Values identified in different groups of Air Force nurses

Fundamental personal values are reflected in the choices and decisions made in every aspect of our lives. This descriptive study identified values held by a convenience sample of 224 Air Force nurses stationed at four U.S. Air Force medical facilities. Study participants identified seven of eight literature-supported values in the categories "important" or "very important" across the demographic factors of age, gender, educational level, military rank, marital status, and years of Air Force or civilian nursing experience. These seven values were ability utilization, achievement, altruism, autonomy, economic reward, economic security, and personal development. Personnel using this information may ease the transition process to military nursing, facilitate job placement to positions reflecting personally held values, and provide valuable insight for Air Force nurse recruiters who have limited knowledge of the nursing profession. In all, this would promote job satisfaction and Air Force nurse retention.

Clinical effectiveness of pneumococcal vaccine. Meta-analysis

OBJECTIVE

To determine the clinical effectiveness of pneumococcal vaccine.

DATA SOURCES

Computerized searches of MEDLINE, EMBASE, and SCISEARCH databases were performed, reference lists of retrieved articles were reviewed, and first authors of published studies were contacted.

STUDY SELECTION

Studies of use of pneumococcal vaccines in adults were included if the study design was a randomized or quasi-randomized controlled trial and at least one of the following clinical outcomes was reported: vaccine-type systemic pneumococcal infection, systemic pneumococcal infection, vaccine-type pneumococcal pneumonia, pneumococcal pneumonia, non-vaccine-type pneumococcal pneumonia.

SYNTHESIS

Study quality was assessed and descriptive information concerning the study populations, interventions, and outcome measurements was extracted for 13 trials involving more than 65,000 patients. Estimates of vaccine efficacy, based on a meta-analysis of randomized and quasi-randomized trials, were determined for clinical outcomes.

CONCLUSIONS

Vaccination with pneumococcal polysaccharide vaccine can be expected to reduce the risk of systemic infection due to pneumococcal types included in the vaccine by 83% and systemic infection due to all pneumococci by 73%. We found no evidence that the vaccine was less efficacious for the elderly, institutionalized people, or those with chronic disease.

Defining the practice population in fee-for-service practice

OBJECTIVE

To develop and validate a technique for defining a practice population of discrete individuals based on multiyear family practice fee-for-service billings data.

DATA SOURCES/STUDY SETTING

Nineteen family physicians in Ontario, Canada who converted from fee-for-service to capitation payment. Data sources were fee-for-service billings data for the three-year period prior to the conversion from fee-for-service to capitation payment and the rosters of enrolled patients for the first and third years after the change to capitation payment.

STUDY DESIGN

The billings-based definition of the physician's practice population was compared against the Year 1 roster. We also compared the billings-based practice population and the Year 1 roster to the physician's Year 3 roster to identify patients who might have been missed during the roster development process. Our principal analyses were an assessment of the sensitivity of the billings-based definition of the practice population (EPP), the positive predictive value of EPP, and the agreement between EPP and the rostered patient population (RPP). We also examined the ratio between EPP and RPP to determine EPP's accuracy in estimating the practice denominator.

DATA COLLECTION/EXTRACTION METHODS

The practice population for each physician at the time of conversion from fee-for-service to capitation payment was defined as (a) all persons for whom the physician billed the provincial health insurance plan for at least one visit during the year immediately prior to joining the capitation-funded program; and (b) all additional patients for whom the physician billed the plan for at least one service in each of the two preceding years. Data extraction was carried out within the Ministry of Health in order to preserve the anonymity of patients and physicians. Data were provided to the investigators stripped of patient and physician identifiers.

PRINCIPAL FINDINGS

The mean sensitivity and positive predictive value of EPP were 95.3 percent and 87.4 percent, respectively. The level of agreement between EPP and RPP averaged 84.4 percent. The mean ratio of EPP to RPP was 1.21 (95 percent C.I. 1.030-1.213). Correction for roster false-negatives increased the sensitivity, positive predictive value, and agreement between EPP and the practice population, and reduced the mean ratio of EPP to the practice population to 1.068 (95 percent C.I. 1.010-1.127).

CONCLUSIONS

The practice population can usefully be defined in fee-for-service family practice on the basis of multiyear fee-for-service billings data. Further research examining alternative encounter-based practice population definitions would be valuable.

Do female primary care physicians practise preventive care differently from their male colleagues?

OBJECTIVE

To assess whether female primary care physicians' reported coverage of patients eligible for certain preventive care strategies differs from male physicians' reported coverage.

DESIGN

A mailed survey.

SETTING

Primary care practices in southern Ontario.

