Jeongyoung Park

The Staffing–Outcomes Relationship in Nursing Homes

OBJECTIVE To assess longitudinally whether a change in registered nurse (RN) staffing and skill mix leads to a change in nursing home resident outcomes while controlling for the potential endogeneity of staffing. DATA SOURCES Minimum Data Set (MDS) nursing home resident assessment data from five states merged with Online Survey Certification and Reporting (OSCAR) data from 1996 through 2000. STUDY DESIGN Resident-level longitudinal analysis with facility fixed effects and instrumental variables. Outcomes studied are incidence of pressure sores and urinary tract infections. RN staffing was measured as the care hours per resident-day and skill mix was measured as RN staffing hours as a proportion of total staffing hours. DATA EXTRACTION METHOD We use all quarterly MDS assessments that fall within 120 days of an annual OSCAR data point, resulting in 399,206 resident-level observations. PRINCIPAL FINDINGS Controlling for endogeneity of staffing increases the estimated impact of staffing on outcomes in nursing homes. Greater RN staffing significantly decreases the likelihood of both adverse outcomes. Increasing skill mix only reduces the incidence of urinary tract infections. CONCLUSIONS Research that fails to account for endogeneity of the staffing-outcomes relationship may underestimate the benefit from increased RN staffing. Increases in RN staffing are likely to reduce adverse outcomes in some nursing homes. More research using a broader array of instruments and a national sample would be beneficial.

Impact of Public Reporting on Quality of Postacute Care

OBJECTIVE Evidence supporting the use of public reporting of quality information to improve health care quality is mixed. While public reporting may improve reported quality, its effect on quality of care more broadly is uncertain. This study tests whether public reporting in the setting of nursing homes resulted in improvement of reported and broader but unreported quality of postacute care. DATA SOURCES/STUDY SETTING 1999-2005 nursing home Minimum Data Set and inpatient Medicare claims. STUDY DESIGN We examined changes in postacute care quality in U.S. nursing homes in response to the initiation of public reporting on the Centers for Medicare and Medicaid Services website, Nursing Home Compare. We used small nursing homes that were not subject to public reporting as a contemporaneous control and also controlled for patient selection into nursing homes. Postacute care quality was measured using three publicly reported clinical quality measures and 30-day potentially preventable rehospitalization rates, an unreported measure of quality. PRINCIPAL FINDINGS Reported quality of postacute care improved after the initiation of public reporting for two of the three reported quality measures used in Nursing Home Compare. However, rates of potentially preventable rehospitalization did not significantly improve and, in some cases, worsened. CONCLUSIONS Public reporting of nursing home quality was associated with an improvement in most postacute care performance measures but not in the broader measure of rehospitalization.

Effects of State Minimum Staffing Standards on Nursing Home Staffing and Quality of Care

OBJECTIVE To investigate the impact of state minimum staffing standards on the level of staffing and quality of nursing home care. DATA SOURCES Online Survey and Certification Reporting System (OSCAR) merged with the Area Resource File from 1998 through 2001. STUDY DESIGN Between 1998 and 2001, 16 states implemented or expanded staffing standards in excess of federal requirements, creating a natural experiment in comparison with facilities in states without new standards. Difference-in-differences models using facility fixed effects were estimated to determine the effect of state standards. DATA COLLECTION/EXTRACTION METHODS OSCAR data were linked to the data on market conditions and state policies. A total of 55,248 facility-year observations from 15,217 freestanding facilities were analyzed. PRINCIPAL FINDINGS Increased standards resulted in small staffing increases for facilities with staffing initially below or close to new standards. Yet the standards were associated with reductions in restraint use and the number of total deficiencies at all types of facilities. CONCLUSIONS Mandated staffing standards affect only low-staff facilities facing potential for penalties, and effects are small. Selected facility-level outcomes may show improvement at all facilities due to a general response to increased standards or to other quality initiatives implemented at the same time as staffing standards.

Performing Well on Nursing Home Report Cards: Does It Pay Off?

