The National Institute of Nursing Research (NINR) is part of the National Institutes of Health. NINR's federal research dollars support clinical and basic nursing research to establish the scientific base for the care of individuals across the life span. Its support extends to problems encountered by patients, families, and caregivers, and emphasizes the special needs of at-risk and underserved populations to reduce health disparities. NINR has a significant mission in research training and career development, supporting predoctoral and postdoctoral education for nurses and mid-career awards for doctorally prepared nurses.
Preventive Health Counseling Remains a Challenge in Adolescent Medicine
Adams SH, Husting S, Zahnd E, Ozer EM. Adolescent preventive services: rates and disparities in preventive health topics covered during routine medical care in a California sample. J Adolesc Health. 2009;44:536-545.
Preventive healthcare for adolescents has been identified as a priority by numerous authorities, and pediatric health counseling has been cited as important in setting the stage for lifelong healthy behaviors. Furthermore, the Healthy People 2010 initiative highlights the need for improved access to preventive care and health counseling as part of an attempt to eliminate health disparities, including those in adolescent populations.
Using the 2003 adolescent California Health Interview Survey (CHIS) (n = 2192), a research team examined how often 7 preventive health topics were discussed during routine care, and modeled the disparities in discussion rates by age, gender, race/ethnicity, family income, and insurance status. The biannual CHIS, conducted by the UCLA Center for Health Policy Study, is the largest multiethnic, multilinguistic state survey in the United States, and it provides statewide estimates for California's population. Adolescents aged 12-14 years were compared with those aged 15-17 years, after interviews with a parent who answered demographic questions and gave permission for the child's participation. The questions regarding discussion of health topics during routine examinations in the past 6 months were adapted from the previously validated Young Adult Health Care Survey and included use of alcohol, tobacco, and drugs; use of seatbelts and helmets; sexually transmitted diseases (STDs), such as gonorrhea or chlamydia; violence or violence prevention; exercise or physical activity; and nutrition or healthy eating.
Bivariate logistic regression was used for the preliminary analyses, followed by multivariate logistic regression models. Across all groups, discussions of preventive health topics occurred relatively infrequently (15%-76% of examinations) and varied by discussion topic and participant characteristics (eg, insurance status, income level) For example, more than 4 out of 5 adolescents reported that, at their most recent examination, there was no discussion of helmet use, violence issues, or seatbelt use. More than two thirds had no discussion on substance use or STDs, and 25% reported a lack of discussion regarding exercise or nutrition. The multivariate disparity analyses highlight unexpected differences between groups. Hispanic adolescents were more likely than whites to have had discussions related to violence prevention (P < .001). When compared with the adolescents in the highest-income group, those in the lowest-income group were more likely to have discussed seatbelt use and STDs (P < .05 for both). Finally, being uninsured increased the likelihood of discussing seatbelts, helmets, violence, and STDs (at least P < .05 for all 4). Although a precise explanation of these findings cannot be drawn from these analyses, the authors speculate that physicians may be adjusting health counseling to their perceived risk for the individual patient.
Chronically Critically Ill Patients' Survival Outcomes and Resource Use Differ by Age
Douglas SL, Daly BJ, O'Toole EE, Kelley CG, Montenegro H. Age differences in survival outcomes and resource use for chronically critically ill patients. J Crit Care. 2009;24:302-310.
Increasing healthcare costs have been attributed to many factors, including an aging population, rising numbers of chronically critically ill (CCI) patients, and increasing severity of illnesses. CCI patients, defined as those who survive intensive care unit (ICU) stays but who remain dependent on advanced technologies, such as mechanical ventilation, consume 25%-40% of ICU resources, although they represent only 10% of ICU admissions. Improved data on mortality and resource use could present opportunities to both improve care and respect patient wishes.
