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PubMed2001

Summary of the practice parameters for the assessment and treatment of children and adolescents with suicidal behavior.

These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide and attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening/case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed.

Adolescent↗
PubMed2001

Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of Child and Adolescent Psychiatry.

These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide and attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening/ case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed.

Adolescent↗
PubMedDate not supplied

Ethical considerations in the recruitment of research subjects from hospitalized, cardiovascular patient populations.

Cardiovascular research nurses play important roles in ensuring that subject recruitment is conducted in an ethically defensible manner. However, these nurses encounter many ethical challenges in the course of research. Sole reliance on regulatory mechanisms such as institutional review board oversight and adherence to legal requirements does not necessarily ensure human subjects' protection or the scientific integrity of researchers (J Law Med Ethics. 2002;30:411-419). Therefore, this article discusses 3 additional ethical considerations associated with recruiting hospitalized cardiovascular patients for research studies. These include (a) the role of the family and patient-delegated "gatekeepers," (b) the effect of transient and subtle mental status changes upon the consent process, and (c) the effect of conflicting patient priorities. This content is illustrated using the authors' experiences recruiting hospitalized coronary artery bypass graft surgical patients for a research study.

Cardiovascular Diseases↗
PubMed2001

Out in the real world: newly graduated nurses in acute-care speak out.

Resources are being spent to develop and implement strategies to attract and retain staff. To further our understanding of work environment factors that affect these issues, the author asked five nurses to reflect on their first 6 months as professional nurses. The author's study provides insight into, and enhances understanding of, recruitment and retention issues for nursing administrators who serve as gatekeepers to the practice orientations and ongoing workplace environments of new nursing graduates.

Adaptation, Psychological↗
PubMed1991

Searching: expectant fathers' experiences during labor and birth.

When expectant fathers are present and view labor and birth as a couple experience, they are co-laboring in one of three roles: coach, teammate, or witness. Within these roles are various degrees and types of engagement. Men in the role of coach experience high degrees of physical and mental engagement. Teammates fluctuate between high and low degrees of physical and mental engagement, and witnesses remain at low degrees of engagement until the second stage of labor, when they experience high degrees of mental engagement. The expectant fathers' experience is influenced by the labor guides' activities of gatekeeping, leading, and informing. Men either maintain or redefine their role during labor and birth. Men who experience a sense of not belonging or who are uncomfortable with their role will redefine their role by using the strategy of searching for place. Searching for place involves the steps of identifying an alternative role, engaging in the new role, testing the role, and evaluating the effectiveness of the alternative role. Men who experience a sense of belonging in their new role will maintain this role. May posed the question, "Is it time to fire the coach?" This theory, which requires further testing and validation, does address May's question. Perhaps it is not time to fire the coach, as May indicated, but it is time to provide couples with options in the role expectant fathers play during labor and birth. This theory can guide nurses in relatively risk-free interventions for the expectant father. Nurses can assist expectant fathers in finding a place in labor and birth that will enhance a mutually satisfying birthing experience.

Adult↗
PubMed1996

The microvascular cell and ischemia-reperfusion injury.

The vascular endothelium has a number of functions that may mediate many of the ischemia-reperfusion (IR) phenomena. The gatekeeper function is disturbed and increased capillary permeability results in edema and organ dysfunction. Vasomotor function is altered, with impairment of relaxation and augmentation of constrictor responses. Coagulation becomes imbalanced, favoring the procoagulant pathways that lead to thrombosis. Vascular adhesion molecules (integrins, selectins) are upregulated or expressed to mediate the adherence and subsequent destructive effects of neutrophils as they interact with the endothelium and the underlying organs. Finally, the more chronic vascular endothelial response may be proliferation of all cellular components of the vessel wall, leading, e.g., to intimal hyperplasia or restenosis. Ultimately, the endothelium plays a significant role either in the reparative processes that lead to recovery of the organ (myocardial stunning) or in the destructive processes that lead to cell or organ death (myocardial infarction). Our research group has been interested in the selectins, particularly E-selectin (endothelial) and P-selectin (platelet). E-selectin is not constitutively present on endothelial cells but can be upregulated by inflammatory mediators such as the cytokines tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1), and endotoxin. We have investigated the upregulation of E-selectin with cytokines in both hypoxia and hypothermia. Hypoxia appears to enhance E-selectin upregulation on stimulation with IL-1 or TNF-alpha, although hypothermia (to 25 degrees C) blunts this response. With rewarming to 37 degrees C, the transduction and surface expression return.

