave as was a diminished assessment of the professional practice environment. Mental health was favourably influenced by coping behaviour.

CONCLUSIONS

Evidence-based strategies which support mental health and reinforce the positive role of coping as a mediating factor may aid in nurse retention efforts.

IMPLICATIONS FOR NURSING MANAGEMENT

This study expands the literature by offering a theoretically supported model to evaluate the response of individuals to the experience of job strain in the work environment. The model demonstrated that the health consequences of job strain are modified through the use of active coping behaviour, and that those nurses with elevated self-assessed health had a lower propensity to leave. As active coping may be taught, the model suggests a means to identify those at risk and support manager intervention.

Nurses in Need of Additional Support: Web Sites Offering Information in Eldercare Nursing Environments

Studies have shown the usefulness of telemedicine and telecare in multiple settings. One form of telemedicine is e-health. Residents of nursing homes are a unique population that may significantly benefit from the e-health resources available to their caregivers. E-health Web sites appear to be viable, feasible, and timely interventional methods to provide the additional knowledge and support practitioners in these settings may need to provide preventative, reactive, and remedial care for frail residents.

Rural Health Clinic efficiency and effectiveness: insight from a nationwide survey

This study reports the results of a nationwide survey of Rural Health Clinics (RHCs). The purpose was to identify factors that contribute to efficiency and effectiveness in RHCs. Factors related to cost efficiency were analyzed using multiple regression; factors related to the likelihood of providing preventive diabetic care, an effectiveness indicator, were analyzed using logistic regression. The study found: (1) technical efficiency to be positively related to cost efficiency; (2) non-profit control to be inversely related to cost efficiency in independent RHCs; and (3) provider-based RHCs and technology use to be related to the likelihood of providing preventive diabetic care. Implications for RHCs are: (1) improvement in technical efficiency could enhance cost efficiency; (2) visits to PAs and NPs, an indicator of process efficiency, may not guarantee the provision of preventive diabetic care; and (3) strategies for improving RHC efficiency and effectiveness may be different for provider-based and independent clinics.

Changes in nursing home staffing levels, 1997 to 2007

A positive relationship has been demonstrated between the quality of care delivered in nursing homes and the quality of nursing staff providing the care. The general perception, however, is that there is a decline in registered nurses' staff hours in nursing homes. The primary objective of this study is to investigate whether the levels of registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs) as well as skill mix has changed in nursing homes between the years 1997 and 2007. A descriptive research design was employed on data derived from Online Survey Certification and Reporting System database. After accounting for facility size and ownership, it was found that more nursing homes have increased-rather than decreased-LPN and NA hours per resident day between 1997 and 2007. On the other hand, more nursing homes have decreased-rather than increased-RN hours per resident day and skill mix during the same time period.

The influence of facility ownership structure on individual responding to stress: a multilevel model

Few studies have investigated the effect of health-care facility ownership on the relationship between patient stressors and coping strategies. The purpose of this study was to investigate whether haemodialysis (HD) patient stressors and coping strategies differ by type of health-care facility ownership, and whether such ownership has a cross-level moderating effect between stressors and coping strategies. We used the Haemodialysis Stressor Scale and the Jalowiec Coping Scale; primary data were collected by interviewing 2642 HD patients 15 years or older on dialysis for at least three months from 27 HD centres. One-way analysis of variance and hierarchical linear modelling were used to attain the research purposes. HD patients from religious-based hospitals had higher stress related to their physical symptoms, dependency on medical staff, role ambiguity and blood vessel problems than those differently owned facilities. Patients in veterans and army (VA) hospitals had higher stress related to food and fluid restriction and dependency on medical staff than private centres. Patients in religious-based hospitals had significantly higher coping scores, followed by VA and private HD centres. Religion-based ownership might serve as a cross-level moderator for patients perceiving role ambiguity stress and using problem-oriented, support seeking and isolated thought-coping strategies.

Breast cancer knowledge and attitudes toward mammography as predictors of breast cancer preventive behavior in Kazakh, Korean, and Russian women in Kazakhstan

OBJECTIVES

To explore differences in breast cancer knowledge and attitudes toward mammography for women representing three ethnic groups (Kazakh, Korean, and Russian) and to determine how these factors affect breast cancer preventive practices in Almaty City, Kazakhstan.

