T • W • O

Identifying Outcomes

Frances Munet-Vilaró and Sonda M. Oppewal

Nurses have a long and rich history of wanting to do the most good for the most people. Today, it is imperative that advanced practice registered nurses (APRNs) continue that tradition by delivering care that improves the health of populations. By assessing community, aggregate, family, and individual factors and conditions that have a strong influence on health, APRNs are better equipped to deliver effective and evidence-based care. Identifying population-level healthcare needs and healthcare disparities can help to improve equality in health outcomes at all levels.

The American Association of Colleges of Nursing’s (AACN) definition of advanced practice nursing includes the importance of identifying and managing health outcomes at the population level (AACN, 2004). In 2006, the AACN specified that graduates of doctorate in nursing practice (DNP) programs have competency in meeting “the needs of a panel of patients, a target population, a set of populations, or a broad community” (p. 10). A core component of DNP education is clinical prevention (health promotion and disease prevention at individual and family levels) and population health (focus of care at aggregate and community levels and examination of environmental, occupational, cultural, and socioeconomic dimensions of health) (AACN, 2006; Allan et al., 2004). Regardless of whether DNP graduates practice with a focus on clinical prevention or population health, the ability to define, identify, and analyze outcomes is imperative for improving the health status of individuals and populations (AACN, 2006; Department of Health and Human Services [HHS], 2014).

The purpose of this chapter is to explore how APRNs can identify determinants of health and define population outcomes. Specific examples from various settings, such as acute care, subacute care, long-term care, and the community, are given, as well as outcomes related to health disparities and national health objectives. The identification of factors that lead to certain outcomes or key health indicators is an essential first step in planning effective interventions and is used later in the evaluation process. By comparing outcomes, APRNs can advocate needed resources and changes in policies at local, regional, state, and/or national levels by identifying areas for improvement in practice, by comparing evidence needed for effective practice, and by better understanding health disparities. Health disparities are not fair or socially just. They are preventable. They reflect an uneven distribution of social determinants and environmental, economic, and political factors. Health disparities can be defined as the differences identified in incidence or prevalence of illness, health outcomes, mortality, injury, or violence, or differences in opportunities to reach optimal health equity due to disadvantages based on ethnicity, socioeconomic status, gender, sexual orientation, geographic location, or other reasons (Meyer, Yoon, & Kaufmann, 2013). APRNs play an important collaborative role with professionals from other disciplines and community members to work toward eliminating health disparities.

Health outcomes are usually defined as an end result that follows some kind of healthcare provision, treatment, or intervention and may describe a patient’s condition or health status (Kleinpell, 2007; Kleinpell & Gawlinski, 2005; Oermann & Floyd, 2002). Using a population perspective, a health outcome can be measured using public health metrics, such as mortality and life expectancies, that are used to demonstrate the contribution of certain diseases to population mortality. New trends also emphasize the inclusion of qualitative metrics that are based on subjective data, such as self-perceived health status, psychological state, or ability to function, that can illustrate collective social well-being (Boothe, Sinha, Bohm, & Yoon, 2013; Parrish, 2010). Evaluating population-based outcomes and their impact on population health involves looking at what to assess and how to assess it. Establishing the impact takes time and requires using an evaluation that is able to link interventions to long-term outcomes such as reducing disease morbidity and mortality at the population level. APRNs can best determine the effectiveness of an intervention and long-term impact by focusing on an accurate assessment and interpretation of data that are generated or collected using individual, population, and community health indicators (Anderson & McFarlane, 2010). Classifying and categorizing outcomes can be done in several ways. For example, outcomes may be classified into categories by describing “who” is measured, such as individuals, aggregates, communities, populations, or organizations; by identifying the “what” or the type of outcome, such as care, patient, or performance-related outcomes (Kleinpell, 2001, 2003; Kleinpell & Gawlinski, 2005); and by determining the “when” or the time it takes to achieve an outcome, such as short-term, intermediate, or long-term outcomes (Rich, 2009). Table 2.1 provides examples of various outcomes using these different classification systems. Each outcome type is listed by beneficiary and has a related example of the type of measurement, the potential outcome, and the potential impact of that outcome. Many of them also include a time frame for the outcome.

