- Email: [email protected]
Clinical Outcomes of a Pediatric Asthma Outreach Program
The Journal for Nurse Practitioners xxx (xxxx) xxx
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Brief Report
Clinical Outcomes of a Pediatric Asthma Outreach Program Martha K. Swartz, PhD, CPNP-PC, Mikki Meadows-Oliver, PhD, CPNP-PC a b s t r a c t Keywords: asthma community home-based outcomes pediatric
This clinical pilot research project evaluated clinical outcomes for asthmatic children enrolled in a home-based Asthma Outreach Program. Through a quasi-experimental single-group intervention design, a convenience sample of 37 children, ranging in age from 6 to 16 years, was used for this study. At 6 months after enrollment in the Asthma Outreach Program, patients reported significantly fewer nighttime symptoms and primary care provider visits compared with the 6 months preceding enrollment. Patients also reported significantly fewer hospital and intensive care unit admissions and courses of oral steroids. Adherence to therapy and asthma control was also significantly improved. © 2019 Elsevier Inc. All rights reserved.
Pediatric asthma remains one of the most common and serious chronic illnesses among children, often necessitating a broad, multidisciplinary approach to care for effective management. This clinical research pilot project was conducted to demonstrate the effectiveness of a home-based care delivery model on clinical outcomes and health care utilization patterns for children with asthma. The practice model consisted of intensive home-based interventions provided by nurse practitioners (NPs) to asthmatic children enrolled in an Asthma Outreach Program (AOP), an initiative sponsored by the pediatric asthma care team at Yale New Haven Children's Hospital, New Haven, Connecticut. To assess outcomes, through medical record reviews, changes in clinical markers were evaluated, including the number of missed school days and courses of oral steroid therapy as well as clinicians’ ratings of adherence to recommended therapy, the level of asthma severity, and level of symptom control. Health care utilization patterns, such as the number of emergency department (ED) visits, primary care provider (PCP) visits, and hospital admissions, were also examined.
outreach, psychosocial assessments, environmental assessments with interventions aimed at minimizing a child’s exposure to asthma triggers, and interventions to promote adherence to asthma management recommendations. The AOP incorporates the clinical guidelines recommended by the National Heart, Lung and Blood Institute,1 which identify 4 components of effective asthma management: (1) the use of objective measures of lung function to assess the severity of asthma and to monitor the course of therapy; (2) environmental control measures to avoid or eliminate factors that precipitate asthma symptoms or exacerbations; (3) comprehensive pharmacologic therapy; and (4) patient education that fosters a partnership among the patient and his or her family and clinicians. Specifically, the NPs from the AOP worked with the children and families in the home to review symptom assessment, conduct physical assessments, review medication delivery, identify and mitigate the effects of asthma triggers, and coordinate planning and information sharing with the specialty care team and PCP. Methods
Background Design Previous research has demonstrated that although evidencebased guidelines for asthma care exist,1 nonadherence among children to recommendations and medication use is a complex process, based on illness perceptions, family beliefs and routines, and social determinants of health such as poverty and access to resources.2 To address these factors, the AOP was developed to provide multidisciplinary, comprehensive services to children and families affected by asthma and who need a higher level of care than can be obtained through their primary and specialty care provider visits. The initiative provides intensive education and https://doi.org/10.1016/j.nurpra.2019.01.012 1555-4155/© 2019 Elsevier Inc. All rights reserved.