METHODS

A cross-sectional, descriptive study design was utilized. Face-to-face interviews were conducted with 500 women in Almaty City. A combination of descriptive (ANOVA) and multivariate analyses (structural equation modeling) was used to estimate differences in respondents' breast cancer knowledge, attitudes, and practices (KAP).

RESULTS

Findings indicate that women may be influenced by their clinicians' advice to engage in breast cancer preventive practices. Multivariate models suggest that breast cancer knowledge and attitudes toward the effectiveness of mammography are significant determinants of breast cancer preventive practices among study participants.

CONCLUSIONS

Clinicians should encourage women to engage in breast cancer preventive practices. Clinical and public health interventions should be aimed at both women and healthcare providers to use mammography as a tool for early detection of breast cancer in Almaty City, Kazakhstan.

The use of public policy analysis to enhance the Nursing Home Reform Act of 1987

Given the prevalence of abuse and neglect in nursing home care delivery vis-à-vis elderly and frail residents, and despite the advent and implementation of the Nursing Home Reform Act of 1987 (a policy that sought to diminish such conduct in such institutional settings), deficiency citations in nursing home care and services remain both problematic and common. By employing public policy analysis, and by analyzing various social science theories applicable to the improvement of care delivery and quality, this article seeks to develop methods to enhance compliance with the Nursing Home Reform Act and reduce care deficiencies in nursing homes.

Has the Medicare prospective payment system led to increased nursing home efficiency?

RESEARCH OBJECTIVE

To assess the impact of recent Medicare prospective payment system (PPS) changes on efficiency in skilled nursing homes.

DATA SOURCE/STUDY SETTING

Medicare Cost Reports (MCR), On-line Survey Certification and Reporting System (OSCAR), Area Resource Files (ARF), a Centers for Medicare and Medicaid Services (CMS) hospital wage index website, a Consumer Price Index (CPI) database, and a survey of state Medicaid reimbursement rates. The sample was 8,361 nursing homes in the Medicare Cost Report databases from the years 1997 to 2003.

STUDY DESIGN

Data-envelopment analyses (DEA) calculated efficiency scores for three separate DEA models: unadjusted, acuity-adjusted, and acuity-and-quality-adjusted efficiency. The efficiency scores from these models were regressed on the Medicare PPS changes (the Balanced Budget Act [BBA], the Balanced Budget Refinement Act [BBRA] and the Benefits Improvement and Protection Act) and other organizational and market explanatory variables using a panel-data truncated regression.

PRINCIPAL FINDINGS

Mean values for all efficiency measures decreased over time, the acuity-quality-adjusted efficiency measures decreasing the most. All policy variables were significantly negatively related to all efficiency measures. Higher nurse staffing was negatively related to efficiency in all but the acuity-quality-adjusted model. Other explanatory variables varied in their relationships to the efficiency variables.

CONCLUSIONS

The results suggest that the reimbursement policy changes had a significantly negative impact on efficiency. Higher nurse staffing contributed to lower efficiency only when efficiency was not adjusted for quality. Various organizational and market factors also played significant roles in all efficiency models.

Ambulatory care visits and physician satisfaction: from medical directors' perspectives

BACKGROUND

Under the universal health insurance system in Taiwan, policy makers seek new approaches to balance rising costs and quality of care. One policy, Ambulatory Care Reimbursement, enacted in 2001 has effectively reduced patient numbers in clinics by cutting per patient reimbursement when a physician has seen over predetermined number of patients.

PURPOSE

To access the impact of this policy on physician satisfaction in regional hospitals and medical centers (MCs) from the point of view of their medical directors.

METHODOLOGY

We conducted a cross-sectional survey of medical directors from 25 MCs and 78 regional hospitals in Taiwan. The survey used a 5-point Likert scale to identify both impacts of reduced ambulatory care visits and physician satisfaction. We randomly selected 30% of all medical directors from both types of medical institutions. Of the 248 medical directors contacted, 142 replied. Excluding 5 incomplete responses, our final sample was 137. Response rates were roughly equivalent for MCs (54.67%) and regional hospitals (57.89%).

