The role of respiratory care practitioners in a changing healthcare system: emerging areas of clinical practice

OBJECTIVE

To evaluate shifts in respiratory care practice in the context of changing healthcare system and market dynamics.

STUDY DESIGN

Telephone survey, structured interview, and case studies.

METHODS

We conducted a telephone survey of 471 respiratory care practitioners (RCPs), drawn from the membership database of the American Association for Respiratory Care. We also interviewed 10 employers of RCPs and conducted 2 in-depth case studies to supplement our survey results. We used several statistical techniques to analyze our data, including calculation of population-weighted descriptive statistics and multivariate regression models.

RESULTS

Changes in the healthcare system have prompted RCPs to broaden their practice settings, skills, and responsibilities. Respiratory care practitioners are taking part in managed care-related activities, such as cost control and disease management. We found that the need for certain skills and responsibilities varies by practice setting. In our interviews, employers considered RCPs cost effective providers for certain services.

CONCLUSIONS

The practice of respiratory care is evolving to meet the changing needs of the healthcare system. A key challenge is to ensure appropriate growth and development of the respiratory care profession, as well as the delivery of appropriate services under new care management settings and processes.

Use of dialectical behavior therapy in a partial hospital program for women with borderline personality disorder

Dialectical behavior therapy, an outpatient psychosocial treatment for chronically suicidal women with borderline personality disorder, has been adapted for use in a partial hospital program for women. Patients attend the program for a minimum of five days of individual and group therapy, and full census is 12 women. About 65 percent of participants meet at least three criteria for borderline personality disorder, and most have suicidal and self-injurious behavior. Their comorbid diagnoses include trauma-related diagnoses and anxiety disorders, severe eating disorders, substance abuse, and depression. The partial hospital program is linked to an aftercare program offering six months of outpatient skills training based on dialectical behavior therapy. Both programs focus on teaching patients four skills: mindfulness (attention to one's experience), interpersonal effectiveness, emotional regulation, and distress tolerance. Two years of operation of the women's partial hospital program provides promising anecdotal evidence that dialectical behavioral therapy, an outpatient approach, can be effectively modified for partial hospital settings and a more diverse population.

The anatomy of online information for physicians

Online medical networked information (OMNI) is one of the newest and fastest growing types of information sources for physicians. The authors present an organizational framework for understanding the range of available OMNI sources and discuss the practical applications, strengths and limitations of online resources. Physicians can now gain access on line to a wealth of information relating to many aspects of clinical medicine and can consult interactively with colleagues on clinical and research questions. The limitations of networked online resources include lack of access, difficulty in navigating online systems and the potential for fraudulent use. Net-worked online systems are growing in popularity and may become integral to medical practice as barriers to efficient use are overcome.

Long term follow-up of children with mixed connective tissue disease

Mixed connective tissue disease (MCTD) is characterized by features of more than one of the rheumatic disorders with antinuclear antibodies in a speckled pattern and with antibodies to nuclear ribonucleoprotein (nRNP). MCTD is uncommon in children and long-term follow-up studies in children are infrequently reported. A retrospective review of clinical experience at five pediatric rheumatology centers provided 11 patients who met the following inclusion criteria: (1) Kasukawa's criteria for MCTD1; (2) presentation younger than 18th birthday; (3) greater than five years of follow-up; (4) completion of data collection form. The widely varying outcomes of these 11 children with MCTD on long-term follow-up may lend doubt that this is a unique and distinctive rheumatologic disorder.

Development of a disability measurement tool for juvenile rheumatoid arthritis. The Juvenile Arthritis Functional Assessment Report for Children and their Parents

Two questionnaires were developed for measuring disability due to juvenile rheumatoid arthritis (JRA), one based on patient reports and one on parent reports. These questionnaires were termed the Juvenile Arthritis Functional Assessment Report for Children (JAFAR-C) and for Parents (JAFAR-P). The questionnaires were administered to 72 JRA patients ages 7-18 years and to their parents. Respondents rated the patient's recent ability to perform 23 activities. Patient reports and parent reports were found to correlate highly with each other and with an objective assessment performed by therapists. Questionnaire scores did not correlate significantly with the age of the patient. The JAFAR appears to be a convenient, reliable, and valid measure of disability in patients with JRA.

Development of a disability measurement tool for juvenile rheumatoid arthritis. The Juvenile Arthritis Functional Assessment Scale

A disability assessment tool, the Juvenile Arthritis Functional Assessment Scale, was developed for, and validated in, patients with juvenile rheumatoid arthritis (JRA). Standards for this 10-item tool were developed using the scores of 63 normal school children as controls and comparing these results with those of 71 age-matched JRA patients (age 7-16 years). The JRA patients scored statistically significantly higher on the scale, which also demonstrated excellent internal and convergent validity and internal reliability. The test is easily administered in 10 minutes by a physical or occupational therapist in a clinical or office setting. This tool represents the first normalized disability assessment tool developed for JRA patients.

Nutrition: interest growing in the medical profession

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Identification of stage-specific polypeptides synthesized during murine preimplantation development

[35S]Methionine-labeled extracts of mouse ova and preimplantation embryos were analyzed by two dimensional polyacrylamide gel electrophoresis. Of the 400-600 molecular species that have been resolved as distinct spots on autoradiograms of gels for every stage of development from unfertilized eggs to early blastocysts, particular attention has been paid to the identification of 36 of these proteins, each of which is expressed only for a portion of the period under investigation. These molecules are referred to as stage-specific polypeptides and they are biochemical markers of early embryonic development and differentiation.

The effect of orientation on the visual resolution of gratings

1. Visual resolving power is known to be poorer for objects oriented obliquely as compared with horizontal and vertical orientations. Experiments were designed to evaluate the optical and neurophysiological factors involved.2. Gratings with a sinusoidal light distribution were generated on the face of an oscilloscope. Spatial frequency and contrast could be varied while keeping the mean luminance of the grating constant.3. Using a homatropinized eye with an artificial pupil and carefully corrected refraction, high resolution in the vertical and horizontal meridians as compared with the oblique meridians was found for gratings ranging in spatial frequency from 1 to 35 c/deg.4. It is concluded from the similar behaviour of low and high frequency gratings that neither focus errors nor optical aniseikonia can account for these findings.5. Additional proof that optical factors cannot significantly account for these preferred directions of resolution was obtained by forming interference fringes directly on the retina using a neon-helium laser as a coherent light source.6. Similar orientational changes in resolution were found by by-passing the dioptrics with interference fringes. It is concluded that the effect is due to some orientational inequality in the visual nervous system.