This retrospective study of 1121 patients compared 700 older (more than 65 years, 72.1% white, 48.7% men), English-speaking CCI patients who received more than 96 hours of mechanical ventilation with 421 otherwise-similar middle-aged (45-64 years, 64.4% white, 51.8% men) CCI patients. Data for this research were drawn from 2 previous prospective studies in Cleveland, Ohio -- the Longitudinal Long-Term Ventilator (1997-1999) study and the Disease Management Intervention (2001-2003) study. Abstracted chart and interview data that described outcomes at 2 and 4 months postdischarge were collected by research nurses. Severity of illness upon ICU admission was assessed using the Acute Physiology and Chronic Health Evaluation III, and the Acute Physiology Score.
Nearly 43% of the older patients died in-hospital, which represents a death rate 1.2 times that of the younger patients (P = .011). This higher mortality rate was more pronounced at 4 months postdischarge, when the relative risk for death was 1.98 (P = .001). Mantel-Cox log-rank tests revealed significantly different survival curves for the 2 age groups (P = .001). The cumulative mortality rate was 60.4% for older patients in contrast to 45.6% for younger patients. Although survival patterns were similar for the first 15-20 days, median time-to-death outside of the early postdischarge period was 99 days for the middle-aged group compared with 46 days for the older group. Logistic regression modeling showed that higher Acute Physiology Scores (P = .03), presence of diabetes (P = .0001), mechanical ventilation at discharge (P = .0001), and older age (P = .001) were significantly related to death. Older patients had significantly higher charges for postdischarge home care (P = .03) and were more likely to have been readmitted and to die (P = .0002). Among those who died without being readmitted, 21.1% of middle-aged patients had advanced directives, significantly fewer than the 43.8% of older patients who had directives (P = .02). The data presented in this study demonstrate that older CCI patients have higher mortality (up to 4 months) and consume more home care resources (up to 2 months) postdischarge. This study highlights the posthospital experiences of CCI patients and adds to the knowledge base about long-term outcomes that can be used by critical care patients, families, and providers in making decisions about treatment preferences and goals.
Trust in Personal Physicians and the Healthcare System Is Critical to Healthcare for Older African American and White Patients
Musa D, Schulz R, Harris R, Silverman M, Thomas SB. Trust in the health care system and the use of preventive health services by older black and white adults. Am J Public Health. 2009;99:1293-1299.
A patient's level of trust in physician competency, the healthcare system, and various sources of health information has been demonstrated, in previous studies, to contribute to healthcare-seeking behaviors (including preventive services). Moreover, level of trust has been shown to vary according to race. Although racial disparities in healthcare have been repeatedly demonstrated, few studies have explored the relationship among race, trust, and preventive care-seeking behavior.
To examine these concepts, a team of researchers conducted a cross-sectional telephone survey that assessed the relationship between trust in the healthcare system and preventive care behaviors. The sample comprised elderly African American and white Medicare beneficiaries (n = 1681, 40.6% African American, 59.4% white). Four types of trust were explored: 1) trust in one's own physician, 2) trust in physician competence, 3) trust in formal health information sources, and 4) trust in informal health information sources. Preventive care behaviors were measured, including flu shots, mammograms, prostate specific antigen (PSA) tests, and routine checkups. Although overall healthcare provider trust levels were high for both groups, African Americans had significantly less trust in their own physicians (P = .002) and formal health sources (P < .001) than did white patients. Conversely, African American patients were more likely to trust informal health information sources (P < .001). Overall, African Americans were less likely than whites to receive flu shots (P < .05), but African American women were more likely than white women to have had a mammogram in the past 2 years (P < .05). For women of both races, trust in their own physicians increased the likelihood of having mammography (P < .05). Similarly, men of both races who reported greater trust in their physicians were significantly more likely to have had a PSA test than those with less trust (P < .05). Overall, regardless of race, patients were more likely to have had a routine check-up in the past year when they reported a high level of trust in their physicians (P < .05). Because of the possible relationship between trust in one's physician and using preventive services, the researchers call for enhancing the physician/patient relationship and increasing the use of informal information sources in the African American community. The authors also suggest that to mitigate the negative health effects of mistrust, outreach efforts should be directed toward building a greater degree of trust between African American populations and formal health information sources.
Abstract
All studies reported here are supported by funding from the National Institute of Nursing Research.
