The impact of nurse practitioner services on cost, quality of care, satisfaction and wait times in the emergency department: A systematic review

Aims To provide the best available evidence to determine the impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department for adult patients. Background The delivery of quality care in the emergency department is one of the most important service indicators in health delivery. Increasing service pressures in the emergency department have resulted in the adoption of service innovation models: the most common and rapidly expanding of these is emergency nurse practitioner services. The rapid uptake of emergency nurse practitioner service in Australia has outpaced the capacity to evaluate this service model in terms of outcomes related to safety and quality of patient care. Previous research is now outdated and not commensurate with the changing domain of delivering emergency care with nurse practitioner services. Data A comprehensive search of four electronic databases from 2006-­‐2013 was conducted to identify research evaluating nurse practitioner service impact in the emergency department. English language articles were sought using MEDLINE, CINAHL, Embase and Cochrane and included two previous systematic reviews completed five and seven years ago. Methods A three step approach was used. Following a comprehensive search, two reviewers assessed identified studies against the inclusion criteria. From the original 1013 studies, 14 papers were retained for critical appraisal on methodological quality by two independent reviewers and data extracted using standardised tools. Results Narrative synthesis was conducted to summarise and report the findings as insufficient data was available for meta-­‐analysis of results. This systematic review has shown that emergency nurse practitioner service has a positive impact on quality of care, patient satisfaction and waiting times. There was insufficient evidence to draw conclusions regarding impact on costs. Conclusion Synthesis of the available research attempts to provide an evidence base for emergency nurse practitioner service to guide healthcare leaders, policy makers and clinicians in reforming emergency department service provision. The findings suggest that further quality research is required for comparative measures of clinical and service effectiveness of emergency nurse practitioner service. In the context of increased health service demand and the need to provide timely and effective care to patients, such measures will assist in delivering quality patient care.

Reconceptualizing digital service quality : a call-to-action and research approach

The nature of services and service delivery has been changing rapidly since the 1980’s when many seminal papers in services research were published. Services are increasingly digital, or have a digital component. Further, a large and heterogeneous literature, with competing and overlapping definitions, many of which are dated and inappropriate to contemporary digital services offerings is impeding progress in digital services research. In this conceptual paper, we offer a critical review of some existing conceptualizations of services and digital services. We argue that an inductive approach to understanding cognition about digital services is required to develop a taxonomy of digital services and a new vocabulary. We argue that this is a pre-requisite to theorizing about digital services, including understanding quality drivers, value propositions, and quality determinants for different digital service types. We propose a research approach for reconceptualising digital services and service quality, and outline methodological approaches and outcomes.

Service quality and performance measurement : evidence from the Indian Water Sector

The conventional measures of benchmarking focus mainly on the water produced or water delivered, and ignore the service quality, and as a result the 'low-cost and low-quality' utilities are rated as efficient units. Benchmarking must credit utilities for improvements in service delivery. This study measures the performance of 20 urban water utilities using data from an Asian Development Bank survey of Indian water utilities in 2005. It applies data envelopment analysis to measure the performance of utilities. The results reveal that incorporation of a quality dimension into the analysis significantly increases the average performance of utilities. The difference between conventional quantity-based measures and quality-adjusted estimates implies that there are significant opportunity costs of maintaining the quality of services in water delivery.

Just what the doctor ordered? Investigating the impact of health service quality on consumer misbehaviour

The growth in demand and expenditure currently being experienced in the Australian health sector is also accompanied by a rise in dysfunctional customer behaviour, such as verbal abuse and physical violence, perpetrated against health service providers. While service failure and poor recovery are known to trigger consumer misbehaviour, this study investigates whether lower than expected perceived service quality generates cognitive and emotional appraisals that trigger two common forms of misbehaviour: refusal to participate and verbal abuse. Data were collected using a 2 × 2 between-subjects experiment administered via online written survey and analysed using path modelling. The findings indicate that perceptions of service encounter quality have an indirect effect on whether consumers refuse to participate in the service and/or verbally abuse the service provider through the mediating effect of anger.

