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PubMed2003

Coding of sounds in the auditory system and its relevance to signal processing and coding in cochlear implants.

OBJECTIVE: To review how the properties of sounds are "coded" in the normal auditory system and to discuss the extent to which cochlear implants can and do represent these codes. DATA SOURCES: Data are taken from published studies of the response of the cochlea and auditory nerve to simple and complex stimuli, in both the normal and the electrically stimulated ear. REVIEW CONTENT: The review describes: 1) the coding in the normal auditory system of overall level (which partly determines perceived loudness), spectral shape (which partly determines perceived timbre and the identity of speech sounds), periodicity (which partly determines pitch), and sound location; 2) the role of the active mechanism in the cochlea, and particularly the fast-acting compression associated with that mechanism; 3) the neural response patterns evoked by cochlear implants; and 4) how the response patterns evoked by implants differ from those observed in the normal auditory system in response to sound. A series of specific issues is then discussed, including: 1) how to compensate for the loss of cochlear compression; 2) the effective number of independent channels in a normal ear and in cochlear implantees; 3) the importance of independence of responses across neurons; 4) the stochastic nature of normal neural responses; 5) the possible role of across-channel coincidence detection; and 6) potential benefits of binaural implantation. CONCLUSIONS: Current cochlear implants do not adequately reproduce several aspects of the neural coding of sound in the normal auditory system. Improved electrode arrays and coding systems may lead to improved coding and, it is hoped, to better performance.

Cochlea↗
PubMed2006

Antifungal prophylaxis with azoles in high-risk, surgical intensive care unit patients: a meta-analysis of randomized, placebo-controlled trials.

OBJECTIVE: The use of antifungal prophylaxis remains controversial in most populations including surgical intensive care unit patients. A meta-analysis of randomized controlled trials was performed to evaluate the safety and effectiveness of azoles as antifungal prophylaxis in high-risk patients receiving treatment in the surgical intensive care unit. DATA SOURCE: Data were obtained from PubMed, Current Contents, Cochrane central register of controlled trials, and references from relevant articles. STUDY SELECTION: Randomized controlled trials using azoles as antifungal prophylaxis vs. placebo were included in the study. DATA EXTRACTION: Two independent reviewers extracted data concerning the development of fungal infections (superficial or invasive), adverse effects, and mortality. SYNTHESIS: Six randomized controlled trials were included in the main analysis. Publication bias and statistically significant heterogeneity were not observed among the analyzed studies. Patients receiving antifungal prophylaxis developed fewer episodes of candidemia (odds ratio [OR] = 0.28, 95% confidence interval [CI] 0.09-0.86), nonbloodstream invasive fungal infections (OR = 0.26, 95% CI 0.12-0.53), and noninvasive (superficial) fungal infections (OR = 0.22, 95% CI 0.11-0.43), respectively. No reduction in mortality was observed among patients who received azole prophylaxis (OR = 0.74, 95% CI 0.52-1.05). There was no significant difference in reported adverse effects (OR = 1.28, 95% CI 0.82-1.98). CONCLUSIONS: Despite its limitations, our meta-analysis suggests that the prophylactic use of azoles in high-risk surgical intensive care unit patients is associated with a reduction of fungal infections but not in all-cause mortality. However, although not noted in the analyzed randomized controlled trials, there is concern about the use of azoles due to possible shift toward non-albicans species and development of resistance to azoles.

Antifungal Agents↗
PubMed2002

Agreement between self-reported and routinely collected health-care utilization data among seniors.

