Efficacy of quality criteria to identify potentially harmful information: a cross-sectional survey of complementary and alternative medicine web sites.

BACKGROUND: Many users search the Internet for answers to health questions. Complementary and alternative medicine (CAM) is a particularly common search topic. Because many CAM therapies do not require a clinician's prescription, false or misleading CAM information may be more dangerous than information about traditional therapies. Many quality criteria have been suggested to filter out potentially harmful online health information. However, assessing the accuracy of CAM information is uniquely challenging since CAM is generally not supported by conventional literature. OBJECTIVE: The purpose of this study is to determine whether domain-independent technical quality criteria can identify potentially harmful online CAM content. METHODS: We analyzed 150 Web sites retrieved from a search for the three most popular herbs: ginseng, ginkgo and St. John's wort and their purported uses on the ten most commonly used search engines. The presence of technical quality criteria as well as potentially harmful statements (commissions) and vital information that should have been mentioned (omissions) was recorded. RESULTS: Thirty-eight sites (25%) contained statements that could lead to direct physical harm if acted upon. One hundred forty five sites (97%) had omitted information. We found no relationship between technical quality criteria and potentially harmful information. CONCLUSIONS: Current technical quality criteria do not identify potentially harmful CAM information online. Consumers should be warned to use other means of validation or to trust only known sites. Quality criteria that consider the uniqueness of CAM must be developed and validated.

Evaluating the prevalence, content and readability of complementary and alternative medicine (CAM) web pages on the internet.

Complementary and alternative medicine (CAM) use is growing rapidly. As CAM is relatively unregulated, it is important to evaluate the type and availability of CAM information. The goal of this study is to deter-mine the prevalence, content and readability of online CAM information based on searches for arthritis, diabetes and fibromyalgia using four common search engines. Fifty-eight of 599 web pages retrieved by a "condition search" (9.6%) were CAM-oriented. Of 216 CAM pages found by the "condition" and "condition + herbs" searches, 78% were authored by commercial organizations, whose pur-pose involved commerce 69% of the time and 52.3% had no references. Although 98% of the CAM information was intended for consumers, the mean read-ability was at grade level 11. We conclude that consumers searching the web for health information are likely to encounter consumer-oriented CAM advertising, which is difficult to read and is not supported by the conventional literature.

Quality of life, symptom experience, and use of complementary and alternative medicine among women with ovarian cancer

The objectives of this dissertation were to determine the quality of life in women with ovarian cancer and the association of their physical and emotional well-being with the number of symptoms, duration of symptoms, and the scores of common symptoms of ovarian cancer; to study the prevalence of complementary and alternative medicine techniques for symptom relief and its association with the number of symptoms, age, education, insurance, comorbidity, and satisfaction with medical care they received, and their pre-diagnostic experience of symptoms.^ This study was based on a secondary data analysis of a study of early detection of ovarian cancer. A sample of 139 women with ovarian cancer was recruited and was administered a questionnaire comprised of questions on their quality of life, their symptoms and what they did about the symptoms, whether they used any complementary and alternative medicine techniques, and other medical conditions they had. Out of this sample, 53 patients underwent in-depth interviews relating to their symptoms before the diagnosis and their experiences with the health care system leading to the ovarian cancer diagnosis. ^ In article #1, ovarian cancer patients were observed to have significantly poorer quality of life on all subscales and summary scores except pain, compared to that of the general population of US women. Physical well-being scores were negatively associated with the number of symptoms before diagnosis and a significant negative association of comorbidity index was observed with physical well-being. Higher education and increase in time since diagnosis was found to have better physical scores. Emotional well-being scores showed marginally significant associations with number of symptoms and bloating. ^ In article #2, a thematic content analysis of the ovarian cancer patients’ interviews revealed that on recognition of their symptoms women first assumed their symptoms to be a normal transient occurrence due to a pre-existing disease condition, or due to some other disease. A series of misattributions of their symptoms on their and their doctors’ part impacted their health care seeking.In article #3, a significantly greater likelihood of CAM use with an increase in the number of symptoms was observed.^ Based on the foregoing results, it is important to educate women on possible signs of ovarian cancer and also to educate doctors about the results of current research regarding ovarian cancer diagnosis. This will help to avoid a delay in getting a diagnosis and improve women’s quality of life. It emphasizes the diagnosis of ovarian cancer in earlier stages by more sensitive screening techniques. This study emphasizes the importance of consideration of comorbidity in any quality of life research. Additionally, educating women in the safe use of CAM techniques carries immense significance because the efficacy and safety of many of the currently advertized CAM products has not been scientifically validated. Further research is needed to confirm the findings of this study. ^

The impact of communication and cultural diversity in utilizing dental services among Saudi Arabian students in U.S.A.

