Promoting Quality Through Research Impact: Challenges, Missed Opportunities and Potential for Nursin

1
Promoting Quality Through Research Impact
Challenges, Missed Opportunities and Potential
for Nursing Research
David Mechanic, Ph.D. Institute for Health,
Health Care Policy and Aging Research Rutgers,
the State University of New Jersey
INQRI Program, Robert Wood Johnson
Foundation July 16, 2008
2
Outline

• Nursings centrality in the care process offers
  a strategic
• location for observation posing key
  questions and
• influencing quality of care
• Asking important but often neglected questions
• Careful observation and focused questions can
• have major influence good research doesnt
  
• have to be complex
• Framing of questions has to be targeted and
• relevant good timing helps
• Nurses are in a position to observe carefully
  avoid
• consensual opinion and retrospective
  reconstructions
• try to get the facts prospectively
• Missed opportunities mental health
• Impact opportunities

3
Location Determines What You Know (Access to
People and Information s Influence)
Mechanic, Students Under Stress, 1962

4
Largest Connected Subcomponent of the Social
Network in the Framingham Heart Study in the Year
2000
N.A. Christakis, J.H. Fowler, New England Journal
of Medicine, 357370-379, 2007
5
Probability that an Ego will Become Obese
According to the Type of Relationship with an
Alter Who May Become Obese in Several Subgroups
of the Social Network of the Framingham Heart
Study
N.A. Christakis, J.H. Fowler, New England Journal
of Medicine, 357370-379, 2007
6
Probability That a Subject Will Quit Smoking
According to the Type of Relationship with a
Contact Who Quits Smoking in the Social Network
of the Framingham Heart Study
N.A. Christakis, J.H. Fowler, New England Journal
of Medicine, 3582249-2258, 2008
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Needed Skepticism About Consensual Views Not
Based on Data
Perhaps the most extraordinary development in
medical practice during the age of managed care
was that time, in the name of efficiency, was
being squeezed out of the doctor-patient
relationship. Managed care organizations, with
their insistence on maximizing throughput, were
forcing physicians to churn through patients in
assembly line fashion at ever-accelerating rates
of speed...By the late 1990s, the pressure on
doctors to see more patients in less time showed
no signs of abating, and many doctors were
staggering under the load. K. Ludmerer, Time
to Heal American Medical Education from the Turn
of the Century to the Era of Managed Care, 1999

8
Mean Length of Patient-Physician Encounters,
1989 -2000
23
21.8
21.7
21.5
21.5
21.6
22
21.3
21.4
20.6
21
20.4
20.4
20.3
Minutes
20
19.3
19.2
19.3
18.9
18.6
19
18.5
18.3
18.4
17.6
18
17
16.7
17
16.3
16
0
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
National Ambulatory Medical Care Survey, National
Center for Health Statistics
Socioeconomic Monitoring System, American Medical
Association
Source Mechanic et al., NEJM, 2001
9
Mean Length of Patient-Physician
Encounters According to Whether Visit is Prepaid,
1989 -2000
19.7
19.7
20
19.5
19.3
18.9
18.9
18.8
19
18.5
17.9
18.5
18
Minutes
18.2
18
17.9
17.8
17.2
17.6
17.3
16.9
17
16.4
16.8
16.7
16
15.9
15.7
15.4
15
0
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Total Prepaid
Total Non-Prepaid
Source Mechanic et al., NEJM, 2001
10
Mean Length of Patient-Physician
Encounters According to Whether Visit is
Prepaid, for Primary and Specialty Care Visits,
1989-2000
24
22
20
Minutes
18
16
14
0
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Specialty Care Prepaid
Specialty Care Non-Prepaid
Primary Care Prepaid
Primary Care Non-Prepaid
Source Mechanic et al., NEJM, 2001
11
Weekly vs. Six-Month Retrospective Reports of
Vomiting After Gastric Surgery
Stunkard et al. Psychosomatic Medicine,
1985 (Correlation between weight loss after
surgery and retrospective reports of vomiting
was -.58 (NS)
12
Simple Observations withPotential for Large
Impact

• Examples
• catheter-related bloodstream infections
• patient linkage with outpatient care

13
Uses of Checklists

• Simple checklist for catheter practice
• hand washing
• full barrier precautions during the insertion
• of central venous catheters
• cleaning the skin with chlorhexidine
• avoiding the femoral site if possible
• removing unnecessary catheters
• Pronovost et al., NEJM, 2006