OBJECTIVE: To examine the agreement between self-reported and routinely collected administrative health-care utilization data, and the factors associated with agreement between these two data sources. DATA SOURCES/STUDY SETTING: A representative sample of seniors living in an Ontario county within Canada was identified using the Ontario Ministry of Health's Registered Persons Data Base in 1992. Health professional billing information and hospitalization data were obtained from the Ontario Ministry of Health and Long-Term Care (OMH) and the Ontario Health Insurance Plan (OHIP). STUDY DESIGN: A cross-sectional survey was carried out to assess any contact and frequency of contacts with health professionals and hospital admissions. Similar information was obtained from routinely collected administrative data. The level of agreement was assessed using the proportion of absolute agreement, Cohen's kappa statistic (kappa), and the intraclass correlation coefficient (ICC). Logistic and linear regressions were used to identify factors that were associated with the magnitude and direction of disagreement respectively. DATA COLLECTION/EXTRACTION METHODS: Telephone interviews were conducted on 1,054 seniors, and complete data were available for 1,038 seniors. Each respondent's personal health number was used to electronically link survey data with health professional billing and hospitalization databases. PRINCIPAL FINDINGS: Substantial to almost perfect agreement was found for the contact utilization measures, while agreement on volume utilization measures varied from poor to almost perfect. In surveys, seniors overreported contact with general practitioners and physiotherapists or chiropractors, and underreported contact with other medical specialists. Seniors also underreported the number of contacts with general practitioners and other medical specialists. The odds of agreement decreased if respondents were male, aged 75 years and older, had incomes of less than $25,000, had poor/fair/good self-assessed health status, or had two or more chronic conditions. CONCLUSION: The findings of this study indicate that there are substantial discrepancies between self-reported and administrative data among older adults. Researchers seeking to examine health-care use among older adults need to consider these discrepancies in the interpretation of their results. Failure to recognize these discrepancies between survey and administrative data among older adults may lead to the establishment of inappropriate health-care policies.

Aged↗
PubMed2003

Race/ethnicity, language, and patients' assessments of care in Medicaid managed care.

OBJECTIVE: Consumer assessments of health care provide important information about how well health plans and clinicians meet the needs of the people they serve. The purpose of this study was to examine whether consumer reports and ratings of care in Medicaid managed care vary by race/ethnicity and language. DATA SOURCES: Data were derived from the National CAHPS Benchmarking Database (NCBD) 3.0 and consisted of 49,327 adults enrolled in Medicaid managed care plans in 14 states in 2000. DATA COLLECTION: The CAHPS data were collected by telephone and mail. Surveys were administered in Spanish and English. The response rate across plans was 38 percent. STUDY DESIGN: Data were analyzed using linear regression models. The dependent variables were CAHPS 2.0 global rating items (personal doctor, specialist, health care, health plan) and multi-item reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables were race/ethnicity, language spoken at home (English, Spanish, Other), and survey language (English or Spanish). Survey respondents were assigned to one of nine racial/ethnic categories based on Hispanic ethnicity and race: White, Hispanic/Latino, Black/African American, Asian/Pacific Islanders, American Indian/Alaskan native, American Indian/White, Black/White, Other Multiracial, Other Race/Ethnicity. Whites, Asians, and Hispanics were further classified into language subgroups based on the survey language and based on the language primarily spoken at home. Covariates included gender, age, education, and self-rated health. PRINCIPAL FINDINGS: Racial/ethnic and linguistic minorities tended to report worse care than did whites. Linguistic minorities reported worse care than did racial and ethnic minorities. CONCLUSIONS: This study suggests that racial and ethnic minorities and persons with limited English proficiency face barriers to care, despite Medicaid-enabled financial access. Health care organizations should address the observed disparities in access to care for racial/ethnic and linguistic minorities as part of their quality improvement efforts.

Adult↗
PubMed2003

Do commercial managed care members rate their health plans differently than Medicaid managed care members?

OBJECTIVE: To determine if members of commercial managed care and Medicaid managed care rate the experience with their health plans differently. DATA SOURCES: Data from both commercial and Medicaid Consumer Assessment of Health Plan Surveys (CAHPS) in New York State. STUDY DESIGN: Regression models were used to determine the effect of population (commercial or Medicaid) on a member's rating of their health plan, controlling for health status, age, gender, education, race/ethnicity, number of office visits, and place of residence. DATA COLLECTION: Managed care plans are required to submit to the New York State Department of Health (NYSDOH) results of the annual commercial CAHPS survey. The NYSDOH conducted a survey of Medicaid enrollees using Medicaid CAHPS. PRINCIPAL FINDINGS: Medicaid managed care members in excellent or very good health rate their health plan higher than commercial members in excellent or very good health. There is no difference in health plan rating for commercial and Medicaid members in good, fair, or poor health. Older, less educated, black, and Hispanic members who live outside New York City are more likely to rate their managed care plan higher. CONCLUSIONS: Medicaid members rating of their health care equals or exceeds ratings by commercial members.

Adolescent↗
PubMed2004

Characterization of bovine serum albumin epitopes and their role in allergic reactions.