Animals↗
PubMed1979

An index of accessibility for ambulatory health services.

This paper discusses an Index developed and used to measure accessibility to health services provided on an outpatient basis at the Kaiser Community Health Foundation, Cleveland, Ohio. The Index is based on four levels of urgency or severity of illness and on the waiting times to get entry into the system. The parameters of the Index, initially established by task force members, were tested on a sample basis against the judgments of Kaiser outpatient facility users and finally refined through the consensus-seeking Delphi technique using a panel representing Kaiser members, gatekeepers, physicians and administrators. The actual times required to gain accessibility in the various process stages and in the various departments were obtained through simulated requests for appointments, by monitoring telephone calls to the various gate-keeping stations, by direct observations, and by the use of a telephone traffic computer. The paper discusses the Index developed, the data collection methodologies, and the data analyses performed.

Ambulatory Care Facilities↗
PubMed1987

The Monterey County Health Initiative. A post-mortem analysis of a California Medicaid demonstration project.

Twenty months after the California State Department of Health Services turned its Medicaid program in Monterey County over to a local health care authority, the Monterey County Health Initiative (MCHI), the state terminated the pilot project in favor of a return to fee-for-service reimbursement. The MCHI, plagued from its inception with shaky provider support and a flawed program design, failed to demonstrate its anticipated cost savings. The key features of this failure were overly generous fees for primary case managers, inadequate utilization control measures, a general hesitancy to assume the necessary gatekeeper function, and a management information system that was not fully operational until well into the implementation of the program. Policy implications and recommendations for future state-sponsored Medicaid demonstration projects are discussed.

California↗
PubMed1995

Severity of depression in prepaid and fee-for-service general medical and mental health specialty practices.

This study compares severity of depression for patients of general medical clinicians, psychiatrists, and nonphysician therapists receiving prepaid or fee-for-service care. Cross-sectional severity comparisons were conducted among 715 outpatients with current major depression or dysthymia, by independent assessment. Severity was assessed by counts of current and lifetime depressive symptoms, prognostic and treatment response indicators, and global measures of psychological and physical sickness. Patients of psychiatrists were the most psychologically ill, patients of nonphysician therapists were intermediate, and general medical patients were least ill; but even in the general medical sector, depression severity was at least ill; but even in the general medical sector, depression severity was at least moderate. No differences in global physical sickness by specialty remained after demographic adjustment. General medical patients whose depression had been detected were only slightly sicker than undetected cases. Type of payment was not consistently related to either psychological or physical aspects of sickness, and payment did not interact with specialty. Mental health specialists, especially psychiatrists, encountered more severely depressed patients, but patients in all sectors were sick enough to warrant treatment. Even undetected patients in the general medical sector were relatively sick, raising questions about gatekeeper policies. There was no evidence of a greater severity gradient by specialty in prepaid care. Because payment was unrelated to severity, treatment implications are similar under prepaid and fee-for-service care. Implications for clinical practice, public policy, and outcomes research design are discussed.

Adult↗
PubMed1996

Chiropractic and medical costs of low back care.

This study compares health insurance payments and patient utilization patterns for episodes of care for common lumbar and low back conditions treated by chiropractic and medical providers. Using 2 years of insurance claims data, this study examines 6,183 patients who had episodes with medical or chiropractic first-contact providers. Multiple regression analysis, to control for differences in patient, clinical, and insurance characteristics, indicates that total insurance payments were substantially greater for episodes with a medical first-contact provider. Most of the cost differences were because of higher inpatient payments for such cases. Analysis of recurrent episodes indicates that chiropractic providers retain more patients for subsequent episodes and that patient exposure to a different provider type during early episodes significantly affects retention rates for later episodes. Patients choosing chiropractic and medical care were comparable on measures of severity and in lapse time between episodes. The lower costs for episodes in which chiropractors serve as initial contact providers along with the favorable satisfaction and quality indicators for patients suggest that chiropractic deserves careful consideration in gatekeeper strategies adopted by employers and third-party payers to control health care spending. More research is needed, especially in developing alternative measures of health status and outcomes.

Adult↗
PubMed1999

Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery.

