Editorials

The Nursing Minimum Data Set: A Major Priority for Public Health Nursing but Not a Panacea For some years a number of visionary nurses have advocated the development of systematic approaches to describing patient problems, nursing interventions, and patient outcomes in terms that are relevant to decisions nurses make and the decisions others make about nursing. With the growing use of computers in patient care settings and the increased attention on documentation, effectiveness of care, and cost issues, the development of computerized data bases has taken on more importance. One of the first nurses to provide leadership in this area-and perhaps the most visionary and persistent of the group, Harriet H. Werley-focused much of her attention on the development of the Nursing Minimum Data Set. In this issue of the Journal, Werley and colleagues ' described the development of the Nursing Minimum Data Set and provided forceful and compelling arguments for its adoption. Werley and colleagues' indicated that the effort to develop a Nursing Minimum Data Set (NMDS) is a follow-up work begun earlier, in 1977, but at that point the timing was not right for serious movement. However, as described in their paper and reflected in their references, since 1985 the momentum has picked up and important work on developing and testing the NMDS has been undertaken and published. What about the future? Will the benefits to clinical practice and administration, research, and policy-making outlined by Werley and associates be forthcoming? What kind of priority should the leadership in public health nursing give to adoption of the

NMDS? I suggest the question for the future is not whether there will be a minimum set of

data collected on each patient receiving personal care services, but, When it will happen and who will take the leadership in deciding what data. And, the question for public health is, "Do we want to provide leadership that makes a difference in the health of populations?" If we do want to make a positive difference, if we feel that the services provided by nurses impact favorably on the health of defined populations, and if we want our professional activities and what we value in them to be more visible and taken seriously, we must make the development of a NMDS a major priority. The NMDS put forth in this issue of the Joumal' has many strengths, but it is not a panacea for all the problems facing public health nursing. The pioneering work described represents an important beginning in addressing a goal that will take much more time and effort to achieve. Werley and colleagues' challenged public health nurses to adopt the NMDS. My challenge is to accept the concept and its importance to public health nursing, to intensify efforts to strengthen the key nursing components of the NMDS, and to aggressively test its use in practice. The elements of the NMDS that are of most interest to nursing-and also most in need of further work-are the Nursing Care Elements (nursing diagnosis, nursing intervention, nursing outcome, and intensity of nursing care). There is a need for refining these elements for use in all pracAddress reprint requests to Carolyn A. Williams, RN, PhD, Dean, College of Nursing, University of Kentucky, 760 Rose Street, Lexington, KY 40536.

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Editorials

tice settings, but a review of the published efforts to test use of the NMDS suggests that the need for additional work is particularly apparent in non-hospital settings. In fact, in discussing their test of the NMDS, Devine and Werley2 reported considerably more variability (less reliability as measured by intercoder agreement) in the ambulatory clinic setting than in the acute hospital setting. They explained this by noting that "the current classifications of Nursing Diagnoses are least developed for ambulatory care."2 Other areas need considerable attention. For example, while the Omaha Classification System3 (still being tested and refined) has been used to categorize nursing diagnoses in at least one test of the NMDS, additional components of the Omaha System (classifications for nursing interventions and outcomes) which is being piloted in several settings throughout the country have not been incorporated into the NMDS's approach to categorizing nursing interventions and outcomes. It is timely to focus attention on the importance of a NMDS (particularly in describing basic aspects of practice and in influencing health policy), but it is prema-

ture to argue for its widespread adoption in its current form. Rather, I believe the agenda should be for specialists in public health nursing to establish the further development of the NMDS (particularly the Nursing Care Elements) as a priority goal and assume a leadership role in achieving that objective. In addition to work on each of the nursing care elements, efforts also should focus on practical ways to: * expedite accurate documentation by providers, * computerize data, * link information across care settings, * retrieve information. Such a goal is entirely consistent with the role public health nursing specialists should be assuming in the design, development, management, monitoring, and evaluation of population-focused health care systems. The eventual adoption of a NMDS will depend not only on its scientific and practical qualities but on widespread consensus within the field regarding its practicality and its relevance in decision-making. One strategy to mobolize resources to foster further development and to achieve

the needed consensus is for key leadership groups in public health nursing, i.e. Public Health Nursing Section of the American Public Health Association, Association of Community Health Nursing Educators, Council of Community Health Nurses of the American Nurses' Association, and State and Terriroal Nursing Directors, to place this matter before their constituencies and develop action plans perhaps. A coordinated effort could be spearheaded by the new QUAD Council recently formed by the four groups identified above. Let's accept the challenge and move forward! [] Carlyn A. W an, RN, PhD