A quasi-experimental single-group intervention design was used to examine the effect of enrollment in the AOP on standard clinical outcomes and health care utilization patterns. Sample A convenience sample of 37 English-speaking children with a known diagnosis of chronic asthma who had been enrolled in the AOP was used for this study. Referral criteria to the AOP included
e2
M.K. Swartz, M. Meadows-Oliver / The Journal for Nurse Practitioners xxx (xxxx) xxx
those children with mild, moderate, or persistent asthma who had demonstrated a poor understanding of disease/medications/selfmanagement, had reported or documented nonadherence to a medical regimen, or had reported or documented obstacles to adherence, such as lack of transportation or housing problems. The children ranged in ages from 6 to 16 years at the time of enrollment in the AOP. Complete medical records for 28 of the 37 children in the initial sample, were available for data analysis. Informed consent was obtained from the families, and the study was approved by the investigators’ associated Institutional Review Board at Yale University. Procedures The investigators conducted a retrospective medical record review to determine the child’s health status as reflected in the pediatric respiratory specialty clinic record for 6 months before and then 6 months after enrollment in the AOP. The results of various clinical measures were documented, including nighttime frequency of symptoms, clinicians’ judgment of the child’s adherence to therapy, usual and best peak flow measurements, whether the child participated in regular exercise, and whether the child required preexercise therapy. AOP data before and after enrollment were also obtained for the number of missed school days due to asthma and the number of visits to the PCP and ED, hospitalizations, intensive care unit (ICU) admissions, and intubations within the 2 time periods. Medications prescribed for the child, including quick-relief, inhaled controllers, oral controllers, nasal preparations, antihistamines, and antibiotics, were noted for the 2 periods before and after AOP enrollment. Finally, according to the medical records, it was noted whether positive environmental changes had been made in the home since enrollment in the AOP, whether there had been changes in the child’s respiratory diagnosis (asthma, cough-variant asthma, exercise-induced asthma, or viral-induced wheezing), the severity of the condition (intermittent, mild persistent, moderate persistent, severe persistent), the level of control (poor, fair, good or excellent), and whether any other diagnoses (seasonal or chronic rhinitis, acute or chronic sinusitis, gastroesophageal reflux disease, chronic otitis media, or upper airway obstruction) had been made for the child. In addition to the record reviews, the investigators met several times with the NPs of the AOP to corroborate their interventions by reviewing cases and discussing the home-based interventions, educational approaches, and any additional referrals made for the families. Data Analysis Data analysis was conducted using SPSS 19.0 software (IBM, Armonk, NY). Descriptive statistics were determined for each variable. The single-group intervention design meant each patient served as his or her own control. For the first and primary aim, the paired-samples t test was used to compare scores on the continuous variables of interest between the 6 months before enrollment in the AOP and the 6 months after enrollment: the frequency of nighttime symptoms, number of missed school days, visits to the PCP and ED, the number of courses of oral steroid therapy, and the number of hospitalizations, ICU admissions, and intubations. The Wilcoxon signed ranks test was used to compare the scores before and after AOP enrollment on the ordinal variables of adherence to therapy, level of asthma severity, and level of control.
Table 1 Paired Samples t Test Results Paired Variables
t Test
df
P Value
Nighttime symptom frequency Missed school days Primary care provider visits Emergency department visits Courses of oral steroids Hospitalizations Intensive care unit admissions Intubations
3.966 1.928 2.179 1.638 3.750 4.399 3.077 1.445
19 15 14 25 18 26 25 24
.001a .073 .047a .114 .001a <.001a .005a .161
a
Statistically significant at P < .05 (2-tailed).
Results The study used a convenience sample of 37 English-speaking children with a known diagnosis of persistent asthma and who had also been referred to the AOP because of concerns about adherence according to the referral criteria. The children were an average age of 9.1 years (range, 6-16 years) at the time of enrollment in the AOP. Of the 37 children in the initial sample, complete medical records for 28 were available for data analysis. Of the 28, 57% were boys, 48% identified as black or African American, 35% identified as white, and 21% as Hispanic or Latino. Several pediatric clinical outcomes were significantly improved for participants in the AOP. At 6 months after enrollment in the AOP, patients reported significantly fewer nighttime symptoms and PCP visits compared with the 6 months preceding enrollment. Patients also reported significantly fewer courses of oral steroids and hospital and ICU admissions. Adherence to therapy and asthma control, as documented in the medical record by respiratory specialty clinicians, was significantly improved. Although not a significant result, enrollees experienced 4 fewer missed school days in the months after enrollment in the AOP. These results are presented in Tables 1 and 2.