Objectives: The purpose of this study is to understand the perceived effects of patient-dental staff communication and cultural diversity on the utilization of dental services in the U.S. by Saudi Arabian students who live in the U.S. and enrolled into the King Abdullah Scholarship program. Methods: The study design was an analytical cross-sectional study. Data for this study was obtained from the Saudi Dental Servicers Utilization Survey, a voluntary internet survey available online for one month through Facebook. Ordered logistic regression analyses and multinomial logistic regression analyses were used to measure the relationships between patient-dental staff communication and cultural diversity on the utilization of dental services. Results: Eight hundred and forty-seven responses were analyzed for this study. Overall, the majority of Saudi students reported having excellent communication experience with dental providers in the U.S. More than 58% of respondents reported at least one regular dental visit last year. Factors that influenced the use of regular dental care were: dentist's explanation of treatment plan, response of dental staff to patient's needs, respectful and polite dental staff, dental staff kindness, availability of up-to-date equipment, and overall communication with dentist. However, the utilization of emergency dental care was not associated with any measurement of patient-dental provider communication. Overall future utilization of dental care is associated with all aspects of patient-dental staff communication measured in this survey. Furthermore, more utilization of regular dental care was related to respondent's perception of the importance of trustworthiness dental staff and the importance of a dentist's reputation was only marginally associated. Respondent's perception of dentist's reputation was associated with more use of emergency dental services. Respondents are more likely to anticipate using dental care in the future if they perceived trustworthiness dental staff, and the dentist's reputation as influencing factors to their usage of dental services. Conclusions: Patient-dental staff communication was partially associated with utilization of regular dental care, not associated with utilization of emergency dental care, and broadly associated with anticipated future utilization of dental care. In addition, trustworthy dental staff, and a dentist's reputation were considered to be strong influencing factors towards utilization of dental services.^

Commentary on “Connecting the Dots: Families and Children with Special Needs in a Rural Community”

Starks et al. discuss an evaluation of educational initiatives to improve rural systems of care for children with special needs. Akin to the medical home neighborhood concept, building a holistic medical "village" entails improving collaboration, sharing accountability, and helping families to navigate the health care system. The article suggests that policymakers should include patient experiences of care in program evaluation, and they should build a community infrastructure for shared information and efficient communication.

Low-Income Fathers’ Barriers to Participation in Family and Parenting Programs

This exploratory study used semi-structured focus groups to examine: 1) where and from whom fathers obtain information about parenting; 2) the types of parenting services men are aware of, and their attitudes about participating in such services; and 3) fathers’ perceived norms about the acceptability and utility of various parenting practices. Low-income men (N = 17) were recruited from a human services agency in Detroit, Michigan. Four major themes emerged. First was the need for male-focused community resources for fathers. Second was that men were aware of and used positive disciplinary strategies. Third was emphasis on fathers’ positive and effective communication, with male children in particular. Finally, men suggested that constructive and concrete activities, such as engaging with children in activities or mentorship programs with other adult men in the community, were preferable to traditional parenting class such as those offered through Child Protective Services.

Cultural models of healing and health: An ethnography of professional nurses and healers

Cultural models of the domains healing and health are important in how people understand health and their behavior regarding it. The biomedicine model has been predominant in Western society. Recent popularity of holistic health and alternative healing modalities contrasts with the biomedical model and the assumptions upon which that model has been practiced. The holistic health movement characterizes an effort by health care providers and others such as nurses to expand the biomedical model and has often incorporated alternative modalities. This research described and compared the cultural models of healing of professional nurses and alternative healers. A group of nursing faculty who promote a holistic model were compared to a group of healers using healing touch. Ethnographic methods of participant observation, free listing and pile sort were used. Theoretical sampling in the free listings reached saturation at 18 in the group of nurses and 21 in the group of healers. Categories consistent for both groups emerged from the data. These were: physical, mental, attitude, relationships, spiritual, self management, and health seeking including biomedical and alternative resources. The healers had little differentiation between the concepts health and healing. The nurses, however, had more elements in self management for health and in health seeking for healing. This reflects the nurse's role in facilitating the shift in locus of responsibility between health and healing. The healers provided more specific information regarding alternative resources. The healer's conceptualization of health was embedded in a spiritual belief system and contrasted dramatically with that of biomedicine. The healer's models also contrasted with holistic health in the areas of holism, locus of responsibility, and dealing with uncertainty. The similarity between the groups and their dissimilarity to biomedicine suggest a larger cultural shift in beliefs regarding health care. ^