OBJECTIVE: This review provides updated information on conformational and sequential epitopes identified in bovine serum albumin (BSA) and summarizes available data about the role of structural modifications on BSA antigenicity/allergenicity. DATA SOURCES: Data on beef allergy and BSA antigenicity are reported, with reference both to the basic literature and to clinical results obtained by our group. RESULTS AND DISCUSSION: BSA is an important allergen involved in milk and beef allergy. The presence of conformational epitopes has been suggested by indirect evidence, while at least one sequential epitope has been experimentally identified. The role of structural modifications on BSA antigenicity is discussed as well as the increased tolerance observed in allergic subjects consuming beef as strained (homogenized) and freeze-dried derivatives. CONCLUSION: Study of the molecular characteristics of a known major allergen allows the identification of technological processes that may be capable of improving the tolerance of allergic subjects to a specific food. Even though any hoped for reduced allergenicity must be verified under medical supervision, the use of new products could obviate the need to avoid important foods such as meat in childhood.

Allergens↗
PubMed2003

Racial segregation and longevity among African Americans: an individual-level analysis.

OBJECTIVE: To test the relationship between racial segregation and mortality using a multidimensional questionnaire-based measure of exposure to segregation. DATA SOURCES: Data for this analysis come from the National Survey of Black Americans (NSBA), a national multistage probability sample of 2,107 African Americans (aged 18-101). The NSBA was conducted as a household survey. The NSBA was matched with the National Death Index (NDI). STUDY DESIGN: Prospective cohort study, where Cox regression analysis was used to examine the effect of baseline variables on time to death over a 13-year period. PRINCIPAL FINDINGS: Respondents who were exposed to racial segregation were significantly less likely to survive the study period after controls for age, health status, and other predictors of mortality. CONCLUSION: The results support previous studies linking segregation with health outcomes.

Adolescent↗
PubMed2004

Antiretroviral therapy and health care utilization: a study of privately insured men and women with HIV disease.

OBJECTIVE: To compare the use of antiretroviral therapy and other health care resources by women and men with HIV disease who are privately insured. DATA SOURCES: Data were obtained from the MarketScan Commercial Claims and Encounter Database produced by the Medstat Group, Inc., of Ann Arbor, Michigan. This database includes eligibility files as well as claims data for inpatient care, outpatient care, physician services, and prescription drugs for enrollees in employer-sponsored benefit plans for 24 large employers around the nation. STUDY DESIGN: Examine utilization by 2,026 privately insured persons (1,494 men and 532 women) with HIV disease in calendar year 2000 under the age of 65. PRINCIPAL FINDINGS: Using a simple comparison, we found that 71 percent of men (68.7 to 73.3 percent is 95 percent confidence interval) and 39 percent of women (35.1 to 43.5 percent is 95 percent confidence interval) with HIV disease received antiretroviral therapy. We also found that the average annual drug cost was $9,037 for a man ($8,372 to $9,702 is 95 percent confidence interval) and $3,893 for a woman ($3,476 to $4,490 is 95 percent confidence interval). Furthermore, we found that the out-of-pocket expenses comprised 10 percent of total expenses for men ($1,617 out of $16,405) and 4 percent for women ($405 out of $10,397). CONCLUSION: There are major differences in the utilization and cost of health care between privately insured men and women with HIV disease.

Adult↗
PubMed2005

Racial and ethnic disparities and perceptions of health care: does health plan type matter?

OBJECTIVE: To examine whether racial and ethnic differences in the distribution of individuals across types of health plans explain differences in satisfaction and trust with their physicians. DATA SOURCES: Data were derived from the 1998-1999 Community Tracking Household and Followback Studies and consisted of a nationwide sample of adults (18 years and older). DATA COLLECTION: The data were collected by telephone survey. Surveys were administered in English and Spanish. The response rate for the Household Survey was 63 percent, and the match rate for the Followback Survey was 59 percent. STUDY DESIGN: Multivariate analyses used regression methods to detect independent effects of respondent race and ethnicity on satisfaction and trust with physician, while controlling for enrollment in different types of health plans. PRINCIPAL FINDINGS: Racial and ethnic minorities are more likely than whites to have lower levels of trust and satisfaction with their physician. The most prominent differences occurred within the Latino and Native American/Asian American/Pacific Islander/Other ("Other") populations. Plan type does not mitigate the relationship between race/ethnicity and trust and satisfaction for the overall adult population. CONCLUSIONS: Disparate levels of trust and satisfaction exist within ethnic and minority populations, even when controlling for the distribution of individuals across types of health plans. The results demonstrate a need to better understand the health care-related factors that drive disparate trust and satisfaction.

