Lisa A. Ronald

Staffing levels in not-for-profit and for-profit long-term care facilities: Does type of ownership matter?

Background: Currently there is a lot of debate about the advantages and disadvantages of for-profit health care delivery. We examined staffing ratios for direct-care and support staff in publicly funded not-for-profit and for-profit nursing homes in British Columbia. Methods: We obtained staffing data for 167 long-term care facilities and linked these to the type of facility and ownership of the facility. All staff were members of the same bargaining association and received identical wages in both not-for-profit and for-profit facilities. Similar public funding is provided to both types of facilities, although the amounts vary by the level of functional dependence of the residents. We compared the mean number of hours per resident-day provided by direct-care staff (registered nurses, licensed practical nurses and resident care aides) and support staff (housekeeping, dietary and laundry staff) in not-for-profit versus for-profit facilities, after adjusting for facility size (number of beds) and level of care. Results: The nursing homes included in our study comprised 76% of all such facilities in the province. Of the 167 nursing homes examined, 109 (65%) were not-for-profit and 58 (35%) were for-profit; 24% of the for-profit homes were part of a chain, and the remaining homes were owned by a single operator. The mean number of hours per resident-day was higher in the not-for-profit facilities than in the for-profit facilities for both direct-care and support staff and for all facility levels of care. Compared with for-profit ownership, not-for-profit status was associated with an estimated 0.34 more hours per resident-day (95% confidence interval [CI] 0.18–0.49, p < 0.001) provided by direct-care staff and 0.23 more hours per resident-day (95% CI 0.15–0.30, p < 0.001) provided by support staff. Interpretation: Not-for-profit facility ownership is associated with higher staffing levels. This finding suggests that public money used to provide care to frail eldery people purchases significantly fewer direct-care and support staff hours per resident-day in for-profit long-term care facilities than in not-for-profit facilities.

Care Outcomes in Long-Term Care Facilities in British Columbia, Canada Does Ownership Matter?

Objectives:This study investigated whether for-profit (FP) versus not-for-profit (NP) ownership of long-term care facilities resulted in a difference in hospital admission and mortality rates among facility residents in British Columbia, Canada. Research design:This retrospective cohort study used administrative data on all residents of British Columbia long-term care facilities between April 1, 1996, and August 1, 1999 (n = 43,065). Hospitalizations were examined for 6 diagnoses (falls, pneumonia, anemia, dehydration, urinary tract infection, and decubitus ulcers and/or gangrene), which are considered to be reflective of facility quality of care. In addition to FP versus NP status, facilities were divided into ownership subgroups to investigate outcomes by differences in governance and operational structures. Results:We found that, overall, FP facilities demonstrated higher adjusted hospitalization rates for pneumonia, anemia, and dehydration and no difference for falls, urinary tract infections, or DCU/gangrene. FP facilities demonstrated higher adjusted hospitalization rates compared with NP facilities attached to a hospital, amalgamated to a regional health authority, or that were multisite. This effect was not present when comparing FP facilities to NP single-site facilities. There was no difference in mortality rates in FP versus NP facilities. Conclusions:The higher adjusted hospitalization rates in FP versus NP facilities is consistent with previous research from U.S. authors. However, the superior performance by the NP sector is driven by NP-owned facilities connected to a hospital or health authority, or that had more than one site of operation.

For-profit versus not-for-profit delivery of long-term care.

Public funds can be used to pay for health care services that are delivered either by for-profit or not-for profit agencies. A systematic review of patient outcomes in US hospitals by ownership status showed that not-for-profit hospitals tended to produce better results.[1][1] Although there are no

Nursing Home Characteristics Associated with Resident Transfers to Emergency Departments