OBJECTIVE: The study sought to determine if there were race/ethnicity or gender differences in access to coronary artery bypass graft (CABG) surgery among patients who have been designated as appropriate and as necessary for that surgery according to the RAND methodology. METHODS: RAND appropriateness and necessity criteria were used to identify a race/gender stratified sample of postangiography patients who would benefit from coronary artery bypass graft surgery. These patients were tracked for 3 months to determine if they had undergone coronary artery bypass graft surgery in New York State. Subjects were a total of 1,261 postangiography patients in eight New York hospitals in 1994 to 1996. Measures included percentages of patients for whom coronary artery bypass graft surgery was appropriate and necessary undergoing surgery by race/ethnicity and gender, as well as multivariate odds ratios for race/ethnicity and gender. RESULTS: After controlling for age, payer, number of vessels diseased, and presence of left main disease, African-American and Hispanic patients were found to be significantly less likely to undergo coronary artery bypass graft surgery than white non-Hispanic patients (respective odds ratios 0.64 and 0.60). When "necessity" was used as a criterion instead of "appropriateness," significant differences in access for African-American patients remained. The gatekeeper physician recommended surgery only 10% of the time that patients did not undergo "appropriate" coronary artery bypass graft surgery, and this percentage did not vary significantly by race/ethnicity or gender of the patient. CONCLUSIONS: Even after controlling for appropriateness and necessity for coronary artery bypass graft surgery in a prospective study, African-American patients had significant access problems in obtaining coronary artery bypass graft surgery. These problems appeared not to be related to patient refusals.

Black or African American↗
PubMedDate not supplied

Telephone triage. The rules are changing.

The pressures of increasing clinical practice productivity as well as the limitations on parents' ability to make pediatric office visits has made it more difficult for children to be seen emergently in primary care clinics. For many children this translates into visiting an acute care center or emergency room to have urgent care needs quickly assessed and treated. Because of the gatekeeping now imposed on many organizations, it has become necessary for many primary care office settings to develop telephone management systems to triage the acuity of office visits or emergency room needs. This article reviews the issues inherent in developing an office-based telephone triage system, demonstrates some legal guidelines to follow for documentation, and describes the process of emergent management of parental concerns about child health.

Adolescent↗
PubMed2002

Exercise testing scores as an example of better decisions through science.

INTRODUCTION: The application of common statistical techniques to clinical and exercise test data has the potential to become a useful tool for assisting in the diagnosis of coronary artery disease, assessing prognosis, and reducing the cost of evaluating patients with suspected coronary disease. Since general practitioners function as gatekeepers and decide which patients must be referred to the cardiologist, they need to optimally use the basic tools they have available (i.e., history, physical exam, and the exercise test). METHODS: Review of the literature with a focus on the scientific techniques for aiding the decision-making process. RESULTS: Scores derived from multivariable statistical techniques considering clinical and exercise data have demonstrated superior discriminating power when compared using receiver-operating-characteristic curves with the ST segment response. In addition, by stratifying patients as to probability of disease and prognosis, they provide a management strategy. While computers as part of information management systems can calculate complicated equations to provide scores, physicians are reluctant to trust them. Thus, these scores have been represented as nomograms or simple additive tables so physicians are comfortable with their application. Scores have also been compared with physician judgment and been found to estimate the presence of coronary disease and prognosis as well as expert cardiologists, and often better than nonspecialists. CONCLUSION: Multivariate scores can empower the clinician to assure the cardiac patient with access to appropriate and cost-effective cardiological care.

Adult↗
PubMedDate not supplied

Comparison of native versus nonnative English-speaking nurses on critical thinking assessments at entry and exit.

Diversity of language among healthcare employees and nursing students is growing as diversity increases among the general population. Institutions have begun to develop systems to accommodate diversity and to assimilate workers. One barrier to nonnative English-speaking nurse hires may be posed by readiness for the licensure exam and the critical thinking assessments that are now an expected outcome of nursing programs, and act as a gatekeeper to graduation and to employment. To assist in preparing for high-stakes testing, the Assessment Technologies Institute Critical Thinking Assessment was developed in compliance with credentialing bodies' educational outcomes criteria. This pilot study of 209 nursing students was designed to reveal any possible language bias that might act as a barrier to nonnative English speakers. Nursing students were entered as whole classes to the study to control for selection bias. A sample representative of national nursing enrollment was obtained from 21 universities, with 192 (92%) native English-speaking students and 17 (8%) nonnative English speakers participating in the study. All students were given the Assessment Technologies Institute Critical Thinking Assessment at entry and exit to their nursing program. Average scores on entry were 66% for nonnative speakers and 72% for native speakers. At exit, the nonnative speakers had closed the gap in academic outcomes. They had an average score of 72% compared to 73% for native speakers. The study found that the slight differences between the native and nonnative speakers on 2 exit outcome measures-National Council licensure examination (NCLEX-RN) pass rates and Critical Thinking Assessment-were not statistically significant, demonstrating that nonnative English speakers achieved parity with native English-speaking peers on the Critical Thinking Assessment tool, which is often believed to be related to employment readiness.