Adult↗
PubMed2006

A needle in a haystack? Uninsured workers in small businesses that do not offer coverage.

OBJECTIVE: To describe the insurance status of workers at small businesses, and to describe the status of uninsured persons by the employment characteristics (employment status, firm size, and whether the employer offers insurance) of the head of household. DATA SOURCES: Data from the March and February 2001 Current Population Survey, and a survey of 2,830 small businesses in San Diego County conducted in 2001. STUDY DESIGN: The survey of small businesses was undertaken as part of a project testing the response of employers to offers of subsidized coverage. Employers were asked whether they offered insurance, and about the insurance status of their employees. The merged February-March 2001 CPS was used to identify the employment status, firm size, and employer-offering status for uninsured persons in the U.S. DATA COLLECTION: Telephone interviews with small businesses in San Diego County. PRINCIPAL FINDINGS: Only 21 percent of the uninsured in the U.S. are full-time employees (or their dependents) in small businesses (<100 employees) that do not offer insurance. The employment status of the uninsured is heterogeneous: many work for large employers, small employers who do offer insurance, or are self-employed, part-time workers, or have no workers in the household. Although there are many small businesses in San Diego that do not offer coverage, most of them have very few uninsured workers. Over 50 percent of businesses that do not offer coverage have either zero or one uninsured worker. There are very few small businesses that do not offer coverage and that have substantial numbers of uninsured workers. These businesses are not quite as rare as a needle in a haystack, but they are very difficult to find. CONCLUSIONS: If all small businesses that do not offer insurance now could be persuaded to start offering coverage, and if all the full-time workers (and their dependents) in those businesses accepted insurance, the number of uninsured would decline by 21 percent--a significant decline, but leaving 80 percent of the problem untouched. If the prime target for programs of subsidized insurance are small businesses that do not offer coverage now and that have substantial numbers of uninsured workers, the target is very small.

California↗
PubMed2006

Do physicians always flee from HMOs? New results using dynamic panel estimation methods.

OBJECTIVE: To assess the impact of changes in relative health maintenance organization (HMO) penetration on changes in the physician-to-population ratio in California counties when changes in the economic conditions in California counties relative to the U.S. average are taken into account. DATA SOURCES: Data on physicians who practiced in California at any time from 1988 to 1998 were obtained from the AMA Masterfile. The analysis was restricted to active, patient care physicians, excluding medical residents. Data on other covariates in the model were obtained from the Bureau of Economic Analysis, InterStudy, the Area Resource File, and the California state government. Data were merged using county FIPS codes. STUDY DESIGN: Changes in the physician-to-population ratio in California counties include the effects of both intrastate migration and interstate migration. A reduced-form model was estimated using the Arellano-Bond dynamic panel estimator. Economic conditions in California relative to the U.S. were measured as the ratio of county-level real per capita income to national-level real per capita income. Relative HMO penetration in California was measured as the ratio of county-level HMO penetration to HMO penetration in the U.S. relative HMO penetration was instrumented using five identifying variables to address potential endogeneity. Omitted-variable bias was controlled for by first differencing the model. The model also incorporated eight other covariates that may be associated with the demand for physicians: the percentage of the population enrolled in Medicaid, beds in short-term hospitals per 100,000 population, the percentage of the population that is black, the percentage of the population that is Hispanic, the percentage of the population that is Asian, the percentage of the population that is below age 18, the percentage of the population that is aged 65 and older, and the percentage of the population that are new legal immigrants in a given year. All of the above variables were lagged one period. The lagged physician-to-population ratio was also included to control for the supply of physicians. Separate equations were estimated for primary care physicians and specialist physicians. PRINCIPAL FINDINGS: Changes in lagged relative HMO penetration are negatively associated with changes in specialist physicians per 100,000 population. However, this effect of HMO penetration is attenuated and at times reversed in areas where the magnitude of the difference in relative economic conditions is sufficiently large. We did not find any statistically significant effects for primary care physicians. CONCLUSIONS: Consistent with prior studies, we find that changes in physician supply are associated with changes in relative HMO penetration. Relative economic conditions are an important moderator of the effect of changes in relative HMO penetration on physician migration.

California↗
PubMed2006

The impact of health plan delivery system organization on clinical quality and patient satisfaction.