FINDINGS

Medical directors were typically male, aged 45.11 years, worked in MCs (60%), and were general practitioners (43.1%). Multiple regressions associated three independent predictors of physician satisfaction: physician-patient interaction (beta = .393, p = .001), mission (beta = .351, p = .007), and reduced health care expenditures (beta = .179, p = .014). Medical directors more often characterized the regulation of reducing number of visits as a means of encouraging MCs and regional hospitals to improve physician interaction with patients and, thus, associated it with greater patient satisfaction. Generally, directors did not believe that the regulation encouraged patients seeking care at other hospitals or that it resulted in reduced pay to physicians.

PRACTICE IMPLICATION

Reducing ambulatory care visits has promoted the physician-patient relationship and allowed many physicians attain their medical mission. Such regulation had influence on the physicians' satisfaction.

The Role of Simulation and Modeling in Disaster Management

The threat of pandemic disaster has motivated many collaborative exercises for the purpose of preparation and evaluation. The nature of these exercises depends upon the status of pre-existing expectations for system behavior and the aims of the exercise stakeholders. The contents of this article argue that these exercises may be developed using the same approach as simulation modeling to advantage. Four levels of maturity are outlined as a guide to understanding reasonable expectations for such activity.

Effects of institutional mechanisms on nursing home quality

This study explores institutional mechanisms explaining the variation in nursing home quality. A two-level panel design with the national data is conducted. Structural equation modeling is employed to examine the main and interaction effects of institutional factors on nursing home quality at both facility and state levels. The findings indicate that the quality of nursing homes is more responsive to regulatory and payment constraints than to normative and mimetic mechanisms. The potential demand for care, Medicaid reimbursement rate, and occupancy rate are positively associated with nursing home quality. An interaction effect between the regulatory mechanism and nurse staffing is statistically significant. The findings lend support to the importance of multi-level analysis of nursing home quality.

A typology of health marketing research methods--combining public relations methods with organizational concern

Research plays a critical role throughout virtually every conduit of the health services industry. The key terms of research, public relations, and organizational interests are discussed. Combining public relations as a strategic methodology with the organizational concern as a factor, a typology of four different research methods emerges. These four health marketing research methods are: investigative, strategic, informative, and verification. The implications of these distinct and contrasting research methods are examined.

Predictors of resident outcome improvement in nursing homes

The effects of contextual characteristics and nursing-related factors on the overall quality improvement of resident outcomes, measured by a weighted index in incidents of pressure ulcers, physical restraints, and catheter use in nursing homes, were investigated by autoregressive latent trajectory modeling of panel data (1997-2003). Findings show that in the initial study period, nursing homes with a smaller bed size, being for-profit, caring for more Medicare residents, having residents with lower acuity levels, being located elsewhere than the South, having a high level of nurse staffing, and certified with lower frequencies of nursing care deficiencies had better quality. The intercept factor, representing the baseline of quality, was well predicted by six of the eight contextual and facility characteristics variables, and the slope trajectory of quality was only weakly predicted by them. The improved quality in resident outcomes was associated with facilities having fewer nursing care deficiency citations than their counterparts.

Minimum nurse staffing ratios for nursing homes

The authors explored minimum nurse staffing ratios for nursing homes using production function simulations. Minimum levels of registered nurse hours per resident day were 0.31, 1.83, and 3.3 at 50%, 75%, and 90% levels of quality respectively. These results suggest that efficiency-oriented minimum nurse staffing points exist, and could be used to inform policymakers and nursing home administrators on better resource allocation and health care delivery.

Healthcare Informatics Research: From Data to Evidence-Based Management

Healthcare informatics research is a scientific endeavor that applies information science, computer technology, and statistical modeling techniques to develop decision support systems for improving both health service organizations' performance and patient care outcomes. The analytical strategies include (1) the formulation of a data warehouse for exploration, (2) data mining, (3) the application of confirmatory statistical analysis, (4) simulation via an interface with computer and information system technologies, and (5) translational research. Healthcare informatics research will help to direct evidence-based strategic management.