TABLE 2.1    •    Examples of Outcomes, Measures, and Impact by Beneficiary, Type, and Time Frame

One of the early frameworks that nurses used to categorize outcomes and that is still used today is based on four dimensions that correspond to points on a compass. Known as the Clinical Value Compass, the four dimensions or categories are clinical (e.g., disease-specific outcomes), functional (e.g., ability to participate in activities of daily living, overall well-being), cost (e.g., number of encounters, length of stay, finances, and resources), and satisfaction (e.g., patient and family satisfaction) (Nelson, Batalden, Plume, & Mohr, 1996; Nelson et al., 1996; Oermann & Floyd, 2002).

Vital statistics provide important outcome measures that APRNs can monitor and compare over time and analyze by demographic variables to detect such things as health disparities. In the United States, the National Center for Health Statistics (NCHS) collects the official records of births, deaths, marriages, divorces, fetal deaths, and induced terminations of pregnancies from state and local health departments (Aschengrau & Seage, 2013). Personnel from local health departments review the data from death certificates, including demographic data, looking at the immediate cause of death and any contributing factors of death, and recording multiple causes of death. Local data are sent to a state office for collation and then sent to the NCHS, which provides this information to the public on its website (http://www.cdc.gov/nchs) and in an annual publication, Vital Statistics of the United States (Friis & Sellers, 2009). APRNs can access national and global health statistics from multiple agency sources, including government agencies, to identify health trends and patterns (Partners, 2014). However, due to the lack of agencies and/or resources in certain populations or regions, health information might not be available or might be limited in scope.

In the early 1980s, personal health behaviors became a key source of information that paved the way to understanding risk behavior and its impact on morbidity and mortality. The Behavioral Risk Factor Surveillance System (BRFSS; http://www.cdc.gov/brfss/), a system established to collect state-level data, also allows states to estimate prevalence for regions that can be compared across states (CDC, 2013). The data generated by this surveillance system have been pivotal in assessing and addressing emerging health issues and other urgent health concerns. Examples of emergent health issues include man-made and natural disasters, vaccine shortages (e.g., influenza, MMR [measles, mumps, and rubella]), and increasing incidence of preventable diseases such as influenza, measles, and so on. The use of cell phone technology has expanded BRFSS’s accessibility to populations that were not accessible by prior data-collection methods and has increased representation and generated higher quality information.

Social determinants of health and inequalities data are areas that APRNs can also use to inform and guide their practice to develop socioculturally appropriate interventions. Social determinants that lead to health inequalities are recognized situations related to where people are born, grow up, work, live, and the systems of care available to them to deal with illness and disease (HHS, 2014; World Health Organization [WHO], 2008). To expand our understanding of the association between social determinants and health outcomes, theoretical models are being tested to examine the interaction between the social environment (physical, chemical, biological, behavioral, and/or life events) and genetics and its application to population health (Reiss, Leve, & Neiderhiser, 2013). For example, in some immigrant populations, factors such as fear of deportation (immigration stress), limited financial resources, perceived racism, and limited social capital and political power can have a negative impact on their health (Agency for Healthcare Research and Quality [AHRQ], 2013). These social conditions may limit a person’s ability to be employed, access healthcare services, and receive timely quality care. This is globally evident with ethnic populations of immigrants that have an expired visa, or an unauthorized or undocumented status (United Nations, 2008). A problem encountered repeatedly by healthcare practitioners is the lack of available census data and statistics about key issues in the health and healthcare of people with unauthorized status. APRNs may be able to access health information needed by working together with other sectors outside of health, such as housing, labor, education, and community-based or faith-based organizations that offer services to immigrant communities. This involves the collection, documentation, and use of data that can be used to monitor health inequalities in exposures, opportunities, and outcomes. Examples of social determinants that are related to health inequalities include poverty, educational level, racism, income, and poor housing. These inequalities can lead to poor quality of life, poor self-rated health, multiple morbidities, limited access to resources, premature death, and unnecessary risks and vulnerabilities.