Patient satisfaction and nursing staff work satisfaction in an urban public teaching hospital

This study examined the level of patient satisfaction and nursing staff work satisfaction at an urban public hospital in the Southwestern United States. The primary objectives of this study were to determine: (1) the level of overall patient satisfaction and satisfaction with specific dimensions of hospital care; (2) the differences in patient satisfaction according to demographic characteristics (age, gender, ethnicity, and education completed) and predispositional factors (perceived health status, perceived level of pain, prior contact with the hospital, and hospital image) and the relative importance of each variable on patient satisfaction; (3) the level of overall work satisfaction and satisfaction with specific dimensions of work experienced by the medical/surgical nursing staff; (4) the differences in work satisfaction experienced by the nursing staff based on demographic variables (age, gender, ethnicity, and marital status) and professional factors (education completed, staff position, the number of years employed with the hospital, and number of years employed in nursing) and the relative importance of each variable on work satisfaction; and (5) to determine the effect of the nursing work milieu on patient and staff satisfaction.^ The study findings showed that patients experienced a moderate to low level of satisfaction with the dimensions of hospital care (admission process, daily care, information, nursing care, physician care, other hospital staff, living arrangements, and overall care). Of the eight dimensions of care, patients reported a relatively positive level of satisfaction (75 percent or better) with only one dimension: physician care. Ethnicity, perceived health status, and hospital image were significantly related to patient satisfaction. Hispanic patients, those who were in good health, and those who felt the hospital had a good image in their community were most satisfied with hospital care. Patients also reported areas of hospital care that needed the most improvement. Responses included: rude staff, better nursing care, and better communication.^ Findings from the nursing satisfaction survey indicated a low level of satisfaction with the dimensions of work (autonomy, pay, professional status, interaction, task requirements, and organizational policies). Only one dimension of work, professional status, received a mean satisfaction score in the positive range. Additionally, staff members were unanimously dissatisfied with their salaries. Frequently mentioned work-related problems reported by the staff included: staffing shortages, heavy patient loads. and excessive paperwork.^ The nursing milieu appeared to have had a significant effect on the satisfaction levels of patients nursing staff employees. The nursing staff were often short staffed, which increased the patient-to-nurse ratio. Consequently, patients did not receive the amount of attention and care they expected from the nursing staff. Crowded patient rooms allowed for little personal space and privacy. Dissatisfaction with living conditions served to influence patients' attitudes and satisfaction levels. These frustrations were often directed toward their primary caregivers, the nursing staff. Consequently, the nursing milieu appeared to directly affect and influence the satisfaction levels of both patients and staff. (Abstract shortened by UMI). ^

Tracking of plasma lipids and lipoproteins, within-person and year-to-year variability in plasma cholesterol levels among participants from age 8 to 18 in Project HeartBeat!

Coronary heart disease remains the leading cause of death in the United States and increased blood cholesterol level has been found to be a major risk factor with roots in childhood. Tracking of cholesterol, i.e., the tendency to maintain a particular cholesterol level relative to the rest of the population, and variability in blood lipid levels with increase in age have implications for cholesterol screening and assessment of lipid levels in children for possible prevention of further rise to prevent adulthood heart disease. In this study the pattern of change in plasma lipids, over time, and their tracking were investigated. Also, within-person variance and retest reliability defined as the square root of within-person variance for plasma total cholesterol, HDL-cholesterol, LDL-cholesterol, and triglycerides and their relation to age, sex and body mass index among participants from age 8 to 18 years were investigated. ^ In Project HeartBeat!, 678 healthy children aged 8, 11 and 14 years at baseline were enrolled and examined at 4-monthly intervals for up to 4 years. We examined the relationship between repeated observations by Pearson's correlations. Age- and sex-specific quintiles were calculated and the probability of participants to remain in the uppermost quintile of their respective distribution was evaluated with life table methods. Plasma total cholesterol, HDL-C and LDL-C at baseline were strongly and significantly correlated with measurements at subsequent visits across the sex and age groups. Plasma triglyceride at baseline was also significantly correlated with subsequent measurements but less strongly than was the case for other plasma lipids. The probability to remain in the upper quintile was also high (60 to 70%) for plasma total cholesterol, HDL-C and LDL-C. ^ We used a mixed longitudinal, or synthetic cohort design with continuous observations from age 8 to 18 years to estimate within person variance of plasma total cholesterol, HDL-C, LDL-C and triglycerides. A total of 5809 measurements were available for both cholesterol and triglycerides. A multilevel linear model was used. Within-person variance among repeated measures over up to four years of follow-up was estimated for total cholesterol, HDL-C, LDL-C and triglycerides separately. The relationship of within-person and inter-individual variance with age, sex, and body mass index was evaluated. Likelihood ratio tests were conducted by calculating the deviation of −2log (likelihood) within the basic model and alternative models. The square root of within-person variance provided the retest reliability (within person standard deviation) for plasma total cholesterol, HDL-C, LDL-C and triglycerides. We found 13.6 percent retest reliability for plasma cholesterol, 6.1 percent for HDL-cholesterol, 11.9 percent for LDL-cholesterol and 32.4 percent for triglycerides. Retest reliability of plasma lipids was significantly related with age and body mass index. It increased with increase in body mass index and age. These findings have implications for screening guidelines, as participants in the uppermost quintile tended to maintain their status in each of the age groups during a four-year follow-up. The magnitude of within-person variability of plasma lipids influences the ability to classify children into risk categories recommended by the National Cholesterol Education Program. ^

