Susan A. Chapman

Patient turnover and the relationship between nurse staffing and patient outcomes

High patient turnover (patient throughput generated by admissions, discharges, and transfers) contributes to increased demands and resources for care. We examined how the relationship between registered nurse (RN) staffing and failure-to-rescue (FTR) varied with patient turnover levels by analyzing quarterly data from the University HealthSystem Consortium. The data included 42 hospitals, representing 759 nursing units and about 1 million inpatients. Higher RN staffing was associated with lower FTR. When patient turnover increased from 48.6% to 60.7% on nonintensive units (non-ICUs), the beneficial effect of non-ICU RN staffing on FTR was reduced by 11.5%. RN staffing should be adjusted according to patient turnover because turnover increases patient care demand beyond that presented by patient count, and outcomes may be adversely affected.

Trends in the Supply of Long-Term-Care Facilities and Beds in the United States

This article examined trends in the supply of institutional long-term-care facilities and beds in states and the United States. Using primary data collected from surveys of state officials, the authors found that licensed nursing home beds increased by 7%, residential care and assisted living beds increased by 97%, and intermediate care facility beds for the mentally retarded and developmentally disabled (ICF-MR/DD) declined by 27% between 1990 and 2002. The total growth in long-term-care beds per 10,000 population was 7.8% during the period, with wide variations in supply among states (ranging from 171 beds per 10,000 in Nebraska to 45.1 beds per 10,000 in Nevada in 2002). Nursing home bed growth may have slowed and ICF-MR/DD beds per population may have declined because of the growth in residential care and assisted living facilities and home and community-based services.

HEALTH PROMOTION AND MANAGED CARE : SURVEYS OF CALIFORNIA'S HEALTH PLANS AND POPULATION

INTRODUCTION The purpose was to examine whether health-promotion programs offered by California health plans are a serious attempt to improve health status or a marketing device used in an increasingly competitive marketplace. The research examined differences in the coverage, availability, utilization, and evaluation of health-promotion programs in California health plans. METHODS A mail survey was done of the 35 HMOs (86% response) and 18 health insurance carriers (83% response) licensed to sell comprehensive health insurance in California in 1996 (some plans sell both HMO and PPO/indemnity products). The final sample included 30 commercial HMOs and 20 PPO and indemnity plans. The 1996 California Behavioral Risk Factor Survey (BRFS) of 4,000 adults was used to estimate population participation rates in health-promotion programs. RESULTS Californias HMOs in 1996 offered more comprehensive preventive benefits and health-promotion programs compared to PPO and indemnity plans. HMOs relied on a more comprehensive set of health-education methods to communicate health information to members and were more likely to open their programs to the public. HMOs are also more likely to have developed relationships with community-based and public health providers. Participation in health-promotion programs is low (2%-3%), regardless of plan type, and most health plans limit evaluations to assessment of member satisfaction and utilization. Only 35%-45% of HMOs, and no PPO/indemnity plans, assess the impact of health-promotion programs on health risks and behaviors, health status, or health care costs. CONCLUSION For the majority of Californias PPO and indemnity plans, health promotion is not an integral part of their business. For the majority of HMOs, health-promotion programs are offered primarily as a marketing vehicle. However, a substantial minority of HMOs offer health-promotion programs to achieve other organizational goals of health improvement and cost control.

Payment Regulations for Advanced Practice Nurses: Implications for Primary Care

The shortage of primary care providers (PCPs) in the United States may be worsened with health reform if more individuals receive health insurance coverage. Previous research suggests that Advanced Practice Registered Nurses (APRNs) can provide as high quality care and achieve the same health outcomes as physicians. However, APRNs are usually reimbursed at lower rates than physicians by both Medicare and Medicaid. Private health insurance regulations and Any Willing Provider laws vary from state to state but in general do little to facilitate the ability of APRNs to be reimbursed for their services or to be credentialed as PCPs. To maximize the utilization of APRNs as PCPs, the payment system should be remodeled. A clear regulatory framework and payment rationale are needed along with data on the type and complexity of care provided by various practitioners to increase efficiencies and improve access to health care.

How have mandated nurse staffing ratios affected hospitals? Perspectives from California hospital leaders.

&NA; In 1999, California became the first state to pass legislation mandating minimum nurse‐to‐patient ratios. Regulations detailing specific ratios by type of hospital unit were released in 2002, with phased‐in implementation beginning in 2004 and completed in 2008. These ratios were implemented at a time of severe registered nurse (RN) shortage in the state and a worsening financial position for many hospitals. This article presents an analysis of qualitative data from interviews with healthcare leaders about the impact of nurse staffing ratios. Twenty hospitals (including public, not‐for‐profit, and for‐profit institutions) representing major geographic regions of California were approached. Twelve agreed to participate; semistructured in‐person and telephone interviews were conducted with 23 hospital leaders. Several key themes emerged from the analysis. Most hospitals found it difficult and expensive to find more RNs to hire to meet the ratios. Meeting the staffing requirements on all units, at all times, was challenging and had negative impacts, such as a backlog of patients in the emergency department and a decrease of other ancillary staff. Hospital leaders do not believe that ratios have had an impact on patient quality of care.

Correlates of intent to leave job and profession for emergency medical technicians and paramedics

Purpose – A very limited number of studies have explored factors related to emergency medical services (EMS) workers leaving their jobs and the profession. This paper aims to investigate the correlates of intent to leave EMS jobs and the profession and compared two types of workers: emergency medical technicians (EMTs) and paramedics.Design/methodology/approach – A national sample of 308 EMTs and 625 paramedics responded to a cross‐sectional survey. Independent variables were personal, job related, and work attitudes (job satisfaction). Outcomes were intent to leave job and profession. Analytic methods included factor analysis, t‐tests, correlation, and hierarchical regression.Findings – Factor analysis identified a five‐item intrinsic job satisfaction measure and a four‐item extrinsic job satisfaction measure across both samples. Contrary to what hypothesis one predicted, paramedics had lower extrinsic job satisfaction than EMTs. There was no difference between these two groups on intrinsic job satisfact...