Cette étude a examiné comment la propriété des maisons de soins infirmiers porte sur les taux de transfert des services urgences (SU), comment les caractéristiques organisationnelles des installations sont réparties entre les groupes de propriété, et comment ces caractéristiques sont associées aux taux de transfert SU. L’échantillon comprenait une cohorte rétrospective de résidents des maisons de soins infirmiers dans la région de Vancouver Coastal Health (n = 13,140). Les taux de transferts SU ont été comparés entre les différents types de propriété des foyers de soins. Pour une analyse exploratoire, des données administratives ont ensuite été liées aux données provenant d’enquêtes auprès des caractéristiques organisationnelles des installations. Taux de transfert brut (SU transferts/100 ans résidents) étaient de 69, 70 et 51, respectivement, dans les installations à but lucratif, celles à but non-lucratif et les installations publiques. Avec des contrôles pour le sexe et l’age, la propriété publique a été associée aux taux de transfert SU inférieurs à ceux des installations à but lucratif et sans but lucratif. Les résultats ont aussi démontré un montant total plus élevé associé aux heures de soins directs infirmières par journée/résident, et la présence de personnel de Allied Health – qui sont présents de manière disproportionnée dans les installations de propriété publique – ont été associés aux taux de transfert inférieurs. This study examined how nursing home facility ownership and organizational characteristics relate to emergency department (ED) transfer rates. The sample included a retrospective cohort of nursing home residents in the Vancouver Coastal Health region (n = 13,140). Rates of ED transfers were compared between nursing home ownership types. Administrative data were further linked to survey-derived data of facility organizational characteristics for exploratory analysis. Crude ED transfer rates (transfers/100 resident years) were 69, 70, and 51, respectively, in for-profit, non-profit, and publicly owned facilities. Controlling for sex and age, public ownership was associated with lower ED transfer rates compared to for-profit and non-profit ownership. Results showed that higher total direct-care nursing hours per resident day, and presence of allied health staff – disproportionately present in publicly owned facilities – were associated with lower transfer rates. A number of other facility organizational characteristics – unrelated to ownership – were also associated with transfer rates.

A Survey of Nursing Home Organizational Characteristics Associated with Potentially Avoidable Hospital Transfers and Care Quality in One Large British Columbia Health Region

L’hospitalisation des résidents en maisons de soins infirmiers peut être futile aussi bien que coûteux, et il y a maintenant des preuves qui indiquent que le traitement des résidents des maisons de soins infirmiers en place donne de meilleurs résultats pour certaines conditions. Nous avons examiné les caractéristiques organisationnelles des installations que des récherches précédentes ont montré sont associées à des transferts de l’hôpital potentiellement évitables et avec une meilleure qualité de soins. En conséquence, nous avons mené une enquête transversale de l’administration des maisons de soins infirmiers dans Vancouver Coastal Health, une grande région sanitaire en la Colombie-Britannique. Le sondage portait sur les niveaux de dotation de personnel et l’organisation, l’accès aux médecins, les soins au fin de vie, et les facteurs influençant transferts de l’installation à l’hôpital. Un bon nombre des caractéristiques organisationnels modifiables, associés dans la littérature avec les transferts hospitaliers potentiellement évitables, et de meilleure qualité de soins, sont présents dans les maisons de soins infirmiers en la Colombie-Britannique. Cependant, leur présence n’est pas universelle, et certaines fonctionnalités sont particulièrement en défaut, en particulier l’organisation des soins médicaux et le planification et les services pour la fin de vie. Hospitalization of nursing home residents can be futile as well as costly, and now evidence indicates that treating nursing home residents in place produces better outcomes for some conditions. We examined facility organizational characteristics that previous research showed are associated with potentially avoidable hospital transfers and with better care quality. Accordingly, we conducted a cross-sectional survey of nursing home directors of care in Vancouver Coastal Health, a large health region in British Columbia. The survey addressed staffing levels and organization, physician access, end-of-life care, and factors influencing facility-to-hospital transfers. Many of the modifiable organizational characteristics associated in the literature with potentially avoidable hospital transfers and better care quality are present in nursing homes in British Columbia. However, their presence is not universal, and some features, especially the organization of physician care and end-of-life planning and services, are particularly lacking.

Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change?

Margaret McGregor and colleagues consider Bradford Hill’s framework for examining causation in observational research for the association between nursing home care quality and for-profit ownership.

Demographic predictors of active tuberculosis in people migrating to British Columbia, Canada: a retrospective cohort study

BACKGROUND: Canadian tuberculosis (TB) guidelines recommend targeting postlanding screening for and treatment of latent tuberculosis infection (LTBI) in people migrating to Canada who are at increased risk for TB reactivation. Our objectives were to calculate robust longitudinal estimates of TB incidence in a cohort of people migrating to British Columbia, Canada, over a 29-year period, and to identify groups at highest risk of developing TB based on demographic characteristics at time of landing. METHODS: We included all individuals (n = 1 080 908) who became permanent residents of Canada between Jan. 1, 1985, and Dec. 31, 2012, and were resident in BC at any time between 1985 and 2013. Multiple administrative databases were linked to the provincial TB registry. We used recursive partitioning models to identify populations with high TB yield. RESULTS: Active TB was diagnosed in 2814 individuals (incidence rate 24.2/100 000 person-years). Demographic factors (live-in caregiver, family, refugee immigration classes; higher TB incidence in country of birth; and older age) were strong predictors of TB incidence in BC, with elevated rates continuing many years after entry into the cohort. Recursive partitioning identified refugees 18–64 years of age from countries with a TB incidence greater than 224/100 000 population as a high-yield group, with 1% developing TB within the first 10 years. INTERPRETATION: These findings support recommendations in Canadian guidelines to target postlanding screening for and treatment of LTBI in adult refugees from high-incidence countries. Because high-yield populations can be identified at entry via demographic data, screening at this point may be practical and high-impact, particularly if the LTBI care cascade can be optimized.