The identification and characterization of the Staphylococcus aureus microbial immunomodulatory molecules (MIMS) Map and Efb

Staphylococcus aureus is an opportunistic pathogen that is a major health threat in the clinical and community settings. An interesting hallmark of patients infected with S. aureus is that they do not usually develop a protective immune response and are susceptible to reinfection, in part because of the ability of S. aureus to modulate host immunity. The ability to evade host immune responses is a key contributor to the infection process and is critical in S. aureus survival and pathogenesis. This study investigates the immunomodulatory effects of two secreted proteins produced by S. aureus, the MHC class II analog protein (Map) and the extracellular fibrinogen-binding protein (Efb). Map has been demonstrated to modulate host immunity by interfering with T cell function. Map has been shown to significantly reduce T cell proliferative responses and significantly reduce delayed-type hypersensitivity responses to challenge antigen. In addition, the effects of Map on the infection process were tested in a mouse model of infection. Mice infected with Map− S. aureus (Map deficient strain) presented with significantly reduced levels of arthritis, osteomyelitis and abscess formation compared to mice infected with the wild-type Map+S. aureus strain suggesting that Map−S. aureus is much less virulent than Map+S. aureus. Furthermore, Map−S. aureus-infected nude mice developed arthritis and osteomyelitis to a severity similar to Map +S. aureus-infected controls, suggesting that T cells can affect disease outcome following S. aureus infection and Map may attenuate cellular immunity against S. aureus. The extracellular fibrinogen-binding protein (Efb) was identified when cultured S. aureus supernatants were probed with the complement component C3. The binding of C3 to Efb resulted in studies investigating the effects of Efb on complement activation. We have demonstrated that Efb can inhibit both the classical and alternative complement pathways. Moreover, we have shown that Efb can inhibit complement mediated opsonophagocytosis. Further studies have characterized the Efb-C3 binding interaction and localized the C3-binding domain to the C-terminal region of Efb. In addition, we demonstrate that Efb binds specifically to a region within the C3d fragment of C3. This study demonstrates that Map and Efb can interfere with both the acquired and innate host immune pathways and that these proteins contribute to the success of S. aureus in evading host immunity and in establishing disease. ^

Cultural competence in an HIV dedicated dental clinic: Application of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS)

This dissertation investigated perspectives on cultural competence among African-American women patients, staff, and the administrator of a dental clinic serving people living with HIV/AIDS; and evaluated the role of the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) in advancing the provision of culturally competent care in the clinic. ^ The study was qualitative with data collection via focus groups and individual interviews with a sample of African-American women patients, and individual interviews with a sample of staff and the clinic administrator. Transcripts were coded and themes identified using the software program ATLAS.ti. A cultural audit template was developed and applied to evaluate cultural competency. ^ Among attitudes and behaviors that contributed to the provision of culturally competent care at the clinic were respect and empathic communication. Formal cultural competency was not featured strongly in the methods by which the staff learned to work with diverse populations. Instead cultural competence among the staff was based on thoughtful hiring practices, natural aptitude and a climate that encouraged learning through informal sharing of experiences. The staff and administrator felt that an African-American dentist would be an asset in improving culturally competent care at the clinic. Previous research and national policy also promote the provider-patient racial/ethnic concordance to improve care. In this study, however, the patients were happy with the care provided regardless of the race/ethnicity of the staff, probably reflecting the well developed cultural competence skills of clinic staff overall. ^ The clinic administrator was unaware of the CLAS standards although the clinic was implicitly operated under their mandates. This occurred because the clinic is supported by federal funding and the CLAS standards were incorporated into the requirements. Incorporation into and monitoring of the CLAS standards in federally funded programs therefore appears to be an effective means for ensuring that they are implemented. ^ This study illustrates that cultural competence, though not universally understood, can be systematically investigated to identify what constitutes appropriate care and the factors that support or inhibit it. Among important elements of culturally competent care are respect and empathic communication. ^