PARTICIPANTS

All primary care physicians who graduated between 1972 and 1988 and practised in a defined geographic area of Ontario were selected from the Canadian Medical Association's physician resource database. Response rate was 50%.

MAIN OUTCOME MEASURES

Answers to questions on sociodemographic and practice characteristics, attitudes toward preventive care, and perceptions about preventive care behaviour and practices.

RESULTS

In general, reported coverage for Canadian Task Force on the Periodic Health Examination's (CTFPHE) A and B class recommendations was low. However, more female than male physicians reported high coverage of women patients for female-specific preventive care measures (i.e., Pap smears, breast examinations, and mammography) and for blood pressure measurement. Female physicians appeared to question more patients about a greater number of health risks. Often, sex of physician was the most salient factor affecting whether preventive care services thought effective by the CTFPHE were offered. However, when evidence for effectiveness of preventive services was equivocal or lacking, male and female physicians reported similar levels of coverage.

CONCLUSION

Female primary care physicians are more likely than their male colleagues to report that their patients eligible for preventive health measures as recommended by the CTFPHE take advantage of these measures.

Preventive care and barriers to effective prevention. How do family physicians see it?

OBJECTIVES

To assess how adequately family physicians think they are delivering preventive care and to examine barriers to providing preventive care.

DESIGN

Cross-sectional survey.

SETTING

Primary care medical practices in south-central Ontario.

PARTICIPANTS

Four hundred eighty family physicians and general practitioners who graduated from medical school between 1972 and 1988.

MAIN OUTCOME MEASURES

Satisfactory preventive care delivery versus self-assessed coverage of patients for 15 preventive maneuvers. Perceived reasons for lack of success in providing recommended preventive care.

RESULTS

For 10 of the 15 maneuvers, the proportion of physicians who regarded 90% or higher as satisfactory coverage was twice as great as the proportion who thought they provided that level of coverage. For 11 of the 15 maneuvers, most respondents reported coverage lower than the level they regarded as satisfactory. For six maneuvers, more than two thirds thought they provided less than satisfactory coverage. More than two thirds of respondents suggested these barriers to providing recommended preventive care: patient is healthy and does not visit; patient refuses, is not interested, or does not comply; no effective systems to remind patients to come in for preventive care; and priority given to presenting problem.

CONCLUSION

Many family physicians and general practitioners in south-central Ontario provide preventive care to their patients at lower levels than they consider satisfactory. They identified barriers to providing preventive services successfully; these barriers suggest approaches for improving care.

A method for the treatment of ureteric complications following renal transplantation

Over an 8-year period, 117 renal transplants (97 cadaveric and 20 living related) were performed at the Sir Charles Gairdner Hospital, Perth, Western Australia, Australia. Ureteric complications following renal transplantation occurred following seven transplants (6%). The technique of using a multiply fenestrated vesicocutaneous stent/drain to manage this problem is described. This was uncomplicated in all cases with the exception of one case in which the stent/drain was removed early because of blockage and sepsis, but most importantly on no occasion was the graft lost. We therefore recommend this technique for the management of this complication, whether early or late. We observed a disproportionate number of ureteric complications in living related transplants, a feature not described previously.

Comprehensiveness and bias in reporting clinical trials. Study of reviews of pneumococcal vaccine effectiveness

PURPOSE

To assess the extent to which relevant controlled clinical trials are cited and summarized in review articles, and to determine whether citation of relevant clinical trails is biased as to study results.

DATA SOURCES

Articles were identified by searching MEDLINE and EMBASE databases.

STUDY SELECTION

Review articles published between 1986 and 1988 on the clinical effectiveness of pneumococcal vaccine.

DATA EXTRACTION

Proportion of relevant clinical trials cited and whether citation is biased by study results.

DATA SYNTHESIS

The proportion of relevant primary studies cited per review article ranged from 0% to 36% (mean 9%). The number of trials cited per review ranged from zero to six (mean 1.2). In nine of 17 reviews, no clinical trials were cited. Study populations and outcome(s) were specified and results presented quantitatively for 0 to 27% of relevant trials per review (mean 6%). Unsupportive trials were almost twice as likely to be cited as supportive trials.

CONCLUSIONS

Reporting of the results of relevant clinical trials in reviews of pneumococcal vaccine effectiveness is incomplete. Our findings suggest a need for greater scientific rigour in preparing, reviewing, and editing review articles.

Reliability of the Guide to Pregnancy Risk Grading of the Ontario Antenatal Record in assessing obstetric risk

OBJECTIVE

To assess the reliability of the Guide to Pregnancy Risk Grading of the Ontario Antenatal Record through evaluation of inter- and intra-observer agreement on the grading of obstetric risk.

