2012 Outstanding Dissertation and Capstone Project Award Winners
Oleg Zaslavsy, PhD, University of Washington
The Excellence in Advancing Nursing Science Award for an outstanding dissertation from a student in a PhD in nursing or DNS program was presented to Dr. Oleg Zaslavsky, who graduated in 2012 with his PhD from the University of Washington. His dissertation chair was Dr. Barbara B. Cochrane (pictured above). For his Longitudinal Dynamics in Indicators of Frailty: Predictors and Long-Term Outcomes study, Dr. Zaslavsky used latent growth mixture modeling to examine trajectories of change in musculoskeletal and neuro-cognitive indicators of frailty in older women, using the large Women’s Health Initiative database.
Description of Dissertation
Background: Frailty is a common geriatric condition with a wide array of sequelae, including increased risks of mortality, morbidity and disability. Despite its long conceptual and operational history in research and publications, frailty and mechanisms of frailty development are still poorly understood. A detailed description of trajectories of frailty indicators was needed to provide vital insights on unfolding longitudinal dynamics involved in the development of frailty.
Purpose:The specific aims of this study were to: (I) Describe longitudinal (-10 years) trajectories of change in musculoskeletal and neuro-cognitive indicators of frailty in older (>/=65 years) women enrolled in the Women's Health Initiative (WHI) Clinical Trial; (2) Estimate the extent to which baseline factors (e.g., demographic characteristics, health status and behaviors) are associated with a likelihood of membership in the derived longitudinal clusters; and (3) determine the extent to which membership in longitudinal trajectories predicts the incidence of clinically relevant geriatric health outcomes (i.e., mortality and hospitalization) over 5-years of follow up in a model adjusted for all other baseline predictors.
Methods: Data for these analyses came from the WI-II, which included three randomized controlled clinical trials (CTs). Details of the design, recruitment strategies, data collection methods, and tabulations of baseline data are published elsewhere (Anderson eta!. (2003). Implementation of the Women's Health Initiative study design. Annals of Epidemiology, 13, S5-17.). In the present stud y we focused on data from \Vomen ages 65 years and older (at baseline) who emolled in one or more of the CTs and also consented to participate in 2005-2010 Extension Study. The final sample included 19,891 women. Measures of frailty indicators (e.g., physical performance-based tests), demographic, health behavior and status, comorbidity, personality and social factors were collected using well-established objective and self-report measures. Study outcomes of hospitali zat ion and mortality were based on mmual medical history update questionnaires from participants in the 2005-2010 WHI Extension Study. These self-reported outcomes were then used to obtain medical records for adjudication both locally and by a panel of central adjudicators. Latent class growth models were used to identify relatively homogeneous clusters of individuals following similar longitudinal trajectories of change. Trajectory parameters were estimated using maximum likelihood methods. A high-order polynomial function (i.e., quadratic) was fitted to the data, and parameters were estimated to define the shape of the trajectories and the probability of trajectory group membership. The number of clusters were chosen based on standard statistical selection criteria. Partial propmtional odds models were used to fit the data and test the effect of predictors on trajectory group membership. Cox proportional hazard models were used to predict mortality and first-incident overnight hospitalization in sequentially-fitted models.
Results: Study findings demonstrated a high degree of heterogeneity in longitudinal dynamics of individual frailty criteria. In addition, results showed that age, soda-demographic variables, health status, health behavior, environmental factors and personality traits are important determinants of individual frailty criteria, but their effect on frailty phenotype is complex, presumably due to the multidimensional nature offrailty phenomenon. Thirdly, the magnitude of risk carried by a membership in a certain longitudinal group for each of the defining elements of frailty is closely linked to the distance of that trajectory estimates from the one that represents the most optimal criterion-specific functioning over time. The futher the distance between trajectory estimates of an individual who maintained the highest level of performance (specific to that indicator) and those who demonstrated less optimal functioning, the higher the risk of incidence of adverse health events.
Conclusion: The study provided an empirical determination that distribution-based cross sectional partitioning of frailty criteria seems to be a valid method for defining frailty, given that elderly women maintained approximately similar levels of functioning over time without demonstrating clear accelerated or decelerated longitudinal patterns.
Honorable mention went to Tiffany Moore, BSN–PhD student from the University of Nebraska Medical Center for her dissertation of Model of Allostatic Load and Complications of Prematurity.
Erin Harnett, DNP, New York University
The Excellence in Advancing Nursing Practice Award for an outstanding capstone project from a student in a Doctor of Nursing Practice (DNP) program was presented to Dr. Erin Harnett. Dr. Harnett graduated in 2011 with her DNP from New York University, and her capstone project advisor was Dr. Barbara Krainovich-Miller (pictured above). Dr. Harnett’s Integrating Preventive Dental Care in a Pediatric Oncology Center evidence-based practice project resulted in a significant policy change in practice at a major Cancer Center for a highly vulnerable pediatric oncology population. The Center admission protocol now requires that all pediatric oncology patients receive a comprehensive oral health assessment and exam on admission as well as receive fluoride varnish treatment and a dental referral if caries are detected prior to initiating their chemotherapy or other forms of cancer treatment.