Impact of interferon-γ release assay on the latent tuberculosis cascade of care: a population-based study

Latent tuberculosis infection (LTBI) screening and treatment can have a significant impact on TB incidence if a high proportion of at-risk people successfully complete an adequate course of LTBI therapy [1–5]. Patient loss and dropouts occur at multiple points along the LTBI screening and treatment process, ultimately resulting in a minority of high-risk people completing LTBI therapy. To understand the public health impact of new screening and treatment strategies, we need to evaluate the impact of various interventions on the LTBI cascade of care. Sequential TST–IGRA testing may reduce LTBI therapy and improve treatment completion without increasing active TB http://ow.ly/2Kzr307W1tm

Predicting tuberculosis risk in the foreign-born population of British Columbia, Canada: study protocol for a retrospective population-based cohort study

Introduction Improved understanding of risk factors for developing active tuberculosis (TB) will better inform decisions about diagnostic testing and treatment for latent TB infection (LTBI) in migrant populations in low-incidence regions. We aim to examine TB risk factors among the foreign-born population in British Columbia (BC), Canada, and to create and validate a clinically relevant multivariate risk score to predict active TB. Methods and analysis This retrospective population-based cohort study will include all foreign-born individuals who acquired permanent resident status in Canada between 1 January 1985 and 31 December 2013 and acquired healthcare coverage in BC at any point during this period. Multiple administrative databases and disease registries will be linked, including a National Immigration Database, BC Provincial Health Insurance Registration, physician billings, hospitalisations, drugs dispensed from community pharmacies, vital statistics, HIV testing and notifications, cancer, chronic kidney disease and dialysis treatment, and all TB and LTBI testing and treatment data in BC. Extended proportional hazards regression will be used to estimate risk factors for TB and to create a prognostic TB risk score. Ethics and dissemination Ethical approval for this study has been obtained from the University of British Columbia Clinical Ethics Review Board. Once completed, study findings will be presented at conferences and published in peer-reviewed journals. An online TB risk score calculator will also be created.

Emergency Department Visit Rates and Patterns in Canada's Vancouver Coastal Health Region

Cette étude a utilisé des données sur la santé administratives pour décrire des visites effectuées par les résidents de vie assistée et ceux des foyers de soins infirmiers à domicile au service d’urgence (SU) dans la région de Vancouver Coastal Health, Colombie-Britannique. Nous avons comparé taux de visite SU, la répartition des visites par résident, et les dispositions SU des deux populations—d’aide à la vie autonome ou du foyer de soins infirmiers pendant une période de 3 ans (2005-2008). Il y avait 13 051 personnes dans la population étudiée. Taux de visite (intervalle de confiance de 95 pourcent) étaient de 124,8 (118,1 à 131,7) et 64,1 (62,9 à 65,3) visites par 100 ans résidants dans les logements avec assistance et les foyers de soins infirmier à domicile, respectivement. Une plus faible proportion de visites à l’urgence par les résidents de vie assistée ont entraîné une hospitalisation par rapport aux résidents des foyers de soins (45% vs 48%, p<0,01). Le taux de visite à l’urgence chez les résidents de vie assistée est significativement plus élevée par rapport à celle des résidents des foyers de soins. De nouvelles recherches s’imposent sur les causes sous-jacentes de cette constation.This study used administrative health data to describe emergency department (ED) visits by residents from assisted living and nursing home facilities in the Vancouver Coastal Health region, British Columbia. We compared ED visit rates, the distribution of visits per resident, and ED dispositions of the assisted living and nursing home populations over a 3-year period (2005–2008). There were 13,051 individuals in our study population. Visit rates (95% confidence interval) were 124.8 (118.1–131.7) and 64.1 (62.9–65.3) visits per 100 resident years in assisted living and nursing home facilities respectively. A smaller proportion of ED visits by assisted living residents resulted in hospital admission compared to nursing home residents (45% vs. 48%, p < .01). The ED visit rate among assisted living residents is significantly higher compared to that among nursing home residents. Future research is needed into the underlying causes for this finding.