African American female adolescents and antecedents of pregnancy

Although the pregnancy rate of teenage girls in the United States has decreased in recent years, African American female adolescents still have one of the highest teen pregnancy rates among girls in the United States. Previous studies report inconsistent relationships between adolescent pregnancy and self-esteem and parental communication, caring, and closeness. The purpose of this study was to assess relationships between pregnancy among African American female adolescents (7th to 12th grades) and self-esteem, communication levels and type of relationships with their parents. This study used data collected from The National Longitudinal Study of Adolescent Health (Add Health). Logistic regression analysis was used to determine if the independent variables of self-esteem, levels of parental caring and closeness and levels of communication with parents predicted the dependent variable of pregnancy. After controlling for age and levels of parental education, self-esteem was the only statistically significant variable that was associated with pregnancy. The findings of this study indicate that levels of self-esteem should be further investigated and that self-esteem may be an important factor when designing interventions to prevent adolescent pregnancy, particularly for African American females. ^

A process evaluation of a health literacy intervention targeting pediatric providers' communication skills at the Texas Children's Health Plan

Background. Health literacy is an important determinant for quality health care, and affects communication between patients and physicians. Poor communication may result in negative effects in health. Improved communication between patients and physicians could positively affect health outcomes. Communication skills are teachable.^ Objectives. (1) to evaluate the process involved in the design and implementation of a health literacy intervention targeting pediatric providers’ communication skills at the Texas Children’s Health Plan in Houston, Texas; and (2) to describe lessons learned from this process that may be used in future attempts to address the issue of health literacy and health communication. ^ Design/methods. The process evaluation of the implementation of a health literacy strategy at the Texas Children’s Health Plan (TCHP) consisted of a critical analysis of all documents and minutes from meetings of the team of investigators. It also involved a secondary analysis of data collected between December 2006 and June 2007. Descriptive statistics, paired t-test and Wilcoxon-signed-rank test were employed in analyzing the data. This information was complemented with a limited review of existing literature on communication skills training programs. ^ Results. The design of the educational intervention followed recommendations from experts in the field of health literacy. The delivery of the intervention was possible and benefited from existing resources and logistics within the TCHP. Very few targeted providers participated in two offerings of the workshop (6.6% and 1.7% respectively). After the educational intervention, providers showed increased knowledge of health literacy facts and its effects in health (p=0.001); increased awareness of the low health literacy problem (p=0.003); increased expectations for change in practice (p=0.002), and intent to use health literacy strategies for communication immediately following the intervention (p=0.001). Low participation indicated the need for further investigation of barriers to, and means for successful implementation of programs aimed to improving health communication. ^ Conclusions. A short, focused intervention utilizing health literacy strategies for communication appeared effective in increasing knowledge and intentions for change in a small group of pediatric providers. ^

Delays in diagnosis and referral and treatment for hematologic malignancies

The purpose of this thesis project was to identify factors that may contribute to a delay in the diagnosis, referral or treatment of the hematologic malignancies. This thesis is a secondary data analysis of both qualitative and quantitative data collected during a pilot study for a parent CDC study to determine factors related to time to diagnosis, referral, and treatment of chronic lymphocytic leukemia (CLL), chronic myelogenous leukemia (CML), multiple myeloma (MM), and myelodisplastic syndrome (MDS). To identify patterns for referral, as well as explore referral, treatment, and follow-up patterns, MDACC performed a pathways analysis, and conducted semi-structured interviews with hematologic cancer patients to help identify factors related to delays. Interviews were also conducted with primary care physicians and community hematologists/oncologists to help identify factors associated with optimal and sub-optimal patterns of diagnosis and referral. The results of these analyses suggest a set of factors that may be related to a fairly smooth and rapid trajectory to treatment, and factors that may be related to a slower, more disrupted trajectory. Factors that may be especially important to facilitating rapid treatment include the presence of cues to seek diagnosis in the patient's environment and the patient recognizing and acting upon these cues to seek immediate medical attention. Furthermore, providers who perform behaviors including recognizing cues as indicators of hematologic malignancies and conducting appropriate diagnostic testing effectively and efficiently indicate that these behaviors may also contribute to shorter times to diagnosis. In regards to referrals, direct and effective communication between providers and patients, as well between providers themselves helped facilitate speedier referrals. A patient's insurance status as well as the presence or absence of social support in his environment served as factors that may increase or decrease time to diagnosis, referral, and treatment for a hematologic malignancy. Further research is needed to define delay to diagnosis, referral and treatment in order to improve early diagnosis, referral, and treatment of hematologic malignancies.^