Discussion This pilot study revealed that several pediatric clinical outcomes were significantly improved for participants in the AOP. At 6 months after enrollment in the AOP, patients reported significantly fewer nighttime symptoms and PCP visits compared with the 6 months preceding enrollment. Patients also reported significantly fewer hospital and ICU admissions and courses of oral steroids. Adherence to therapy and asthma control, as documented in the medical record, was significantly improved. Thus, this intervention also helped to decrease health care costs associated with the acute management of asthma in the hospital setting and visits to the PCP. Using a patient-centered, home-based approach for each patient and his or her family, the NPs ensured that each patient had an asthma action plan, used the asthma medication delivery devices correctly, and was aware of their asthma triggers. The NPs from the AOP also worked closely with school nurses to ensure that they were adhering to the child’s treatment recommendations as indicated on the asthma action plan. In addition, the NPs worked closely with the local health department to obtain pest control items and air filters for families enrolled in the AOP. Having NPs in the home setting, where most asthma management takes place, provides an excellent opportunity to expand patient education beyond the health care provider’s office. Conducting home visits allows the practitioner a chance to see what triggers are present in the home and what environmental modifications are needed. Home visits conducted by NPs can assist with tailoring asthma-related services to the individual client’s needs. In
M.K. Swartz, M. Meadows-Oliver / The Journal for Nurse Practitioners xxx (xxxx) xxx Table 2 Wilcoxon Test Results for Ordinal Ranked Paired Variables Paired Variables
z Score
P Value
Adherence to therapy Asthma severity Level of control
e3.272 e1.698 e4.132
.001a .090 <.001a
a
Statistically significant at P < .05 (asymptotic 2-tailed).
addition, the NPs may help to coordinate asthma care among multiple caregivers for the child. These findings are consistent with clinical recommendations put forth by others based on qualitative and quantitative research findings. Bellin et al,3 through a grounded theory approach, reinforced the need for a comprehensive approach to improving asthma control among high-risk populations, with attention to child and family self-management, environmental control, housing resources, and psychosocial support. Similarly, McClure et al4 described positive clinical outcomes and improved patient and family management of asthma as a result of a home visiting program through an academic practice partnership. The major limitation to this study is that the investigators did not have the resources over an extended time period to conduct home visits before and after AOP enrollment. Thus, the primary data source for this project was medical record data review. Medical record data were incomplete for a number of children because the family was lost to follow-up. Also, specific interventions by the AOP were not entered into the child’s electronic medical record but were documented in shadow files maintained by the AOP. Conclusion The NPs working with the families who participated in the AOP were able to help children and families experience significantly improved outcomes on a variety of important clinical factors. Specifically, improvements were reflected by decreases in the number of visits to the child’s PCP, the number of hospitalizations,
e3
the number of courses of oral steroids, and the extent of nighttime symptoms. Respiratory specialty clinicians also rated significant improvements in adherence to therapy and overall level of control. Because of the small sample size, this study should be replicated using a larger sample, possibly in a randomized-controlled trial. In the larger study, patient satisfaction with a homevisiting program could be studied. It would also be beneficial to examine outcomes related to the child’s quality of life, which has become a commonly used outcome measure when assessing the impact of asthma on a child’s daily activities.5 Overall, this project validated the work of an existing interdisciplinary health care and outreach program for high-risk children with asthma in an urban setting. References 1. National Heart, Lung, and Blood Institute. Putting guideline priorities into action. https://www.nhlbi.nih.gov/health-pro/resources/lung/naci/discover/ priorities.htm. January 2013. Accessed October 30, 2018. 2. Klok T, Kaptein A, Brand P. Non-adherence in children with asthma reviewed: the need for improvement of asthma care and medical education. Pediatr Allergy Immunol. 2015;26(3):197-205. https://doi.org/10.1111/pai.12362. 3. Bellin MH, Newsome A, Land C, et al. Asthma home management in the innercity: what can the children teach us? J Pediatr Health Care. 2017;31(3):362-371. https://doi.org/10.1016/j.pedhc.2016.11.002. 4. McClure N, Lutenbacher M, O’Kelley E, Dietrich M. Enhancing pediatric asthma care and nursing education through an academic practice partnership. J Pediatr Nurs. 2017;36:64-69. https://doi.org/10.1016/j.pedn.2017.04.008. 5. Miadich SA, Everhart RS, Borschuk AP, Winter MA, Fiese BH. Quality of life in children with asthma: a developmental perspective. J Pediatr Psychol. 2015;40(7):672-679. https://doi.org/10.1093/jpepsy/jsv002.
Martha K. Swartz, PhD, CPNP-PC, FAAN, is professor and chair, Primary Care Division, Yale University School of Nursing, West Haven, CT. She can be reached at martha. [email protected]. Mikki Meadows-Oliver, PhD, CPNP-PC, FAAN, is an associate professor, Quinnipiac University, Hamden, CT. This project was partially supported by the Beatrice RenfieldeYale School of Nursing Clinical Research Initiatives Fund. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.
