A. David Mangelsdorff

Common symptoms in ambulatory care: Incidence, evaluation, therapy, and outcome

PURPOSE AND PATIENTS AND METHODS Many symptoms in outpatient practice are poorly understood. To determine the incidence, diagnostic findings, and outcome of 14 common symptoms, we reviewed the records of 1,000 patients followed by house staff in an internal medicine clinic over a three-year period. The following data were abstracted for each symptom: patient characteristics, symptom duration, evaluation, suspected etiology of the symptom, treatment prescribed, and outcome of the symptom. Cost estimates for diagnostic evaluation were calculated by means of the schedule of prevailing rates for Texas employed by the Civilian Health and Medical Program of the Uniformed Services for physician reimbursement. RESULTS A total of 567 new complaints of chest pain, fatigue, dizziness, headache, edema, back pain, dyspnea, insomnia, abdominal pain, numbness, impotence, weight loss, cough, and constipation were noted, with 38 percent of the patients reporting at least one symptom. Although diagnostic testing was performed in more than two thirds of the cases, an organic etiology was demonstrated in only 16 percent. The cost of discovering an organic diagnosis was high, particularly for certain symptoms, such as headache (

Patient Satisfaction Questionnaire

7,778) and back pain (

Lessons learned and forgotten: The need for prevention and mental health interventions in disaster preparedness.

7,263). Treatment was provided for only 55 percent of the symptoms and was often ineffective. Where outcome was documented, 164 (53 percent) of 307 symptoms improved. Three favorable prognostic factors were an organic etiology (p = 0.006), a symptom duration of less than four months (p = 0.009), and a history of two or fewer symptoms (p = 0.001). CONCLUSION The classification, evaluation, and management of common symptoms need to be refined. Diagnostic strategies emphasizing organic causes may be inadequate.

Building from within: identifying leadership competencies for future navy nurse executives.

A Patient Satisfaction Questionnaire was developed using factor analytic techniques. The 19-item questionnaire uses a five-point Likert scale, has a coefficient alpha of .972, and consists of three factors. Validity was assessed using correlations with specific criterion items.

Executive Competencies of Nurses in the Veterans Health Administration

Human beings have been subjected to the effects of both natural and man-made disasters for centuries. How humans have coped with catastrophes has been recorded through history. This review proceeds from an examination of the efforts in legislation and disaster research through a brief history of war-time experiences and treatment of combat stress reactions. As warfare changed, so did the ability of soldiers to cope. Likewise, treatment interventions to restore soldiers to effectiveness evolved with the changes in warfare. The treatment principles developed in war and the concepts recognized from the stress literature can be integrated to understand how the treatment interventions work. Examples of the delivery of mental health services are reviewed. The lesson learned during war were often forgotten after the war. It was not until the 1970s that the need for prevention and planning for mental health interventions during and after disasters was legislated. Research efforts are now focusing on planning, implementing interventions, and following survivors/victims for posttraumatic effects.

Patient satisfaction in military medicine: model refinement and assessment of Department of Defense effects.

The purpose of this research is to forecast the relevant competencies and important skills, knowledge, and abilities (SKAs) for Navy nurse executives in the next 5 to 10 years. Using 2 iterations, Wave I and Wave II, of the Delphi technique, 6 competency domains emerged: business management, executive leadership, professional development, global awareness and interoperability, communications, and personnel management. For Wave I, 38 (19%) of 200 nurses identified what they considered to be the 5 most relevant competencies and skills, knowledge, and abilities. Reviewed by an expert panel, the results were used to develop the Wave II questionnaire to determine SKA importance ratings. Using the same respondent pool, 93 (47%) of the 200 nurses rated 100 SKA items. The top 3 rated SKAs were as follows: “Maintains the utmost integrity: has the trust of all members inside and outside of the organization,” “Communication skills: ability to communicate in all forms,” and “Ability to lead and mentor junior personnel.” The Cronbach coefficient α was used to assess internal consistency. All results were above the recommended and acceptable level of .70. The results will provide the foundation for a leadership education continuum enabling the critical link among educational offerings, role-based experiences, timely mentoring, and specific career milestones.

Patient Satisfaction in Military Medicine: Model Refinement and Assessment of Continuity of Care Effects

This study identifies competencies and accompanying skills, knowledge, and abilities (SKAs) required by the Veterans Health Administration (VHA) nurse executives. Using the Delphi decision-making method, 144 VHA directors of nursing identified five top competencies necessary for nurse executives. An expert panel sorted competencies into the eight core domains of the VHA high-performance development model. Next, nurse executives rated SKAs by using a 7-point importance scale. Response rates were 34% and 48.2% for Delphi rounds 1 and 2, respectively. Round 1 generated 245 unique nurse executive competencies. In round 2, the highest rated SKAs involved ethical conduct, decision-making, abilities to continuously learn and lead, staffing, and conflict-resolution skills. Competency list outcomes are expected to be useful for executive self-assessment, professional development, and identification of continuing education needs. Specific SKAs can provide a means for development of job requirements and career performance criteria.

Patients' satisfaction with an Army family practice setting.

A sample of 154,893 patient responses from the Customer Satisfaction Survey database was drawn for 1999 to 2000. Average patient satisfaction levels consistently appeared to be high (between 6, very satisfied, and 7, completely satisfied, on the 7-point rating scale). Hierarchical regression results essentially replicated all three major constructs of an earlier theoretical attitude model. Refinements included adjustment and addition of categorical age and military beneficiary status for individual patient variables, addition of two beliefs about the care itself, substitution of waiting time variables, and addition of reason for visit situation variables. Hypothesis test results indicated that patient satisfaction constructs were homogeneous across the uniformed services for patients from all service branches, both enrolled and not enrolled within TRICARE regions, and among branch of service medical center, hospital, and clinic facilities. The final attitude model coefficient of multiple determinations obtained was R2 = 0.701 [F(25,154,867) = 14,539.33, p < 0.0001].

Patient-Centered Medical Home Implementation Effects on Emergency Room Utilization: A Case Study

The Military Health System (MHS) identified patient-centered care and satisfied beneficiaries as main objectives in their 2006 Strategic Plan. The objective of this study was to expand upon the previous MHS model to determine predictors of patient satisfaction behaviors based upon associated attitudes and beliefs in addition to determining the predictive qualities presented by continuity of care. A sample of 90,318 patient responses from 2002 to 2004 was drawn from the Customer Satisfaction Survey database. Hierarchical multiple linear regression analyses were conducted to assess the uniquely predictive effects of the independent variables on the outcome variable. Results indicated the constructs from previous studies of satisfaction within the MHS using an attitude model were consistent when tested in a behavioral model. Hypothesis tests also indicated continuity of care demonstrated uniquely predictive qualities suggesting inclusion in the model. The final satisfaction with visit model yielded F(29, 90, 288) = 7062.37, p < 0.01 with R2 = 0.694.

Personality and attitudes: A re-emphasis upon the cognitive component

Using the Patient Satisfaction Questionnaire to assess consumer satisfaction, patients were very satisfied with the quality of the health care received. The care received by patients who visited the family practice clinics was rated as significantly more satisfying than the care received at either the non-family practice clinics or at the General Medical clinic.