APRNs are often responsible for reviewing morbidity and mortality trends and can use this information to advocate improved health policy and additional resources, or to develop innovative interventions. For example, if an APRN notices an increase over the past year of closed head injuries in teenagers because of motor vehicle crashes (MVCs), she or he can design a plan of care that targets risk factors associated with teenage driving and MVCs. The APRN may review emergency department (ED) records of teenage drivers in car accidents to assess factors such as seat belt usage, distracted driving behaviors, blood alcohol levels, drug screening, prior ED visits for accidents, and age at the time of the incident. The APRN may also approach high schools in order to collaborate with school nurses for the purpose of developing peer training programs. High school students could be trained as peer teachers to encourage classmates to wear seat belts, avoid entering a car with an impaired driver, say no to drug and alcohol usage, and eliminate use of electronic devices, such as cellular phones, while driving. Nurse educators could encourage teachers to integrate the importance of wearing seat belts in their classes by discussing the potential for traumatic brain injury in MVCs, especially in unrestrained drivers. Review of the biomechanics of accidents in a physics or science class might provide teens with knowledge that is both beneficial and relatable and may reinforce the dangers of unrestrained driving. Additionally, the use of web-based simulation education regarding the use of cellular phones and its similarities to driving under the influence could also be integrated into this type of curriculum (Buckley, Chapman, & Sheehan, 2014). Finally, school nurses could lead spot surveillance of seat belt usage as teenagers enter and exit school parking lots. After developing and implementing appropriate interventions, the APRN should reassess (e.g., in 6 months, 1 year) seat belt usage and repeat ED visits for motor vehicle accidents, and revaluate whether there have been any positive drug screens or elevated blood alcohol concentrations in relation to MVCs. Reevaluation of these data can help to identify those interventions that work. It may also lead to changes in school policy and/or curriculum to modify behavior, thereby reducing MVCs among teens. Statewide policy changes that the APRN can advocate include legislation whereby any detectable blood alcohol concentration is illegal, more stringent and enforced driving fines for unrestrained passengers and drivers, and graduated driving license laws that increase driving supervision time and/or call for limits with driving past 9 p.m. until the driver is of a certain age (Mirman et al., 2014). Although this is just one example of how surveillance by an APRN could lead to the development of interventions to improve outcomes in a population, one can see the potential value of community collaboration and the use of such outcomes to identify a need for change and to evaluate the impact of interventions.

Morbidity data are less standardized in general than mortality data because state legislatures and local agencies decide what illnesses must be reported to the Centers for Disease Control and Prevention (CDC). Reporting of cases of infectious diseases and related conditions is an important step in controlling and preventing the spread of communicable disease. The list of reportable or notifiable diseases can change as some diseases may become eradicated and other, new diseases and conditions are discovered or felt to be preventable and/or treatable. The accuracy of morbidity data is diminished if healthcare providers fail to report a disease or illness for fear of invading the individual’s privacy or because they may not be aware of reporting requirements or because the healthcare provider misdiagnosed the illness (Macha & McDonough, 2012). It is imperative that APRNs educate themselves on the reporting requirements in their state. Certain diseases with easy and/or rapid transmission are more likely to harm a population’s health. Infectious or communicable diseases, such as certain sexually transmitted infections (STIs) or other diseases such as rabies, rubella, plague, measles, tetanus, and food-borne illnesses, can lead to more significant morbidity and mortality if not reported promptly (Friis & Sellers, 2009). Provisional weekly updates of reportable diseases can be accessed electronically through the Morbidity and Mortality Weekly Report (MMWR), published by the CDC.

The NCHS collects data in four main ways, each method yielding information that is readily available on the Internet for use by healthcare providers, researchers, and educators. First, the National Vital Statistics System provides information about state and local vital statistics, including teen birth rates, prenatal care, birth weights, risk factors related to poor pregnancy outcomes, infant mortality rates, life expectancy, and leading causes of death (www.cdc.gov/nchs/nvss.htm). Second, the National Health Interview Survey (NHIS) provides health information from household interviews conducted by Census Bureau personnel. Data on health status, access to care, use of health services, immunization rates, risk factors and health-related behaviors, and health insurance coverage can be gleaned from the NHISs (www.cdc.gov/nchs/nhis.htm). The National Health and Nutrition Examination Survey (NHANES) is the third major survey source conducted through mobile examination centers held at randomly selected sites throughout the United States. Data are obtained from interviews (e.g., environmental exposures, risk factors), and additional data are collected from physical examinations, diagnostic procedures, laboratory tests, and indicators of growth and development, including weight, diet, and nutrition (www.cdc.gov/nchs/nhanes.htm). The fourth major method of data collection from the NCHS is the National Healthcare Surveys (www.cdc.gov/nchs/dhcs.htm). Information is obtained using a collection of surveys targeted toward various healthcare providers and healthcare settings. A variety of data are collected, including information regarding patient safety and safety indicators, clinical management of specific health conditions, disparities in healthcare utilization and health quality, and information about the use of healthcare innovations. All these survey data are collated and made available for policy makers, practitioners, and researchers. Each of the four key methods conducted by the NCHS provides useful outcome information. Additional surveys can be found on the CDC’s website (www.cdc.gov/nchs), but the aforementioned surveys are most useful for analyzing outcomes data.