An acute cough-specific quality of life questionnaire for children: Development and validation

Background Patient-relevant outcome measures are essential for high-quality clinical research, and quality-of-life (QoL) tools are the current standard. Currently, there is no validated children's acute cough-specific QoL questionnaire. Objective The objective of this study was to develop and validate the Parent-proxy Children's Acute Cough-specific QoL Questionnaire (PAC-QoL). Methods Using focus groups, a 48-item PAC-QoL questionnaire was developed and later reduced to 16 items by using the clinical impact method. Parents of children with a current acute cough (<2 weeks) at enrollment completed 2 validated cough score measures, the preliminary 48-item PAC-QoL, and 3 other questionnaires (the State Trait Anxiety Inventory [STAI], the Short-Form 8-item 24-hour recall Health Survey [SF-8], and the Depression, Anxiety, and Stress 21-item Scale [DASS21]). All measures were repeated on days 3 and 14. Results The median age of the 155 children enrolled was 2.3 years (interquartile range, 1.3-4.6). Median cough duration at enrollment was 3 days (interquartile range, 2-5). The reduced 16-item scale had high internal consistency (Cronbach α = 0.95). Evidence for repeatability and criterion validity was shown by significant correlations between the domains and total PAC-QoL scores and the SF-8 (r = −0.36 and −0.51), STAI (r = −0.27 and −0.39), and DASS21 (r = −0.32 and −0.41) scales on days 0 and 3, respectively. The final PAC-QoL questionnaire was sensitive to change over time, with changes significantly relating to changes in cough score measures (P < .001). Conclusion The 16-item PAC-QoL is a reliable and valid outcome measure that assesses QoL related to childhood acute cough at a given time point and reflects changes in acute cough-specific QoL over time.

A hybrid quality function deployment and cybernetic analytic network process model for project manager selection

Identifying appropriate decision criteria and making optimal decisions in a structured way is a complex process. This paper presents an approach for doing this in the form of a hybrid Quality Function Deployment (QFD) and Cybernetic Analytic Network Process (CANP) model for project manager selection. This involves the use of QFD to translate the owner's project management expectations into selection criteria and the CANP to weight the expectations and selection criteria. The supermatrix approach then prioritises the candidates with respect to the overall decision-making goal. A case study is used to demonstrate the use of the model in selecting a renovation project manager. This involves the development of 18 selection criteria in response to the owner's three main expectations of time, cost and quality.

Parent feeding interactions and practices during childhood cancer treatment: A qualitative investigation

In the general population it is evident that parent feeding practices can directly shape a child’s life long dietary intake. Young children undergoing childhood cancer treatment may experience feeding difficulties and limited food intake, due to the inherent side effects of their anti-cancer treatment. What is not clear is how these treatment side effects are influencing the parent–child feeding relationship during anti-cancer treatment. This retrospective qualitative study collected telephone based interview data from 38 parents of childhood cancer patients who had recently completed cancer treatment (child’s mean age: 6.98 years). Parents described a range of treatment side effects that impacted on their child’s ability to eat, often resulting in weight loss. Sixty-one percent of parents (n = 23) reported high levels of stress in regard to their child’s eating and weight loss during treatment. Parents reported stress, feelings of helplessness, and conflict and/or tension between parent and the child during feeding/eating interactions. Parents described using both positive and negative feeding practices, such as: pressuring their child to eat, threatening the insertion of a nasogastric feeding tube, encouraging the child to eat and providing home cooked meals in hospital. Results indicated that parent stress may lead to the use of coping strategies such as positive or negative feeding practices to entice their child to eat during cancer treatment. Future research is recommended to determine the implication of parent feeding practice on the long term diet quality and food preferences of childhood cancer survivors.

Transit route occupancy load factor and passenger average travel time for quality of service assessment

This paper investigates quality of service (QoS) and resource productivity implications of transit route passenger loading and travel time. It highlights the value of occupancy load factor as a direct passenger comfort QoS measure. Automatic Fare Collection data for a premium radial bus route in Brisbane, Australia, is used to investigate time series correlation between occupancy load factor and passenger average travel time. Correlation is strong across the entire span of service in both directions. Passengers tend to be making longer, peak direction commuter trips under significantly less comfortable conditions than off-peak. The Transit Capacity and Quality of Service Manual uses segment based load factor as a measure of onboard loading comfort QoS. This paper provides additional insight into QoS by relating the two route based dimensions of occupancy load factor and passenger average travel time together in a two dimensional format, both from the passenger’s and operator’s perspectives. Future research will apply Value of Time to QoS measurement, reflecting perceived passenger comfort through crowding and average time spent onboard. This would also assist in transit service quality econometric modeling. The methodology can be readily applied in a practical setting where AFC data for fixed scheduled routes is available. The study outcomes also provide valuable research and development directions.