OBJECTIVE To examine whether high performance or improvement on quality measures leads to economic rewards for nursing homes in the presence of public reporting. DATA SOURCES Data from 6,286 freestanding Medicare-certified nursing homes between 1999 and 2005 were identified in Medicare Cost Reports, Minimum Data Set, and Online Survey and Certification Reporting System. STUDY DESIGN Using a facility-level fixed-effects model, the effect of public reporting on financial performance was measured by comparing each of four financial outcomes (revenues, expenses, operating, and total profit margins) before (1999-2002) to after (2003-2005) public reporting was initiated. The effects were estimated separately by level of performance and improvement over time. PRINCIPAL FINDINGS Facilities that improved on publicly reported performance had increased revenues and higher profit margins after public reporting, mainly through increased Medicare admissions. High-scoring facilities showed similar patterns, though differences were not statistically significant. CONCLUSIONS Providers that improve their performance under public reporting may receive a return on their investment in quality improvement. This supports the business case for public reporting.

Changes in the relationship between nursing home financial performance and quality of care under public reporting

The relationship between financial performance and quality of care in nursing homes is not well defined and prior work has been mixed. The recent focus on improving the quality of nursing homes through market-based incentives such as public reporting may have changed this relationship, as public reporting provides nursing homes with increased incentives to engage in quality-based competition. If quality improvement activities require substantial production costs, nursing home profitability may become a more important predictor of quality under public reporting. This study explores the relationship between financial performance and quality of care and test whether this relationship changes under public reporting. Using a 10-year (fiscal years 1997-2006) panel data set of 9444 skilled nursing facilities in the US, this study employs a facility fixed-effects with and without instrumental variables approach to test the effect of finances on quality improvement and correct for potential endogeneity. The results show that better financial performance, as reflected by the 1-year lagged total profit margin, is modestly associated with higher quality but only after public reporting is initiated. These findings have important policy implications as federal and state governments use market-based incentives to increase demand for high-quality care and induce providers to compete based on quality.

Malpractice Litigation and Nursing Home Quality of Care

OBJECTIVE To assess the potential deterrent effect of nursing home litigation threat on nursing home quality. DATA SOURCES/STUDY SETTING We use a panel dataset of litigation claims and Nursing Home Online Survey Certification and Reporting (OSCAR) data from 1995 to 2005 in six states: Florida, Illinois, Wisconsin, New Jersey, Missouri, and Delaware, for a total of 2,245 facilities. Claims data are from Westlaws Adverse Filings database, a proprietary legal database, on all malpractice, negligence, and personal injury/wrongful death claims filed against nursing facilities. STUDY DESIGN A lagged 2-year moving average of the county-level number of malpractice claims is used to represent the threat of litigation. We use facility fixed-effects models to examine the relationship between the threat of litigation and nursing home quality. PRINCIPAL FINDINGS We find significant increases in registered nurse-to-total staffing ratios in response to rising malpractice threat, and a reduction in pressure sores among highly staffed facilities. However, the magnitude of the deterrence effect is small. CONCLUSIONS Deterrence in response to the threat of malpractice litigation is unlikely to lead to widespread improvements in nursing home quality. This should be weighed against other benefits and costs of litigation to assess the net benefit of tort reform.

Use of hospitalists and office-based primary care physicians' productivity.

ABSTRACTBACKGROUNDGrowth in the care of hospitalized patients by hospitalists has the potential to increase the productivity of office-based primary care physicians (PCPs) by allowing them to focus on outpatient practice.OBJECTIVEOur aim was to examine the association between utilization of hospitalists and the productivity of office-based PCPs.DESIGN/PARTICIPANTSThe cross-sectional study was conducted using the 2008 Health Tracking Physician Survey Restricted Use File linked to the Area Resource File. We analyzed a total of 1,158 office-based PCPs representing a weighted total of 97,355 physicians.MAIN MEASURESUtilization of hospitalists was defined as the percentage of a PCP’s hospitalized patients treated by a hospitalist. The measures of PCPs’ productivity were: (1) number of hospital visits per week, (2) number of office and outpatient clinic visits per week, and (3) direct patient care time per visit.KEY RESULTSWe found that the use of hospitalists was significantly associated with a decreased number of hospital visits. The use of hospitalists was also associated with an increased number of office visits, but this was only significant for high users. Physicians who used hospitalists for more than three-quarters of their hospitalized patients had an extra 8.8 office visits per week on average (p = 0.05), which was equivalent to a 10 % increase in productivity over the predicted mean of 87 visits for physicians who did not use hospitalists. We did not find any significant differences in direct patient care time per visit.CONCLUSIONSOur study demonstrates that the increase in productivity for the one-third of PCPs who use hospitalists extensively may not be sufficient to offset the current loss of PCP workforce. However, our findings provide cautious optimism that if more PCPs effectively and efficiently used hospitalists, this could help mitigate a PCP shortage and improve access to primary care services.