14
Example 1 Rates of Catheter-Related Bloodstream
Infection from Baseline (before implementation of
the study intervention) To 18 Months of Follow-Up
Study Period No of ICUs No of Bloodstream
Infections per 1000 Catheter-Days
Teaching Nonteaching
Overall Hospital Hospital
(interquartile range) Baseline 55 2.7
(0.6-4.8) 2.7 (1.3-4.7) 2.6 (0-4.9) 2.1
(0-3.0) 2.7 (1.3-4.8) During Implementation
96 1.6 (0-4.4) 1.7 (0-4.5) 0
(0-3.5) 0 (0-5.8) 1.7 (0-4.3) After
Implementation 0-3 months 96
0 (0-3.0) 1.3 (0-3.1) 0 (0-1.6) 0
(0-2.7) 1.1 (0-3.1) 4-6 months
96 0 (0-2.7) 1.1 (0-3.6) 0
(0-0) 0 (0-0) 0 (0-3.2)
7-9 months 95 0 (0-2.1) 0.8
(0-2.4) 0 (0-0) 0 (0-0) 0
(0-2.2) 10-12 months 90 0
(0-1.9) 0 (0-2.3) 0 (0-1.5) 0
(0-0) 0.2 (0-2.3) 13-15 months
85 0 (0-1.6) 0 (0-2.2) 0
(0-0) 0 (0-0) 0 (0-2.0)
16-18 months 70 0 (0-2.4) 0
(0-2.7) 0 (0-1.2) 0 (0-0) 0
(0-2.6) Pronovost et al., NEJM, 2006
P0.05 and P0.002 for the comparison with
the baseline (preimplementation) period
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Example 2 Three-Month Postdischarge Outcomes
among Medicaid Patients with Schizophrenia who
had Contact with Outpatient Clinicians While in
Hospital (for patients with new clinicians)
Predischarge No Predischarge
Contact (N53) Contact (N51)
P Outcome Psychiatric outpatient visit
98.1 62.7
.001 Psychiatric emergency room visit 18.9
26.0 .38 Psychiatric hospitalization 17.3
25.5 .31 Medication noncompliance 20.8
34.7 .11 Homeless 3.8
13.7 .07 Self-reported Psychosocial
Difficulties Symptom Control 12.0
30.6 .02 Control of anger 13.5
18.0 .58 Concentration 22.0
28.6 .45 Recognition of symptoms 12.2
17.0 .51 Occupational functioning
Had paid employment 13.2 14.3 .84
Sought paid employment 26.1 25.6
.96 Olfson, Mechanic, Boyer, Hansell,
Psychiatric Services, 1998
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Mental Health Nursings Missed Opportunity for
National Leadership

Nursing may have unique opportunities in mental
health practice because of the way it is
structured relative to medical practice and
because of the special needs of mental patients,
and, in addition because it more effectively
bridges the physical and social needs of patients
than competing mental health specialties. Mechan
ic, in Aiken (ed.), 1982
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Two Psychiatric Nurses Who Have Made a Difference
Hildegard Peplau
Claire M. Fagin
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Why Focus OnImproved Mental Health Services

• Extraordinary burden contributing to impairment
• and incapacity
• Enormous suffering
• Long delays in seeking treatment
• Inadequate treatment
• Major losses in productivity
• Broad effects on families, children,
  co-workers,
• and community

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Good Treatment for the SMI isMore Than
Traditional ServicesDimensions of a Long-Term
Treatment Orientation

• Linkage to social and rehabilitative services
• Attention to stable housing
• Medication management
• Illness and medication education
• Family involvement
• Substance abuse treatment
• Psychosocial rehabilitation supported
  employment
• Attention to physical comorbidity

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Clinically Trained Mental Health Personnel By
Year (Rough Estimates)
Psychiatry 29,000 36,000 40,000
--- (40-45,000
est) Psychology 45,000 56,000 73,000
77,000 88,000 est Social
Work --- 86,000 93,000
96,000 Psychiatric Nursing 10,000
15,000 18,000 25,000
est Counseling 61,000
108,000 Marriage and Family Therapy
45,000 Psycho-social rehabilitation 21,000
35,000 100,000 School
Psychology 24,000
26,000 31,000 FTEs in
Mental Health Org (Patient Care) 347,000 (1986)
371,000 532,000
427,000 1982-84 1989-94
1996-98 1999-2000 2004-2006