DESIGN

Retrospective chart review.

SETTING

Urban community teaching hospital in Hamilton, Ont.

PATIENTS

Obstetric charts of 77 women were randomly selected from those of all women who delivered at the hospital or were transferred before delivery to the regional perinatal centre between Apr. 1, 1987, and Mar. 31, 1988. Six family physicians and two obstetricians participated as chart reviewers.

MAIN OUTCOME MEASURES

Agreement beyond chance (kappa [kappa] statistic) between (a) different reviewers, (b) the same reviewer at different times and (c) the majority of reviewers (majority risk grade) and the antenatal record.

MAIN RESULTS

The kappa value for interobserver agreement ranged from 0.48 (95% confidence interval [CI] 0.34 to 0.62) to 0.51 (95% CI 0.36 to 0.66). For intraobserver agreement it was 0.69 (95% CI 0.37 to 1.0). Agreement between the majority risk grade and the risk grade last recorded in the antenatal record had a kappa value of 0.58 (95% CI 0.54 to 0.61).

CONCLUSION

The guide possesses only modest reliability. Efforts should be made to make descriptions of risk factors more explicit and to improve the training of health care providers in the use of the guide in order to prevent errors in pregnancy risk assessment and resulting inappropriate patient care and misdirection of health care resources.

Personal, home and community safety promotion with community-dwelling elderly persons: response to a public health nurse intervention

Public health clients aged 65 years and older were randomly allocated to receive an intervention by a public health nurse during a home visit, promoting either safety behaviours or influenza immunization. Sixty-eight clients reported making a total of 103 safety changes, with almost equal proportions making changes in the safety and influenza groups (21.9% vs. 18.3%). A higher percentage of males (25.0%) than females (17.3%) reported making safety changes following the intervention. Further research should focus on the effectiveness of safety promotion strategies which are expanded to include seniors participation, policy development and community planning and design.

The regulation of calcitriol by parathyroid hormone and absorbed dietary phosphorus in subjects with moderate chronic renal failure

The two best-recognized stimuli for calcitriol production are parathyroid hormone (PTH) and dietary phosphorus deprivation. We studied the relative importance of these two stimuli in subjects with moderate chronic renal failure (MCRF). We recruited 10 subjects with MCRF aged 49 +/- 13 years (mean +/- SD) and having a creatinine clearance rate of 31 +/- 24 mL/min. After an overnight fast, they received 400 IU human PTH 1-34 subcutaneously, and blood and urine samples were collected over the subsequent 24 hours. They then took aluminum hydroxide 30 mmol/d for 2 months to reduce gut phosphorus absorption, at the end of which the PTH stimulation test was repeated. Responses were compared with those obtained in 11 normal subjects aged 44 +/- 16 years and having a creatinine clearance rate of 102 +/- 37 mL/min who were only studied while on their normal diet. Following PTH stimulation in the normal subjects but not the MCRF subjects, there was a significant increase in plasma calcium and calcitriol levels, with a significant decrease in renal phosphorus threshold. In both groups there was a similar and significant increase in urine cyclic adenosine monophosphate (cAMP) levels. Following restriction of absorption of dietary phosphorus in MCRF subjects, plasma calcitriol levels increased compared with baseline values. This study shows that these MCRF subjects were unable to respond with an increase in calcitriol to a PTH stimulus that produced a similar urine cAMP response in normal subjects. However, they were capable of responding to a reduction in phosphorus absorption with an increase in calcitriol.(ABSTRACT TRUNCATED AT 250 WORDS)

Critical appraisal of review articles

Review articles are an important source of clinical information for family physicians. However, the volume of available reviews is vast and their scientific quality varies enormously. Family physicians must be able to identify trustworthy reviews quickly. This article outlines practical and flexible guidelines for critical appraisal and discusses the respective roles of review articles and original research reports in guiding clinical practice.

Use of reminders to increase compliance with tetanus booster vaccination

OBJECTIVE

To assess the effect of three computerized reminder systems on compliance with tetanus vaccination.

DESIGN

Prospective randomized controlled trial.

SETTING

Ottawa Civic Hospital Family Medicine Centre.

PARTICIPANTS

Of 8069 patients 20 years of age or more who were not in a hospital or institution 5589 were randomly assigned, by family, to a control group, a physician reminder group, a telephone reminder group or a letter reminder group. The remaining 2480 patients were not included in the randomized portion of the study but were monitored. Results are presented for the 5242 randomized patients and the 2369 nonrandomized patients for whom there was no up-to-date record of tetanus vaccination at the start of the trial.