Contents lists available at ScienceDirect
The Journal for Nurse Practitioners journal homepage: www.npjournal.org
Brief Report
Clinical Outcomes of a Pediatric Asthma Outreach Program Martha K. Swartz, PhD, CPNP-PC, Mikki Meadows-Oliver, PhD, CPNP-PC a b s t r a c t Keywords: asthma community home-based outcomes pediatric
This clinical pilot research project evaluated clinical outcomes for asthmatic children enrolled in a home-based Asthma Outreach Program. Through a quasi-experimental single-group intervention design, a convenience sample of 37 children, ranging in age from 6 to 16 years, was used for this study. At 6 months after enrollment in the Asthma Outreach Program, patients reported significantly fewer nighttime symptoms and primary care provider visits compared with the 6 months preceding enrollment. Patients also reported significantly fewer hospital and intensive care unit admissions and courses of oral steroids. Adherence to therapy and asthma control was also significantly improved. © 2019 Elsevier Inc. All rights reserved.
Pediatric asthma remains one of the most common and serious chronic illnesses among children, often necessitating a broad, multidisciplinary approach to care for effective management. This clinical research pilot project was conducted to demonstrate the effectiveness of a home-based care delivery model on clinical outcomes and health care utilization patterns for children with asthma. The practice model consisted of intensive home-based interventions provided by nurse practitioners (NPs) to asthmatic children enrolled in an Asthma Outreach Program (AOP), an initiative sponsored by the pediatric asthma care team at Yale New Haven Children's Hospital, New Haven, Connecticut. To assess outcomes, through medical record reviews, changes in clinical markers were evaluated, including the number of missed school days and courses of oral steroid therapy as well as clinicians’ ratings of adherence to recommended therapy, the level of asthma severity, and level of symptom control. Health care utilization patterns, such as the number of emergency department (ED) visits, primary care provider (PCP) visits, and hospital admissions, were also examined.
outreach, psychosocial assessments, environmental assessments with interventions aimed at minimizing a child’s exposure to asthma triggers, and interventions to promote adherence to asthma management recommendations. The AOP incorporates the clinical guidelines recommended by the National Heart, Lung and Blood Institute,1 which identify 4 components of effective asthma management: (1) the use of objective measures of lung function to assess the severity of asthma and to monitor the course of therapy; (2) environmental control measures to avoid or eliminate factors that precipitate asthma symptoms or exacerbations; (3) comprehensive pharmacologic therapy; and (4) patient education that fosters a partnership among the patient and his or her family and clinicians. Specifically, the NPs from the AOP worked with the children and families in the home to review symptom assessment, conduct physical assessments, review medication delivery, identify and mitigate the effects of asthma triggers, and coordinate planning and information sharing with the specialty care team and PCP. Methods
Background Design Previous research has demonstrated that although evidencebased guidelines for asthma care exist,1 nonadherence among children to recommendations and medication use is a complex process, based on illness perceptions, family beliefs and routines, and social determinants of health such as poverty and access to resources.2 To address these factors, the AOP was developed to provide multidisciplinary, comprehensive services to children and families affected by asthma and who need a higher level of care than can be obtained through their primary and specialty care provider visits. The initiative provides intensive education and https://doi.org/10.1016/j.nurpra.2019.01.012 1555-4155/© 2019 Elsevier Inc. All rights reserved.