Policy analysis of Texas Senate Bill 532 and the regulation of nurse practitioners in the convenience care model

Background. Retail clinics, also called convenience care clinics, have become a rapidly growing trend since their initial development in 2000. These clinics are coupled within a larger retail operation and are generally located in "big-box" discount stores such as Wal-mart or Target, grocery stores such as Publix or H-E-B, or in retail pharmacies such as CVS or Walgreen's (Deloitte Center for Health Solutions, 2008). Care is typically provided by nurse practitioners. Research indicates that this new health care delivery system reduces cost, raises quality, and provides a means of access to the uninsured population (e.g., Deloitte Center for Health Solutions, 2008; Convenient Care Association, 2008a, 2008b, 2008c; Hansen-Turton, Miller, Nash, Ryan, Counts, 2007; Salinsky, 2009; Scott, 2006; Ahmed & Fincham, 2010). Some healthcare analysts even suggest that retail clinics offer a feasible solution to the shortage of primary care physicians facing the nation (AHRQ Health Care Innovations Exchange, 2010). ^ The development and performance of retail clinics is heavily dependent upon individual state policies regulating NPs. Texas currently has one of the most highly regulated practice environments for NPs (Stout & Elton, 2007; Hammonds, 2008). In September 2009, Texas passed Senate Bill 532 addressing the scope of practice of nurse practitioners in the convenience care model. In comparison to other states, this law still heavily regulates nurse practitioners. However, little research has been conducted to evaluate the impact of state laws regulating nurse practitioners on the development and performance of retail clinics. ^ Objectives. (1). To describe the potential impact that SB 532 has on retail clinic performance. (2). To discuss the effectiveness, efficiency, and equity of the convenience care model. (3). To describe possible alternatives to Texas' nurse practitioner scope of practice guidelines as delineated in Texas Senate Bill 532. (4). To describe the type of nurse practitioner state regulation (i.e. independent, light, moderate, or heavy) that best promotes the convenience care model. ^ Methods. State regulations governing nurse practitioners can be characterized as independent, light, moderate, and heavy. Four state NP regulatory types and retail clinic performance were compared and contrasted to that of Texas regulations using Dunn and Aday's theoretical models for conducting policy analysis and evaluating healthcare systems. Criteria for measurement included effectiveness, efficiency, and equity. Comparison states were Arizona (Independent), Minnesota (Light), Massachusetts (Moderate), and Florida (Heavy). ^ Results. A comparative states analysis of Texas SB 532 and alternative NP scope of practice guidelines among the four states: Arizona, Florida, Massachusetts, and Minnesota, indicated that SB 532 has minimal potential to affect the shortage of primary care providers in the state. Although SB 532 may increase the number of NPs a physician may supervise, NPs are still heavily restricted in their scope of practice and limited in their ability to act as primary care providers. Arizona's example of independent NP practice provided the best alternative to affect the shortage of PCPs in Texas as evidenced by a lower uninsured rate and less ED visits per 1,000 population. A survey of comparison states suggests that retail clinics thrive in states that more heavily restrict NP scope of practice as opposed to those that are more permissive, with the exception of Arizona. An analysis of effectiveness, efficiency, and equity of the convenience care model indicates that retail clinics perform well in the areas of effectiveness and efficiency; but, fall short in the area of equity. ^ Conclusion. Texas Senate 532 represents an incremental step towards addressing the problem of a shortage of PCPs in the state. A comparative policy analysis of the other four states with varying degrees of NP scope of practice indicate that a more aggressive policy allowing for independent NP practice will be needed to achieve positive changes in health outcomes. Retail clinics pose a temporary solution to the shortage of PCPs and will need to expand their locations to poorer regions and incorporate some chronic care to obtain measurable health outcomes. ^