Transit route occupancy load factor and passenger average travel time for quality of service assessment

This presentation investigates quality of service (QoS) and resource productivity implications of transit route passenger loading and travel time. It highlights the value of occupancy load factor as a direct passenger comfort QoS measure. Automatic Fare Collection data for a premium radial bus route in Brisbane, Australia, is used to investigate time series correlation between occupancy load factor and passenger average travel time. Correlation is strong across the entire span of service in both directions. Passengers tend to be making longer, peak direction commuter trips under significantly less comfortable conditions than off-peak. The Transit Capacity and Quality of Service Manual uses segment based load factor as a measure of onboard loading comfort QoS. This paper provides additional insight into QoS by relating the two route based dimensions of occupancy load factor and passenger average travel time together in a two dimensional format, both from the passenger’s and operator’s perspectives. Future research will apply Value of Time to QoS measurement, reflecting perceived passenger comfort through crowding and average time spent onboard. This would also assist in transit service quality econometric modeling. The methodology can be readily applied in a practical setting where AFC data for fixed scheduled routes is available. The study outcomes also provide valuable research and development directions.

Weight and weight change following breast cancer : evidence from a prospective, population-based, breast cancer cohort study

Background: While weight gain following breast cancer is considered common, results supporting these findings are dated. This work describes changes in body weight following breast cancer over 72 months, compares weight with normative data and explores whether weight changes over time are associated with personal, diagnostic, treatment or behavioral characteristics. Methods: A population-based sample of 287 Australian women diagnosed with early-stage invasive breast cancer was assessed prospectively at six, 12, 18 and 72 months post-surgery. Weight was clinically measured and linear mixed models were used to explore associations between weight and participant characteristics (collected via self-administered questionnaire). Those with BMI changes of one or more units were considered to have experienced clinically significant changes in weight. Results: More than half (57%) of participants were overweight or obese at 6 months post-surgery, and by 72 months post-surgery 68% of women were overweight or obese. Among those who gained more weight than age-matched norms, clinically significant weight gain between 6 and 18 months and 6 and 72 months post-surgery was observed in 24% and 39% of participants, respectively (median [range] weight gain: 3.9kg [2.0-11.3kg] and 5.2kg [0.6-28.7], respectively). Clinically-significant weight losses were observed in up to 24% of the sample (median [range] weight loss between 6 and 72 months post-surgery: -6.4kg [-1.9--24.6kg]). More extensive lymph node removal, being treated on the non-dominant side, receiving radiation therapy and lower physical activity levels at 6 months was associated with higher body weights post-breast cancer (group differences >3kg; all p<0.05). Conclusions: While average weight gain among breast cancer survivors in the long-term is small, subgroups of women experience greater gains linked with adverse health and above that experienced by age-matched counterparts. Weight change post-breast cancer is a contemporary public health issue and the integration of healthy weight education and support into standard breast cancer care has potential to significantly improve the length and quality of cancer survivorship.

Feasibility and acceptability of wrist actigraph in assessing sleep quality and sleep quantity: A home-based pilot study in healthy volunteers

Purpose This study aimed to determine the feasibility and acceptability of actigraphy to monitor sleep quality and quantity in healthy self-rated good sleeper adults at home-based settings. Method Sixteen healthy volunteers (age > 18) were invited to participate. Each participant was provided with a wrist actigraph device to be worn for 24-hour/day for seven consecutive days to monitor their sleep-wake patterns. Actigraphy data were downloaded using-proprietary software to generate an individual-sleep report. Participants also completed a set of self-reported Health Related Quality of Life (HRQOL) using WHO (five) Well Being Index (WBI) questionnaires. Results Actigraphy was well accepted by all participants. Only 43.8% of the participants achieved normal total sleep time (TST) and 62.5% had a mean sleep efficiency value below the normal range. Despite a reduced quality of sleep among the participants, the self-reported HRQOL scores produced by the WHO-5 WBI showed a “fair” to “good” among the participants. Conclusions To maintain healthy well-being, it is vital to have efficient and quality sleep. Insufficient and poor sleep may contribute to various health problems and hazardous outcomes. People often believe they have normal and efficient sleep, not realising they may be developing poor sleep habits. This study found that actigraphy can be easily utilized to monitor sleep-wake patterns at home-based settings. We proposed that actigraphy could be adapted for use in the primary care settings (e.g. community pharmacy) to improve the sleep health management in the community.