A quasi-experimental single-group intervention design was used to examine the effect of enrollment in the AOP on standard clinical outcomes and health care utilization patterns. Sample A convenience sample of 37 English-speaking children with a known diagnosis of chronic asthma who had been enrolled in the AOP was used for this study. Referral criteria to the AOP included
e2
M.K. Swartz, M. Meadows-Oliver / The Journal for Nurse Practitioners xxx (xxxx) xxx
those children with mild, moderate, or persistent asthma who had demonstrated a poor understanding of disease/medications/selfmanagement, had reported or documented nonadherence to a medical regimen, or had reported or documented obstacles to adherence, such as lack of transportation or housing problems. The children ranged in ages from 6 to 16 years at the time of enrollment in the AOP. Complete medical records for 28 of the 37 children in the initial sample, were available for data analysis. Informed consent was obtained from the families, and the study was approved by the investigators’ associated Institutional Review Board at Yale University. Procedures The investigators conducted a retrospective medical record review to determine the child’s health status as reflected in the pediatric respiratory specialty clinic record for 6 months before and then 6 months after enrollment in the AOP. The results of various clinical measures were documented, including nighttime frequency of symptoms, clinicians’ judgment of the child’s adherence to therapy, usual and best peak flow measurements, whether the child participated in regular exercise, and whether the child required preexercise therapy. AOP data before and after enrollment were also obtained for the number of missed school days due to asthma and the number of visits to the PCP and ED, hospitalizations, intensive care unit (ICU) admissions, and intubations within the 2 time periods. Medications prescribed for the child, including quick-relief, inhaled controllers, oral controllers, nasal preparations, antihistamines, and antibiotics, were noted for the 2 periods before and after AOP enrollment. Finally, according to the medical records, it was noted whether positive environmental changes had been made in the home since enrollment in the AOP, whether there had been changes in the child’s respiratory diagnosis (asthma, cough-variant asthma, exercise-induced asthma, or viral-induced wheezing), the severity of the condition (intermittent, mild persistent, moderate persistent, severe persistent), the level of control (poor, fair, good or excellent), and whether any other diagnoses (seasonal or chronic rhinitis, acute or chronic sinusitis, gastroesophageal reflux disease, chronic otitis media, or upper airway obstruction) had been made for the child. In addition to the record reviews, the investigators met several times with the NPs of the AOP to corroborate their interventions by reviewing cases and discussing the home-based interventions, educational approaches, and any additional referrals made for the families. Data Analysis Data analysis was conducted using SPSS 19.0 software (IBM, Armonk, NY). Descriptive statistics were determined for each variable. The single-group intervention design meant each patient served as his or her own control. For the first and primary aim, the paired-samples t test was used to compare scores on the continuous variables of interest between the 6 months before enrollment in the AOP and the 6 months after enrollment: the frequency of nighttime symptoms, number of missed school days, visits to the PCP and ED, the number of courses of oral steroid therapy, and the number of hospitalizations, ICU admissions, and intubations. The Wilcoxon signed ranks test was used to compare the scores before and after AOP enrollment on the ordinal variables of adherence to therapy, level of asthma severity, and level of control.
Table 1 Paired Samples t Test Results Paired Variables
t Test
df
P Value
Nighttime symptom frequency Missed school days Primary care provider visits Emergency department visits Courses of oral steroids Hospitalizations Intensive care unit admissions Intubations
3.966 1.928 2.179 1.638 3.750 4.399 3.077 1.445
19 15 14 25 18 26 25 24
.001a .073 .047a .114 .001a <.001a .005a .161
a
Statistically significant at P < .05 (2-tailed).
Results The study used a convenience sample of 37 English-speaking children with a known diagnosis of persistent asthma and who had also been referred to the AOP because of concerns about adherence according to the referral criteria. The children were an average age of 9.1 years (range, 6-16 years) at the time of enrollment in the AOP. Of the 37 children in the initial sample, complete medical records for 28 were available for data analysis. Of the 28, 57% were boys, 48% identified as black or African American, 35% identified as white, and 21% as Hispanic or Latino. Several pediatric clinical outcomes were significantly improved for participants in the AOP. At 6 months after enrollment in the AOP, patients reported significantly fewer nighttime symptoms and PCP visits compared with the 6 months preceding enrollment. Patients also reported significantly fewer courses of oral steroids and hospital and ICU admissions. Adherence to therapy and asthma control, as documented in the medical record by respiratory specialty clinicians, was significantly improved. Although not a significant result, enrollees experienced 4 fewer missed school days in the months after enrollment in the AOP. These results are presented in Tables 1 and 2.