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The Motivating Model Managed Behavioral Health
Care Mental Health / Substance Abuse Average
Length of Stay per Admission - 1987 to 1994 Xerox
Corporation
After Utilization Review
Length of Stay
Before Utilization Review
22
Average Length of Stay in General Hospitals for
Psychiatric Discharges by Hospital Ownership
Adapted and extended from Mechanic, McAlpine and
Olfson, Archives of General Psychiatry, 55
785-791, 1998
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Outpatient Treatment for Depression, United
States, 1987 and 1997
1987 1997 Rate for 100 persons 0.73
2.33 Treatment Characteristics of Persons Treated
for Depression Pharmacotherapy
47 79 Anti-depressants 37 75
SSRIs 0 58 Other 37
28 Benzodiazepines 16 10
Psychotherapy 71 60 mean
of visits 13 9 Psychotherapy and
Antidepressants 23 45
Adapted from Olfson, Marcus, Druss et al. JAMA,
287(2)203-209, 2002.
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Use of Psychotropic Medication for Children Years, 1987-1996
1987 1996
Annual rate of use of Psychotropic medications
1.4 3.9 antidepressants 0.3 1.0
stimulants 0.6 2.4
co-prescriptions of psychotropics 0.03
0.23 Psychotropic use by age years 0.46 0.82 6-14 years
1.89 5.41 15-18 years 1.76
5.15 Adapted from Olfson et al., Journal of the
American Academy of Child and Adolescent
Psychiatry, 2002, 41(5) 514-521
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Major Challenges in Mental Health CareWhere
Nursing Can Make the Difference

• Care decisions are now dominated by managed
• behavioral health organizations thoughtful
• balanced decision making essential and often
• deficient
• Efforts to integrate care across relevant
  sectors
• a continuing struggle including attention
  to
• physical comorbidities
• Broad neglect of long-term management and
• maintenance therapies for appropriate chronic
  care
• Needed attention to psychosocial and
  rehabilitative
• management as well as medication typically
  neglected

26
The Importance ofResearch Quality, Timing and
ImpactFindings Based on a 1956 Study of 10
Michigan Hospitals

• Findings Quality of medical care in hospitals is
  higher when
• the quality of nursing care is higher
• the proportion of nursing staff members who are
• RNs is greater
• the number of registered nurses per patient, or
  per
• average census is greater
• quality of organizational coordination and
  mutual
• understanding between nurses and doctors is
  greater

Georgopoulis and Mann, The Community General
Hospital, MacMillan, 1962
27
Comparable Findings withBetter Methodology and
Greater Impact

• In hospitals with high patient to nurse
  ratios,
• surgical patients experience higher
  risk-adjusted
• 30-day mortality and failure to rescue rates,
  and
• nurses are more likely to experience burnout
  and
• job dissatisfaction1
  (citations 436)
• In hospitals with higher proportions of nurses
  
• educated at the baccalaureate level or
  higher,
• surgical patients experienced lower mortality
  and
• failure to rescue rates2
  (citations 157)

1. Aiken et al., JAMA, 2002 2. Aiken et al.,
JAMA, 2003
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Impact Looking Inward or Outward Impact of
Journal 2006-Science Citation Index
Nursing Leaders Impact 1. Birth Issues in
Perinatal Care 2.06 2. Nursing Economics
1.81 3. American Journal of Critical Care
1.69 4. Nursing Research 1.60 5. Oncology
Nursing Forum 1.48 6. Journal of Clinical
Nursing 1.43 7. Journal of Advanced Nursing
1.34 8. Research in Nursing and Health 1.34
29
Impact Looking Inward or Outward Impact of
Journal 2006-Science Citation Index
Health Care/Policy Impact 1. Annual Review of
Public Health 6.85 2. Milbank Quarterly
6.79 3. Health Technology Assessment 5.29 4.
American Journal of Epidemiology 5.24 5.
Medical Care 3.75 6. American Journal of
Public Health 3.70 7. Health Affairs
3.68 8. Value in Health 3.43
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Impact Looking Inward or Outward Impact of
Journal 2006-Science Citation Index
Super Resources Impact 1. New England Journal
of Medicine 51.30 2. Science 30.03 3.
Nature 26.68 4. Lancet 25.80 5.
JAMA 23.18 6. Annals of Internal
Medicine 13.25 7. Annual Review of Medicine
10.38 8. British Medical Journal 9.05