Description of Capstone
Background: Dental caries is an infectious process, which may cause serious problems for children both during and after cancer treatment (Haytac, Dogan, & Antmen, 2004; Yeazel et al., 2004). The American Academy of Pediatrics (AAP, 2009, 2010) and the American Academy of Pediatric Dentistry (AAPD, 2008, 2010) recent policies have recommended that primary care providers perform oral assessment, provide preventive dental care during routine well child visits, and refer children to the dentist by age one year. The Surgeon General mandated that the evidence-base about the oral-systemic connection be used to improve the health of all by implementing it in the curricula of all health care practitioners and that a comprehensive oral assessment be a gold standard of practice (IOM, 2011) for the public. The needs assessment of this project uncovered the glaring gap between existing extensive evidence and recommendations regarding the need for oral health assessment and current practice. Although children being treated for cancer are seeing the pediatric oncology team on a regular basis, they are not receiving expected normal pediatric or dental preventive care prior to or during cancer treatment. This issue is of paramount concern as the development of oral problems during childhood cancer care results in pain, fever, delay in treatment, additional hospitalizations, and increased cost to families/significant others and the health care system which, in turn, impacts the public at large (Carrillo, Vizeu, Soares-Junior, Fava, & Filho, 2010; da Fonesca, 2004).
Methods: A Clinical Microsystems approach was used to ensure successful implementation of
the project conducted by the DNP (PNP) student. She collaborated with members of a university dental school and the leadership of the major urban outpatient pediatric oncology cancer center and IRB to gain approval to implement her educational project for the pediatric oncology providers (pediatric oncology MDs, NPs, RNs) at the cancer center. The participants: (a) completed a pre-survey assessing their oral systemic health knowledge, current oral health practice, perceived barriers to dental referral and attitudes toward incorporating preventive oral health care into their oncology practice, and (b) attended an oral health educational intervention and fluoride varnish skills lab conducted by the DNP candidate (PNP), dental residents and dental fellows where they learned how to perform an oral assessment to detect the existence of carries, make a referral for caries if identified, and how to apply fluoride varnish on children who were to be treated for cancer. Participant knowledge and skills were assessed after the educational program and chart data indicated whether these new competencies were used with the pediatric population. A one year follow-up survey was instituted.
Results: The results of this innovative capstone project indicated that pediatric oncology providers were in a unique position to provide preventive oral health care and improve oral health outcomes in pediatric cancer patients. The educational program increased their oral health knowledge of the providers; a review of chart data indicated that children who came to the cancer center were now receiving oral health assessments, had fluoride varnish as needed, and referrals were being made as needed. In this center only children who were seen by a dental resident once a week had ever received this standard of care. Prior to this project none of the oncology providers (MDs, NPs, RNs) had included this in their practice. At the end of the projects, data indicated that children being treated by oncology providers, who participated in this project, had increased from zero to 100%. This educational program was adopted as a standard of practice at the center and all providers complete this oral health program. Fluoride varnish is now on the standard formulary; all pediatric patients receive this gold standard of oral health care prior to treatment. One-year follow up survey data indicate that this practice continues to be implemented by all providers. The improvement on care delivery demonstrated in this project may be replicated in other settings and serves as a model for pediatric oncology clinics across the country. Feedback from invited as well as competitive presentations at local,
regional, and national interprofessional conferences, as well as quality improvement data provide evidence that this clinical project is realistic and can be easily replicated in other settings. Currently, it is being implemented on the in-patient unit at this major medical center.
Implications for Practice, Education, and Policy: The project has several implications for practice. DNP prepared advanced nursing practice NPs need to assume a clinical leadership role and instruct other providers regarding evidence-based standards of care that need to be instituted. Specifically DNP prepared PNPs must assume the role of educating health care providers who care for both well and chronically ill children to include oral health care in acute and chronic healthcare settings and schools. This project also has important implications for pediatric cancer survivors who may develop late effects from their cancer treatment that will require dental care. Interprofessional education and practice collaboration between medical, nursing, and dental providers must become an integral part of health care delivery systems. The implications for education of DNP programs that prepare NPs is that DNP graduates must obtain clinical leadership competencies that include: (a) use of an appropriate implementation framework, (b) the ability to critically appraise and synthesize the best available evidence in order to change the practice of health care providers, (b) making recommendations and creating policies based on the best appraised evidence, and (d) teaching oral health competencies and best practices as part of the standard of care regardless of the population. It further highlights the need for all health care provides to receive oral-systemic health care knowledge and related competencies during their education. The specific implications for policy are at the institutional practice setting level. When successful results are obtained from evidence-based clinical improvement projects, such as Dr. Hartnett’s, these practices will be sustained when they demonstrate positive clinical outcomes and become the expected gold standard policy.
Honorable mentions went to:
- Vicky Grossman, MPH-DNP student from Duke University for her capstone on The Role of Health Promoters in Zinc Compliance in Guatemala.
- Carrie Kairys, DNP student from Johns Hopkins University for her capstone on Improving Contraceptive Counseling by Instituting a Provider Reminder with Clinical Decision Support in the Electronic Health Record.