Bias↗
PubMed1994

Matriarchal model for cardiovascular prevention.

Family patterns of cardiovascular risk behavior are well documented. Significant correlation exists between spouse-spouse, parent-child, and sibling-sibling for cholesterol, high- and low-density lipoprotein, diet, physical activity, and smoking. Family/environmental influences are important in how/if risk and/or preventive behavior is learned. The family matriarch commonly functions as gatekeeper, controlling eating behavior, access to health care, and other patterns. She often acts as menu planner, shopper, and preparer of meals for all family members. She provides information and verbal reinforcement about food and is a powerful model concerning dietary practices. In fact, the mother, as head of household in most single-parent families, may be the only adult model for many children. Because relevance and credibility are the most important characteristics of a behavioral model, parents (especially mothers) are strong models for observational learning by children. Risk factor information and risk reduction activities adopted by the matriarch can be generalized to the entire family if she learns the skills to act as a change agent. Initiation of this process of education and training the matriarch lies with primary care providers for women (Ob-Gyns see most women). By teaching risk reduction to the matriarch as a component of primary care, physician interaction can have a rippling effect.

Adult↗
PubMed1995

Rationing health care: preparing for a new era.

As the American health care system struggles to provide universal access to quality care at an acceptable price, many planners focus on rationing as the only way to make available the necessary resources. I discuss some of the ethical, economic, and political issues that relate to health care rationing. The four important questions to consider when examining a rationing plan are: (1) Who acts as the gatekeeper? (2) What kinds of goods or services are rationed? (3) What happens to the money and resources that are saved by rationing? (4) Does the system provide a safety valve for the well-to-do? This article examines two prototypical rationing systems--the British system and the Oregon plan--and answers these four questions for both systems. Because of the absence of an efficient market economy in health care and the certainty of resource constraints, rationing is inevitable in American health care. The primary issues are whether rationing will be done implicitly or explicitly and whether it will be based primarily on ability to pay (as in the present system) or on comparative judgments about the costs and benefits of medical interventions.

Ethics, Medical↗
PubMed2002

Patient education on the internet: opportunities and pitfalls.

The Internet, an increasingly pervasive part of our culture, has vastly increased the rate at which information is disseminated. Unfortunately, a substantial portion of medical information on the Internet is false or misleading. Realizing this, many patients would like their physicians to help guide their online searches for medical information, but most physicians do not feel comfortable enough with the Internet to provide this service. A recent poll by Cyberdialogue (2000) found that 70% of all patients would like their physicians to recommend a health care web site for their condition, but that only 4% of patients receive such a recommendation. In recommending medical web sites, physicians need to consider the quality of the web site, the quality of the content, and especially the ethics of the site. The most important ethical standard a web site must meet is the clear separation of its editorial comment from promotional material. Patients do not have enough knowledge to distinguish unbiased information from information designed to push a product or service. There are organizations such as the Health on the Net Foundation and the E-Health Code of Ethics that have established clear quality and ethical criteria, but very few resources exist for these organizations to use in policing the sites that claim to adhere to their criteria. The National Institutes of Health recently started a consumer web site (www.medlineplus.gov) that takes web sites that adhere to their stringent criteria and places them on their web site, thus ensuring proper compliance. Patient education from sources other than face-to-face contact with a physician should be seen as an adjunct to the medical practice of physicians, and not as competition. Information is a form of therapy, and should lead to better referrals, more realistic outcome expectations, better treatment compliance, and better outcomes. As long as patients are referred to information that is unbiased, well-written, and not proprietary, their decision making should be enhanced, bringing them into the decision-making loop. This allows the patient to be much more involved with his or her care. As the medical profession changes from a "gatekeeper" model to a patient choice model, patient education will take on a much greater role.

Bioethics↗
PubMed2001

Legal issues affecting medical clearance to resume play after mild brain injury.

Physician care of athletes suffering mild brain trauma involves medical and legal considerations. Physicians must adhere to their primary responsibility to protect their athletes' health by following good medical practice and not allowing nonmedical factors to unduly influence their judgment. Courts recognize the team physician's role as gatekeeper and generally defer to his or her medical judgment in return-to-play decisions.

Athletic Injuries↗