OBJECTIVES: The purpose of this study was to examine the extent to which measures of health plan clinical performance and measures of patient perceptions of care are associated with health plan organizational characteristics, including the percentage of care provided based on a group or staff model delivery system, for-profit (tax) status, and affiliation with a national managed care firm. DATA SOURCES: Data describing health plans on region, age of health plan, for-profit status, affiliation with a national managed care firm, percentage of Medicare business, total enrollment, ratio of primary care physicians to specialists, HMO penetration, and form of health care delivery system (e.g., IPA, network, mixed, staff, group) were obtained from InterStudy. Clinical performance measures for women's health screening rates, child and adolescent immunization rates, heart disease screening rates, diabetes screening rates, and smoking cessation were developed from HEDIS data. Measures of patient perceptions of care are obtained from CAHPS survey data submitted as Healthplan Employer Data and Information Set, Consumer Assessment of Health Plans 2.0 H. STUDY DESIGN: Multivariate regression cross-sectional analysis of 272 health plans was used to evaluate the relationship of health plan characteristics with measures of clinical performance and patient perceptions of care. PRINCIPAL FINDINGS: The form of delivery system, measured by percent of care delivered by staff and group model systems, is significantly related (p < or = .05) with four of the five clinical performance indices but none of the three satisfaction performance indices. Other variables significantly associated with performance were being geographically located in the Northeast, having nonprofit status, and for patient satisfaction, not being part of a larger insurance company. CONCLUSIONS: These comparative results provide evidence suggesting that the type of delivery system used by health plans is related to many clinical performance measures but is not related to patient perceptions of care. These findings underscore the importance of the form of the delivery system and the need for further inquiry that examines the relationship between organizational form and performance.

Adolescent↗
PubMed2006

Restrictions on provider access in health plans and socioeconomic status.

OBJECTIVE: To model the socioeconomic determinants of restrictions on provider access and choices in health plans. DATA SOURCES: Data from the 1996-97 Community Tracking Study are used. Publicly available enrollee data including enrollee reports of health care plan characteristics are linked with restricted use data with insurer reports of health plan characteristics. STUDY DESIGN: This is an observational study. A mixed multinomial logit model is used to model the enrollees' choice between health plans, each plan being treated as a bundle of attributes formed from restrictions on provider access. PRINCIPAL FINDINGS: There are important differences between the enrollee responses and the insurer reports, which may be due to poor information dissemination on the part of health plans and/or lack of attention on the part of enrollees. There is no evidence of selection into plans with restrictive attributes on the basis of observed health status but there is evidence of selection on the basis of race, ethnicity, gender and other socioeconomic characteristics. Determinants of plan supply, i.e., employment characteristics, are the most important determinants of plan attribute choices. CONCLUSION: The finding suggests that plan designs optimized using "objective" knowledge and with the best intentions may not receive favorable reviews from enrollees because enrollees have different perceptions of these plans.

Adolescent↗
PubMed2006

Crowd-in: the effect of private health insurance markets on the demand for Medicaid.

OBJECTIVE: To investigate the effects of local labor market conditions and the availability of employer-sponsored health insurance on exits from the Medicaid program. DATA SOURCE: Data for this project come from a unique administrative database containing a 2 percent sample of all cases on California's Medicaid program in 1987 and a 2 percent sample of all new cases starting each year between 1987 and 1995. STUDY DESIGN: The results are estimated using a discrete duration model where the monthly exit probability is a function of demographic characteristics, local labor market variables, the probability of having employer-sponsored insurance, and fixed year and county effects. PRINCIPAL FINDINGS: Improvements in labor market opportunities (i.e., employment growth, wage growth, and increases in the availability of employer-sponsored health insurance) promote exits off the Medicaid program. A 2.5 percentage point increase in the availability of employer-sponsored insurance leads to a 6 percent increase in the probability that a completed spell lasts no more than 2 years. It would take a 2 percentage point decrease in unemployment rates or a 10 percent increase in average quarterly earnings to yield an equivalent increase in the likelihood of exiting Medicaid within 2 years. These effects are robust to the inclusion of county-level fixed effects and time effects. CONCLUSIONS: Medicaid expenditures and caseloads are sensitive to local economic fluctuations and secular trends in the availability of health insurance. Continued decreases in employer-based health insurance coverage will greatly increase the demand for public insurance coverage and the financial pressures on state governments.