References 1. Werley HH, Devine EC, Zom CR, Ryan P, Westra BL: The Nursing Minimum Data Set: Abstraction tool for standardized, comparable, essential data. Am J Public Health 1991; 81:421-426. 2. Devine EC, Werley HH: Test ofthe Nursing Minimum Data Set: Availability of data and reliability. Res Nurs Health 1988; 11:97-104. 3. Visiting Nurse Association of Omaha: Client management information system for

community health nursing agencies (Technical Report). Rockville, MD: US Department of Health and Human Services, Division of Nursing, 1986.

The Cost-Effectiveness of Orphan Drugs Constrained by limited resources, health care payers and providers are forced to set priorities for the use ofhealth care technologies. Cost-effectiveness analysis has been used as a guide to determining whether a particular health care practice yields more health benefit, dollar for dollar, than other health practices that compete for the same limited resources. Indices such as cost per year of life gained and cost per quality-adjusted year of life gained are frequently used to rank alternative uses of resources within a disease or across diseases.1-3 Typically, the costeffectiveness ratio for a health program is assessed from the perspective of the society as a whole, with lives and life-years of different segments of the population weighted equally, andwith cost calculated as the net resource burden of the program on the entire health sector. The pluralistic American health care system often produces situations in which less cost-effective programs are adopted while more cost-effective programs are not. Economic incentives for developers and providers play a role in creating these departures from the socially optimal use of health resources.4 So-called orphan drugs

414 American Journal of Public Health

are one class of technologies which may be less widely utilized than would be socially optimal because of adverse economic incentives. In this issue of the Joumal, Hay and Robin report a cost-effectiveness study of alpha-1 antitrypsin replacement therapy (AAT-RT) in the prevention of chronic obstructive pulmonary disease (COPD).5 AAT deficiency accounts for perhaps only 100,000 ofthe 10 million prevalent cases of COPD in the United States; this has led some to conclude that clinical trials to establish the efficacy of AAT-RT are not economically justified. In the absence of clinical trials, Hay and Robin are forced to assess cost-effectiveness under alternative assumptions about its efficacy, which they define as the fraction by which treated patients with AAT deficiency could reduce the difference between their age-specific mortality rates and normal mortality rates. (This concept is analogous to the concept of "fraction of benefit", used by Weinstein and Stason in modeling the benefit of blood pressure reduction.6) They vary this parameter by assumption from 10 percent to 90 percent. Hay and Robin conclude that the cost

of extending life one year by giving AAT-RT to 40-year-old smokers would range from $28,000-$29,000 if efficacy is 90 percent, to $38,000 if efficacy is 50 percent, to $107,000 if efficacy is 10 percent (reference 5, table 2). For 40-year-old nonsmokers these figures are $38,000-53,000 at 90 percent efficacy, $56,000-83,000 at 50 percent efficacy, and $214,000-352,000 at 10 percent efficacy. Such cost-effectiveness ratios can be interpreted only by comparing them with ratios for other programs that compete for resources. Hay and Robin cite several ratios in the range from $30,000 to $135,000 for what they term "generally accepted medical interventions." Whether singlevessel coronary artery bypass surgery for mildly symptomatic patients, or antihypercholesterolemic therapy for patients with no other coronary risk factors and serum cholesterol levels of 240 mg/dl, are "generally accepted" is debatable. Most "generally accepted" preventive interventions have cost-effectiveness ratios below $50,000 per life year gained.1-3 Placed in this context, the cost per year of life saved by AAT-RT is less than $50,000 for smokers only if efficacy is at least 30 per-

April 1991, Vol. 81, No. 4

The Nursing Minimum Data Set: a major priority for public health nursing but not a panacea.

Editorials The Nursing Minimum Data Set: A Major Priority for Public Health Nursing but Not a Panacea For some years a number of visionary nurses hav...
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