A Mouse Model of Early-Onset Renal Failure Due to a Xanthine Dehydrogenase Nonsense Mutation

Chronic kidney disease (CKD) is characterized by renal fibrosis that can lead to end-stage renal failure, and studies have supported a strong genetic influence on the risk of developing CKD. However, investigations of the underlying molecular mechanisms are hampered by the lack of suitable hereditary models in animals. We therefore sought to establish hereditary mouse models for CKD and renal fibrosis by investigating mice treated with the chemical mutagen N-ethyl-N-nitrosourea, and identified a mouse with autosomal recessive renal failure, designated RENF. Three-week old RENF mice were smaller than their littermates, whereas at birth they had been of similar size. RENF mice, at 4-weeks of age, had elevated concentrations of plasma urea and creatinine, indicating renal failure, which was associated with small and irregularly shaped kidneys. Genetic studies using DNA from 10 affected mice and 91 single nucleotide polymorphisms mapped the Renf locus to a 5.8Mbp region on chromosome 17E1.3. DNA sequencing of the xanthine dehydrogenase (Xdh) gene revealed a nonsense mutation at codon 26 that co-segregated with affected RENF mice. The Xdh mutation resulted in loss of hepatic XDH and renal Cyclooxygenase-2 (COX-2) expression. XDH mutations in man cause xanthinuria with undetectable plasma uric acid levels and three RENF mice had plasma uric acid levels below the limit of detection. Histological analysis of RENF kidney sections revealed abnormal arrangement of glomeruli, intratubular casts, cellular infiltration in the interstitial space, and interstitial fibrosis. TUNEL analysis of RENF kidney sections showed extensive apoptosis predominantly affecting the tubules. Thus, we have established a mouse model for autosomal recessive early-onset renal failure due to a nonsense mutation in Xdh that is a model for xanthinuria in man. This mouse model could help to increase our understanding of the molecular mechanisms associated with renal fibrosis and the specific roles of XDH and uric acid. © 2012 Piret et al.

Significant deterioration in nanomechanical quality occurs through incomplete extrafibrillar mineralization in rachitic bone: Evidence from in-situ synchrotron X-ray scattering and backscattered electron imaging

Bone diseases such as rickets and osteoporosis cause significant reduction in bone quantity and quality, which leads to mechanical abnormalities. However, the precise ultrastructural mechanism by which altered bone quality affects mechanical properties is not clearly understood. Here we demonstrate the functional link between altered bone quality (reduced mineralization) and abnormal fibrillar-level mechanics using a novel, real-time synchrotron X-ray nanomechanical imaging method to study a mouse model with rickets due to reduced extrafibrillar mineralization. A previously unreported N-ethyl-N-nitrosourea (ENU) mouse model for hypophosphatemic rickets (Hpr), as a result of missense Trp314Arg mutation of the phosphate regulating gene with homologies to endopeptidase on the X chromosome (Phex) and with features consistent with X-linked hypophosphatemic rickets (XLHR) in man, was investigated using in situ synchrotron small angle X-ray scattering to measure real-time changes in axial periodicity of the nanoscale mineralized fibrils in bone during tensile loading. These determine nanomechanical parameters including fibril elastic modulus and maximum fibril strain. Mineral content was estimated using backscattered electron imaging. A significant reduction of effective fibril modulus and enhancement of maximum fibril strain was found in Hpr mice. Effective fibril modulus and maximum fibril strain in the elastic region increased consistently with age in Hpr and wild-type mice. However, the mean mineral content was ∼21% lower in Hpr mice and was more heterogeneous in its distribution. Our results are consistent with a nanostructural mechanism in which incompletely mineralized fibrils show greater extensibility and lower stiffness, leading to macroscopic outcomes such as greater bone flexibility. Our study demonstrates the value of in situ X-ray nanomechanical imaging in linking the alterations in bone nanostructure to nanoscale mechanical deterioration in a metabolic bone disease. Copyright

Assessment of transit quality of service with occupancy load factor and passenger travel time measures

This paper investigates quality of service (QoS) and resource productivity implications of transit route passenger loading and travel time. It highlights the value of occupancy load factor as a direct passenger comfort QoS measure. Automatic Fare Collection data for a premium radial bus route in Brisbane, Australia, is used to investigate time series correlation between occupancy load factor and passenger average travel time. Correlation is strong across the entire span of service in both directions. Passengers tend to be making longer, peak direction commuter trips under significantly less comfortable conditions than off-peak. The Transit Capacity and Quality of Service Manual uses segment based load factor as a measure of onboard loading comfort QoS. This paper provides additional insight into QoS by relating the two route based dimensions of occupancy load factor and passenger average travel time together in a two dimensional format, both from the passenger’s and operator’s perspectives. Future research will apply Value of Time to QoS measurement, reflecting perceived passenger comfort through crowding and average time spent onboard. This would also assist in transit service quality econometric modeling. The methodology can be readily applied in a practical setting where AFC data for fixed scheduled routes is available. The study outcomes also provide valuable research and development directions.