INTERVENTIONS

For the patients in the physician reminder group the physician was reminded at an office visit to assess the patient's tetanus vaccination status and to recommend vaccination; those in the other two reminder groups received a telephone call or letter enquiring about their tetanus vaccination status and recommending a booster dose.

MAIN OUTCOME MEASURE

Proportion of patients who received tetanus toxoid during the study year or who had a claim of vaccination in the previous 10 years.

MAIN RESULTS

The rate of recorded tetanus vaccination in the randomized control group was 3.2%. The difference between that rate and those for the three reminder groups was 19.6% in the physician reminder group (95% confidence interval [CI] 17.1% to 22.2%, p less than 0.00001), 20.8% in the telephone reminder group (95% CI 18.3% to 23.5%, p less than 0.00001) and 27.4% in the letter reminder group (95% CI 24.8% to 30.2%, p less than 0.00001)). The letter reminders were more effective than either the telephone reminders (p = 0.00013) or the physician reminders (p less than 0.00001) in improving compliance. The cost to the practice per additional vaccination recorded was 43 for the physician reminders, $5.43 for the telephone reminders and $6.05 for the letter reminders.

CONCLUSIONS

Although all three reminder systems increased the rate of recorded tetanus vaccination they fell far short of achieving complete population coverage. More intensive interventions would be required to approach that goal. However, such interventions do not appear to be justified given the rarity of tetanus.

Agreement among reviewers of review articles

OBJECTIVE

To assess the consistency of an index of the scientific quality of research overviews.

DESIGN

Agreement was measured among nine judges, each of whom assessed the scientific quality of 36 published review articles. ITEM SELECTION: An iterative process was used to select ten criteria relative to five key tasks entailed in conducting a research overview.

SAMPLE

The review articles were drawn from three sampling frames: articles highly rated by criteria external to the study; meta-analyses; and a broad spectrum of medical journals. JUDGES: Three categories of judges were used: research assistants; clinicians with research training; and experts in research methodology; with three judges in each category.

RESULTS

The level of agreement within the three groups of judges was similar for their overall assessment of scientific quality and for six of the nine other items. With four exceptions, agreement among judges within each group and across groups, as measured by the intraclass correlation coefficient (ICC), was greater than 0.5, and 60% (24/40) of the ICCs were greater than 0.7.

CONCLUSIONS

It was possible to achieve reasonable to excellent agreement for all of the items in the index, including the overall assessment of scientific quality. The implications of these results for practising clinicians and the peer review system are discussed.

Effectiveness of Haemophilus influenzae type b vaccines

PURPOSE

To determine the clinical effectiveness of Haemophilus influenzae type b (Hib) vaccines. STUDY IDENTIFICATION AND SELECTION: Computerized searches of MEDLINE, EMBASE and SCISEARCH databases were performed, and the reference list of each retrieved article was reviewed. Two prospective clinical trials of Hib polyribosyl ribitol phosphate conjugated with diphtheria toxoid (PRP-D) were identified. In addition, one cohort study of the PRP-D vaccine, two trials of the PRP vaccine, five case-control studies of the PRP vaccine and 10 randomized controlled trials of the immunogenicity of the PRP-D vaccine were identified.

DATA EXTRACTION

Study quality was assessed and descriptive information concerning the study populations, the interventions and the outcome measurements was extracted.

RESULTS

The difference in the effectiveness of the PRP-D vaccine between the prospective trials, in which a three-dose schedule had been used beginning at 2 to 3 months of age, was clinically important (37% v. 83%) but not statistically significant. The PRP vaccine, which induces lower antibody responses than the PRP-D vaccine does, was clinically effective only in a subgroup of one prospective trial; 90% effectiveness was reported among children 18 to 60 months of age.

CONCLUSIONS

Hib vaccine appears to be less effective in high-risk populations. None the less, because of the large variation in baseline risk, the number of children who would have to be vaccinated to prevent one case of invasive Hib disease is substantially less for high-risk than for low-risk populations. The vaccination of children at high risk, such as native children, with the PRP-D vaccine using a four-dose schedule (at 2, 4, 6 and 14 months of age) seems warranted. The currently available evidence does not strongly support a policy of universal vaccination with either a one-dose or a four-dose schedule.

Effect of computer-generated nurse/physician reminders on influenza immunization among seniors

Despite long-standing recommendations by the Canadian and U.S. national immunization advisory committees that all persons aged 65 or older be vaccinated annually against influenza, vaccination rates among North American seniors remain approximately 20%. This paper reports a study of the effect of computer-generated nurse/physician reminders to offer influenza vaccine to elderly patients seen during the pre-influenza season in a community based group family practice. The study employed a pretest-post-test design strengthened by the use of a no-intervention comparison practice and repeated pretest measures of vaccine coverage. Outcome was measured by clinical records review. The influenza vaccination rate increased by 165% from 10.1% to 26.8% following introduction of the computer-generated reminders. There was no increase in influenza immunization in the comparison practice during the corresponding time period. Over 60% of eligible patients were seen in the practice during the pre-influenza season; 41.6% of those received influenza vaccinations.