How do APRNs decide what outcomes to study? There are a variety of outcomes that exist in relation to cost, clinical and functional data, social conditions, and community and environmental indicators. Often, outcomes will reflect the desired or anticipated effects of the intervention that are related to the problem or population of interest. Another way to select outcomes is by reviewing available epidemiological and social epidemiological data for outcomes that may be of interest or relevance to an APRN’s intervention or study (Krieger, 2001; Macha & McDonough, 2012; Minkler & Wallerstein, 2007). Using the earlier example of designing an intervention to reduce teenage MVCs, an APRN could seek out epidemiological data from the National Annenberg Risk Survey of Youth conducted by researchers at the University of Pennsylvania. This survey includes teen attitudinal risk factors and protective factors, and identifies several factors that could potentially be identified as outcomes of interest for an APRN working on reducing teen MVCs (www.annenbergpublicpolicycenter.org/teen-drivers-need-better-training-to-counter-inexperience-and-inattention). In addition, an Internet application known as the Community Health Status Indicators (CHSI) uses the Geographic Information Systems (GIS) Analyst, a user-friendly web-based data source, to map geographical areas, which allow the visualization, exploration, and understanding of the indicators (wwwn.cdc.gov/CommunityHealth/homepage.aspx?j=1). Indicators can be mapped and compared visually with those in other areas, counties, and neighboring counties (Heitgerd et al., 2008).

There is no shortage of usable resources for identifying outcomes. The Guide to Community Preventive Services is a helpful resource (available at www.thecommunityguide.org). It provides evidence-based recommendations about public health interventions, analyses from systematic reviews to determine program and policy effectiveness, information on whether an intervention might work in one’s community, and information about the intervention’s costs and benefits. APRNs can review topics or areas of focus and strategies that work for various outcomes. For example, systematic reviews are available on adolescent health. By spending a few minutes exploring the website, one can find numerous outcomes such as number of self-reported risk behaviors, including engagement in any sexual activity, frequency of sexual activity, number of partners, frequency of unprotected sexual activity, use of protection to prevent STIs, use of protection to prevent pregnancy, and self-reported or clinically documented STIs. Other community-guide topics are listed in Table 2.2 with example outcomes adapted from the website.

Outcome monitoring has become increasingly important over the years and, in many cases, is a necessity to justify program implementation or program funding. For example, outcome monitoring is used to assess quality of healthcare by examining the association between the level of improved health services and the desired health outcomes of individuals and populations (IOM, 2013). This is best done by having a quality-improvement plan that systematically and consistently implements improvement strategies to address areas that are deficient and not meeting benchmarks. Electronic health records help to simplify the recording and monitoring of outcomes over time, between patient groups and populations. Outcomes are an expected part of what APRNs must collect when their focus is on populations. When combined with an evidence-based practice approach, outcomes can help provide standards or parameters for developing innovative interventions, instituting approaches more likely to impact the problem, and/or developing new practice guidelines or protocols (Robert Wood Johnson Foundation, 2009). For example, an APRN working in a community-based clinic with a lesbian, gay, bisexual, and transgender (LGBT) population may gather information about factors that contribute to documented risk behaviors, such as smoking and excessive drinking, in this community. An assessment can be made to determine whether differences in health outcomes exist based on age, perceived differential treatment by healthcare providers due to sexual orientation, access to LGBT support networks, barriers to access services that address the specific health needs of this diverse population, and other variables of interest (Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-Ellis, 2013). Once these outcomes are assessed, action can be taken to address those issues that may be contributing to high-risk behaviors. Interventions can be designed or policy changed to better address those factors, with a reassessment of outcomes after the intervention to see whether there is a reduction in high-risk behaviors.