Adolescent↗
PubMed2004

Flu vaccines and patient decision making: what we need to know.

PURPOSE: To describe and compare patient-perceived barriers and motivators and decision-making conflict between two groups of hospitalized patients, those who received flu vaccines and those who did not. DATA SOURCES: Data collection included extracting data from databases and mailing two surveys to 436 discharged patients. One hundred eight patients participated in the study. CONCLUSIONS: Top motivators for obtaining a flu vaccine included previous vaccination (93%) and provider recommendation (62%). Top barriers included fear of side effects from the vaccine (35%) and fear of contracting the flu (30%). Motivators, barriers, and patient decisional conflict differed depending upon the patient's vaccination status. IMPLICATIONS FOR PRACTICE: Given the potential negative consequences of contracting the flu, prevention is the best strategy. Prevention is contingent upon motivating patients to obtain an annual flu vaccine. Recommending flu vaccinations, offering vaccinations in convenient locations free of charge, and discussing perceived barriers with patients may increase vaccinations among high-risk patients. Helping to clarify the advantages and disadvantages from the patient's perspective may decrease decisional conflict and increase vaccination rates.

Adolescent↗
PubMed2004

Evidenced-based use of botanicals, minerals, and vitamins in the prophylactic treatment of migraines.

PURPOSE: To analyze evidence-based information about alternative prophylactic pharmacological migraine treatments utilizing feverfew, butter-bur, magnesium, and riboflavin and to discuss the mechanism of action, dosage recommendations, side effects, and contraindications for each treatment. DATA SOURCES: Data obtained via electronic databases and professional medical references. CONCLUSIONS: Current clinical data support the use of fever-few, butterbur, magnesium, and riboflavin in migraine prophylaxis; however, studies are limited but promising regarding the participants' perceived relief. Studies with rigorous methodologies and larger sample sizes are needed to further support the safe and effective use of these treatments. IMPLICATIONS FOR PRACTICE: With increased patient access to information regarding alternative migraine treatments, nurse practitioners (NPs) and other health care providers must be knowledgeable about evidence-based data regarding these alternative treatments to appropriately offer safe patient care.

Evidence-Based Medicine↗
PubMed2006

Concordance of provider recommendations with American Diabetes Association's Guidelines.

PURPOSE: To determine if selected client characteristics were factors influencing the provision of provider advice for diet, exercise, smoking cessation, alcohol cessation, eye and foot care, and influenza and pneumonia vaccine for those told by a provider that they had diabetes. DATA SOURCES: Data from the 2001 National Health Interview Survey were used in a secondary analysis to answer the research question. This study used a subsample who self-reported having provider-diagnosed diabetes; the subsample comprised 2287 unweighted subjects that, when weighted, represent 6.38% of the civilian noninstitutionalized individuals with diabetes in the United States. CONCLUSIONS: This study suggests that many patients are not receiving all the eight processes of care studied, particularly those with new onset diabetes, elders, black people, and Hispanics. IMPLICATIONS FOR PRACTICE: This study suggests that the present paradigm is not early prevention but treatment of established disease. Changes in entrenched thinking about clinical care need to be addressed. Patients with diabetes need to have an awareness that there is a standard of optimal care, and they should be encouraged to seek those who provide this care. Further, system changes may be required to address changes that are not easily made at the provider level.

Attitude to Health↗
PubMed2006

Integrating practice issues in managed care into the curriculum: a Delphi survey.

PURPOSE: This project evolved from a partnership between an advanced practice nurse (APN) graduate program and a care management insurer. The purpose of this Delphi survey was to identify (a) role components germane to the practice of APNs in managed care and (b) topics reflecting these components in the curriculum. DATA SOURCES: Data were gathered from two expert panels, clinician preceptors and faculty members. Each panel had 11 members: 11.3% and 100%, respectively, of the target populations of clinicians and faculty in the partnering agencies. CONCLUSIONS: There was considerable congruence between the panels on the survey. IMPLICATIONS FOR PRACTICE: Case vignettes could be used as a vehicle for discussion of the broader issues of population approaches to specific problems. Faculty could partner with clinicians to develop cases for discussion of evidence-based practice. Faculty and clinicians could create preceptorships focused on business management, postgraduate fellowships within managed care systems, and regular opportunities to dialogue about curriculum and essential attributes of APN graduates.

Boston↗