Measurement of influenza vaccination status of the elderly by mailed questionnaire: response rate, validity and cost

Response rate, validity and cost of measurement of influenza vaccination status by mailed questionnaire were studied among seniors enrolled in a group family practice. The response rate to the questionnaire was 73%, 85% and 90% after one, two and three mailings, respectively. Questionnaire responses regarding influenza vaccination were compared with vaccination status as determined by review of office records. For the immediately preceding vaccination period, agreement beyond chance (Kappa statistic) between questionnaire responses and office records was .88. When questionnaire responses were assessed against a "gold standard" of office records supplemented by telephone interview of apparent false positives, the questionnaire performed with a sensitivity of .93 (95% CI .87-.96) and specificity of .98 (95% CI .96-.99). As assessed by records review, questionnaire respondents were four times more likely to have received influenza vaccine than non-respondents (p less than .003, 2-tailed).

Cost-effectiveness of primary tetanus vaccination among elderly Canadians

Although tetanus is now rare, vaccination is currently recommended for the entire population. Most elderly North Americans have never received tetanus vaccination. We evaluated the expected cost-effectiveness of using mailed reminders from family physicians to increase primary tetanus vaccination coverage among elderly Canadians. We estimated that over 10 years the program would prevent five cases of tetanus and one death from tetanus, resulting in a gain of 13 life-years. There would be 16,700 adverse reactions to tetanus toxoid, 17% in people already immune to tetanus. The net cost of the program (in 1984 Canadian dollars) would be $1.9 million per case of tetanus prevented, $7.1 million per death prevented and $810,000 per life-year gained. These high cost-effectiveness ratios are largely attributable to the very low risk of tetanus, even among nonimmune elderly people. Tetanus toxoid and physicians' services for vaccination would account for 86% of the program costs. Because the mailed reminders would be responsible for only 13% of the program costs, other possible programs to increase primary tetanus vaccination coverage could not be expected to have substantially lower cost-effectiveness ratios. We conclude that efforts to increase primary tetanus vaccination coverage among elderly Canadians would be a questionable use of health care resources.

Health, functional, and social status of an elderly primary-care population

Non-institutionalized family-practice patients aged 75 years or older were screened at home by nurse practitioners using a comprehensive health-assessment instrument. A majority of subjects showed no serious impairment of physical, psychological, or social functioning. An élite minority experienced excellent health.

Calcitriol deficiency with retained synthetic reserve in chronic renal failure

Serum calcitriol and the free calcitriol index together with factors considered to regulate calcitriol production were measured in eleven patients with moderate chronic renal failure (MCRF) and eleven age- and sex-matched normal subjects. Although the serum dialysable calcium levels were similar in the two groups, there was depression of calcitriol levels and an elevation of PTH and nephrogenous cyclic AMP (NcAMP) levels in the MCRF patients. Furthermore, plasma phosphate levels were higher and the renal phosphate threshold was depressed in this patient group. When all subjects were grouped together calcitriol was positively correlated with GFR. When calcitriol levels were factored for GFR, to permit an assessment of calcitriol production per unit functioning renal mass, there was no significant difference between normal and MCRF subjects. To determine whether reserve for calcitriol production existed, six of the MCRF patients and six of the age- and sex-matched normal subjects received a low calcium diet for one week supplemented by cellulose phosphate to bind calcium within the gut. In both groups there was a significant rise in calcitriol, although the absolute levels were much lower in the MCRF patients than the normal subjects. These results suggest that calcitriol deficiency is a major feature of MCRF despite marked hyperparathyroidism. The rise in calcitriol levels in MCRF suggests persistent reserve secretory capacity in this condition. Therefore, the low serum calcitriol concentration may be due not only to structural renal damage, but also to suppression of calcitriol formation perhaps due to altered renal phosphate handling.

Hypercalcemia during resolution of acute renal failure associated with rhabdomyolysis: evidence for suppression of parathyroid hormone and calcitriol

Hypercalcemia during the recovery phase of renal function is a relatively common complication of rhabdomyolysis-associated acute renal failure. The cause is unclear but it has been suggested recently that both hyperparathyroidism and high levels of calcitriol are implicated. We present evidence which does not support these hypotheses.