Discussion This pilot study revealed that several pediatric clinical outcomes were significantly improved for participants in the AOP. At 6 months after enrollment in the AOP, patients reported significantly fewer nighttime symptoms and PCP visits compared with the 6 months preceding enrollment. Patients also reported significantly fewer hospital and ICU admissions and courses of oral steroids. Adherence to therapy and asthma control, as documented in the medical record, was significantly improved. Thus, this intervention also helped to decrease health care costs associated with the acute management of asthma in the hospital setting and visits to the PCP. Using a patient-centered, home-based approach for each patient and his or her family, the NPs ensured that each patient had an asthma action plan, used the asthma medication delivery devices correctly, and was aware of their asthma triggers. The NPs from the AOP also worked closely with school nurses to ensure that they were adhering to the child’s treatment recommendations as indicated on the asthma action plan. In addition, the NPs worked closely with the local health department to obtain pest control items and air filters for families enrolled in the AOP. Having NPs in the home setting, where most asthma management takes place, provides an excellent opportunity to expand patient education beyond the health care provider’s office. Conducting home visits allows the practitioner a chance to see what triggers are present in the home and what environmental modifications are needed. Home visits conducted by NPs can assist with tailoring asthma-related services to the individual client’s needs. In
M.K. Swartz, M. Meadows-Oliver / The Journal for Nurse Practitioners xxx (xxxx) xxx Table 2 Wilcoxon Test Results for Ordinal Ranked Paired Variables Paired Variables
z Score
P Value
Adherence to therapy Asthma severity Level of control
e3.272 e1.698 e4.132
.001a .090 <.001a
a
Statistically significant at P < .05 (asymptotic 2-tailed).
addition, the NPs may help to coordinate asthma care among multiple caregivers for the child. These findings are consistent with clinical recommendations put forth by others based on qualitative and quantitative research findings. Bellin et al,3 through a grounded theory approach, reinforced the need for a comprehensive approach to improving asthma control among high-risk populations, with attention to child and family self-management, environmental control, housing resources, and psychosocial support. Similarly, McClure et al4 described positive clinical outcomes and improved patient and family management of asthma as a result of a home visiting program through an academic practice partnership. The major limitation to this study is that the investigators did not have the resources over an extended time period to conduct home visits before and after AOP enrollment. Thus, the primary data source for this project was medical record data review. Medical record data were incomplete for a number of children because the family was lost to follow-up. Also, specific interventions by the AOP were not entered into the child’s electronic medical record but were documented in shadow files maintained by the AOP. Conclusion The NPs working with the families who participated in the AOP were able to help children and families experience significantly improved outcomes on a variety of important clinical factors. Specifically, improvements were reflected by decreases in the number of visits to the child’s PCP, the number of hospitalizations,
e3
the number of courses of oral steroids, and the extent of nighttime symptoms. Respiratory specialty clinicians also rated significant improvements in adherence to therapy and overall level of control. Because of the small sample size, this study should be replicated using a larger sample, possibly in a randomized-controlled trial. In the larger study, patient satisfaction with a homevisiting program could be studied. It would also be beneficial to examine outcomes related to the child’s quality of life, which has become a commonly used outcome measure when assessing the impact of asthma on a child’s daily activities.5 Overall, this project validated the work of an existing interdisciplinary health care and outreach program for high-risk children with asthma in an urban setting. References 1. National Heart, Lung, and Blood Institute. Putting guideline priorities into action. https://www.nhlbi.nih.gov/health-pro/resources/lung/naci/discover/ priorities.htm. January 2013. Accessed October 30, 2018. 2. Klok T, Kaptein A, Brand P. Non-adherence in children with asthma reviewed: the need for improvement of asthma care and medical education. Pediatr Allergy Immunol. 2015;26(3):197-205. https://doi.org/10.1111/pai.12362. 3. Bellin MH, Newsome A, Land C, et al. Asthma home management in the innercity: what can the children teach us? J Pediatr Health Care. 2017;31(3):362-371. https://doi.org/10.1016/j.pedhc.2016.11.002. 4. McClure N, Lutenbacher M, O’Kelley E, Dietrich M. Enhancing pediatric asthma care and nursing education through an academic practice partnership. J Pediatr Nurs. 2017;36:64-69. https://doi.org/10.1016/j.pedn.2017.04.008. 5. Miadich SA, Everhart RS, Borschuk AP, Winter MA, Fiese BH. Quality of life in children with asthma: a developmental perspective. J Pediatr Psychol. 2015;40(7):672-679. https://doi.org/10.1093/jpepsy/jsv002.
Martha K. Swartz, PhD, CPNP-PC, FAAN, is professor and chair, Primary Care Division, Yale University School of Nursing, West Haven, CT. She can be reached at martha. [email protected]. Mikki Meadows-Oliver, PhD, CPNP-PC, FAAN, is an associate professor, Quinnipiac University, Hamden, CT. This project was partially supported by the Beatrice RenfieldeYale School of Nursing Clinical Research Initiatives Fund. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.