TABLE 2.2    •    Community Guide Topics and Outcome Examples

Nurse-Sensitive Quality Indicators

The ANA broadened the identification of nurse-sensitive indicators from acute care hospital settings to community-based, nonacute care settings such as long-term care facilities, schools, and home healthcare settings. This work began in 1998, and by 2000, 10 indicators were identified: pain management, consistency of communication, staff mix (combination and number of RNs, LPNs, nursing assistants), client satisfaction, prevention of tobacco use, cardiovascular disease prevention, caregiver activity, identification of primary caregiver, activities of daily living (ADL), independent activities of daily living (IADL), and psychosocial interaction (Gallagher & Rowell, 2003; Press Ganey Associates, 2014). The ability to collect and compare data on nurse-sensitive indicators and the ability to develop new indicators over time enhance the NDNQI initiative and provide APRNs with important information to help measure, compare, and improve the health and safety of populations.

The use of standardized language is important in any field to ensure a level of communication that is both consistent and effective in ensuring quality outcomes. Specifically, in nursing and other health professions, standardized language is critical for patient safety and quality of care. By establishing a uniform nursing language in electronic health records, research, and the development of evidence-based practice, APRNs will have a stronger foundation to communicate and improve patient outcomes and standards of care. The North American Nursing Diagnosis Association (NANDA) was developed in the 1970s to classify and standardize nursing diagnoses. Now referred to as NANDA International or NANDA-I, the nursing diagnoses include a name or label, signs and symptoms or defining characteristics, and risk factors associated with the diagnosis. The NANDA definitions and classifications have been recently updated to reflect new trends in nursing healthcare (www.nanda.org). Members of NANDA worked with nursing researchers at the University of Iowa to develop the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC). NANDA, NIC, and NOC, now referred to as NNN, collectively reflect a standardized way of communicating with defined terms within and across various national and international settings (Smith & Craft-Rosenberg, 2010). As APRNs contribute to the body of evidence-based practice and collaborate with others to generate more evidence of effective practice, their work may benefit from reviewing and using the NNN language for diagnoses, nursing interventions, and patient outcomes (Kautz & Van Horn, 2008). It is imperative that APRNs use standardized language in their research and in their practice so that outcomes can be compared in similar ways with larger databases for evaluation and research purposes.

NATIONAL HEALTHCARE OBJECTIVES

Healthy People 2020

Healthy People 2020, released by the U.S. Department of Health and Human Services (HHS) in early December 2010, serves as a blueprint or road map for the United States to achieve health promotion and disease prevention objectives that are designed to improve the health of all Americans. The Healthy People initiative started in 1979 when the surgeon general released a report that focused on promoting health and preventing disease for all Americans. It was followed by Healthy People 2000 in 1989 and, 10 years later, Healthy People 2010. With leadership provided by the HHS, an appointed Advisory Committee and numerous public and private groups, local and state policy makers and officials, and numerous organizations (voluntary, advocacy, faith-based, and for-profit businesses), input is solicited regionally, statewide, and nationally to help craft the vision, mission, and overarching goals. These groups and organizations also develop strategies to improve health and prevent disease with the ultimate goal of helping Americans live longer and healthier lives. The resulting objectives, whether on the county, state, or national level, are intended for use by broad audiences and stakeholders to help motivate, guide, and focus action for a healthier nation.

Table 2.3 provides a summary of the Healthy People 2020 initiatives with its vision, mission, goals, foundation health measures, and topic areas. Each topic area has a list of objectives with data sources, baseline, and target measures to achieve. The new features of Healthy People 2020 are additional topic-related clinical recommendations, evidence-based interventions, and other resources and links with consumer health information. Information about Healthy People 2020 can be found at www.healthypeople.gov/2020/default.aspx.

The website has useful information that APRNs can use to identify and monitor outcomes. Other tools, referred to as indicators, exist that APRNs can use for determining outcomes or measures of the quality of healthcare. These tools are available from the AHRQ Indicators website at www.qualityindicators.ahrq.gov, along with software used to compute the quality-indicator rates, users’ guides, reports, and other technical assistance and support. The inpatient quality indicators were designed to help hospitals identify possible issues and problems in need of quality improvement by using hospital administrative data to analyze morbidity and mortality rates for specific conditions and procedures, hospital- and area-level procedure utilization rates, and number of procedures (for select procedures). In addition to the inpatient quality indicators, other sets of quality indicators are available, including preventative quality indicators, patient safety indicators, and pediatric quality indicators.

TABLE 2.3    •    Vision, Mission, Goals, Foundation Health Measures, and Topic Areas of Healthy People 2020

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