To What Extent Are State Scope of Practice Laws Related to Nurse Practitioners’ Day-to-Day Practice Autonomy?

We explore the extent to which state scope of practice laws are related to nurse practitioners (NPs)’ day-to-day practice autonomy. We found that NPs experienced greater day-to-day practice autonomy when they had prescriptive independence. Surprisingly, there were only small and largely insignificant differences in day-to-day practice autonomy between NPs in fully restricted states and those in states with independent practice but restricted prescription authority. The scope of practice effects were strong for primary care NPs. We also found that the amount of variation in day-to-day practice autonomy within the scope of practice categories existed, which suggests that factors other than state scope of practice laws may influence NP practice as well. Removing barriers at all levels that potentially prevent NPs from practicing to the full extent of their education and training is critical not only to increase primary care capacity but also to make NPs more efficient and effective providers.

Advanced practice nursing in Latin America and the Caribbean: regulation, education and practice

Objetivo: identificar el estado actual de la regulacion, educacion y practica de la enfermera de practica avanzada en Latinoamerica y el Caribe y la percepcion de los lideres de enfermeria en la region hacia un rol de practica avanzada de enfermeria dentro de la atencion primaria de salud para apoyar las iniciativas de Acceso Universal a la Salud y la Cobertura Universal de Salud. Metodo: un diseno transversal descriptivo que utilizo una encuesta basada en la web a 173 lideres de enfermeria acerca de sus percepciones sobre el estado de la enfermeria y el desarrollo potencial de la practica avanzada de enfermeria en sus paises, incluyendo definicion, ambiente laboral, regulacion, educacion, practica de enfermeria, cultura de enfermeria y la receptividad percibida a un papel mas amplio en atencion primaria de salud. Resultado: los participantes estaban ampliamente familiarizados con el rol de la enfermera de practica avanzada, pero la mayoria desconocia la legislacion o reportaba no existencia actual de legislacion para el rol de practica avanzada en sus paises. Los participantes reportaron la necesidad de aumentar la preparacion docente y reformas curriculares para apoyar programas de atencion primaria de salud para capacitar las enfermeras de practica avanzada. La gran mayoria de los participantes creian que las poblaciones de sus paises se podrian beneficiar de un rol de practica avanzada de enfermeria en atencion primaria de salud. Conclusion: un fuerte apoyo legislativo y un marco educacional solido que continuen informandose entre si, son criticos para el desarrollo exitoso de programas de practica avanzada y de nurse practitioners para apoyar las iniciativas de Acceso Universal a la Salud y Cobertura Universal de Salud.

Malpractice Environment vs Direct Litigation: What Drives Nursing Home Exit?:

An ongoing concern about medical malpractice litigation is that it may induce provider exit, potentially affecting consumer welfare. The nursing home sector is subject to substantial litigation activity but remains generally understudied in terms of the effects of litigation, due perhaps to a paucity of readily available data. In this article, we estimate the association between litigation and nursing home exit (closure or change in ownership), separating the impact of malpractice environment from direct litigation. We use 2 main data sources for this study: Westlaw’s Adverse Filings database (1997-2005) and Online Survey, Certification and Reporting data sets (1997-2005). We use probit models with state and year fixed effects to examine the relationship between litigation and the probability of nursing home closure or change in ownership with and without adjustment for malpractice environment. We examine the relationship on average and also stratify by profit status, chain membership, and market competition. We find that direct litigation against a nursing home has a nonsignificant effect on the probability of closure or change in ownership within the subsequent 2 years. In contrast, the broader malpractice environment has a significant effect on change in ownership, even for nursing homes that have not been sued, but not on closure. Effects are stronger among for-profit and chain facilities and those in more competitive markets. A high-risk malpractice environment is associated with change of ownership of nursing homes regardless of whether they have been directly sued, indicating that it is too blunt an instrument for weeding out low-quality nursing homes.