Coverage of tobacco dependence treatments for pregnant smokers in health maintenance organizations

Approximately 13% of pregnant women in the United States smoke,1 with serious health consequences for themselves and their infants.2–7 However, many women make important changes in health behavior when pregnant and approximately 30% of women smokers quit spontaneously early in their pregnancies.8 In June 2000, the US surgeon general released clinical practice guidelines for smoking cessation programs and recommended that “because of the serious risks of smoking to the pregnant smoker and fetus, whenever possible pregnant smokers should be offered extended or augmented psychosocial interventions that exceed minimal advice to quit.”9 Minimal contact interventions also have been shown to have some benefit for pregnant smokers and their offspring.10–14 We surveyed coverage of prenatal tobacco dependence treatments in health maintenance organizations (HMOs) in California to assess the availability, accessibility, use, and effectiveness of services offered to pregnant smokers. The survey addressed the following services: individual, group, and telephone counseling and self-help kits. The eligible sample included 39 full-service HMOs, all of which responded to the survey. For each HMO, we identified the most knowledgeable staff member to answer the survey. Only 3 HMOs (8%) covered all 4 services. Thirty-six HMOs (92%) covered at least 1 treatment, whereas 3 (8%) covered no tobacco dependence treatments for pregnant women. Seventeen HMOs (44%) reported covering at least 1 additional smoking cessation service, such as nicotine replacement therapy, for pregnant women beyond those about which we asked. Coverage ranged from a low of 44% for self-help kits and individual counseling to a high of 56% for telephone counseling (Figure 1 ▶). FIGURE 1— Coverage of prenatal smoking cessation services among California health maintenance organizations (N = 39). In many cases, HMOs delegated decisions about provision of treatments to the medical groups with which they contract. Among HMOs covering each service, prior authorization requirements for coverage were low. Specialty training requirements were highest for group counseling (57%) and lowest for staff providing self-help kits (18%). Thirteen HMOs (33%) reported having established memoranda of understanding or contractual relationships with other organizations to provide tobacco dependence treatment services to their members. Of the HMOs covering services, only 67% monitored utilization (e.g., keeping lists of participants). Only 28% of these HMOs monitored quit rates among pregnant smokers. Thirty-two of the 39 HMOs (82%) reported that their providers screen all pregnant women for smoking, whereas 7 HMOs (18%) did not know whether screening took place. Medi-Cal managed care plans were more likely to provide coverage for face-to-face services (individual and group counseling) compared with commercial HMOs (Figure 1 ▶). In California, members of Medi-Cal managed care plans may have better access to the most effective, clinically intensive tobacco dependence treatment services, because providers of Medi-Cal managed care are mandated to identify and intervene on risk conditions identified during pregnancy. Our findings suggest that in 1997, most California HMOs were not covering the extended or augmented psychosocial interventions that have been recommended for all pregnant smokers by the US Public Health Service.9,15 Although managed care offers the potential for increasing the availability and accessibility of such services for plan members, this survey suggests that that potential is not being realized. In addition, many California HMOs are unable to judge the use or effectiveness of these services and can neither track the costs and benefits of existing programs nor determine the need for additional services.

Capturing Heterogeneity in Medical Marijuana Policies: A Taxonomy of Regulatory Regimes Across the United States

ABSTRACT Background: There is considerable movement in the U.S. to legalize use of cannabis for medicinal purposes. Twenty-three U.S. states and the District of Columbia have laws that decriminalize use of marijuana for medicinal purposes. Most prior studies of state medical marijuana laws and their association with overall marijuana use, adolescent use, crime rates, and alcohol traffic fatalities have used a binary coding of whether the state had a medical marijuana law or not. Mixed results from these studies raise the question of whether this method for measuring policy characteristics is adequate. Objectives: Our objective was to develop a validated taxonomy of medical marijuana laws that will allow researchers to measure variation in aspects of medical marijuana statutes as well as their overall restrictiveness. Methods/Results: We used a modified Delphi technique using detailed and validated data about each states medical marijuana law. Three senior researchers coded elements of the state laws in initiation of use, quantity allowed, regulations around distribution, and overall restrictiveness. We used 2013 data from the U.S. National Survey on Drug Use and Health to assess validity of the taxonomy. Results indicate substantial state-level variation in medical marijuana policies. Validation analysis supported the taxonomys validity for all four dimensions with the largest effect sizes for the quantity allowed in the states medical marijuana policy. Conclusions/Importance: This analysis demonstrates the potential importance of nondichotomous measurement of medical marijuana laws in studies of their impact. These findings may also be useful to states that are considering medical marijuana laws, to understand the potential impact of characteristics of those laws.

Comparison of Nurse Staffing Measurements in Staffing-Outcomes Research.

Background:Investigators have used a variety of operational definitions of nursing hours of care in measuring nurse staffing for health services research. However, little is known about which approach is best for nurse staffing measurement. Objective:To examine whether various nursing hours measures yield different model estimations when predicting patient outcomes and to determine the best method to measure nurse staffing based on the model estimations. Data Sources/Setting:We analyzed data from the University HealthSystem Consortium for 2005. The sample comprised 208 hospital-quarter observations from 54 hospitals, representing information on 971 adult-care units and about 1 million inpatient discharges. Methods:We compared regression models using different combinations of staffing measures based on productive/nonproductive and direct-care/indirect-care hours. Akaike Information Criterion and Bayesian Information Criterion were used in the assessment of staffing measure performance. Results:The models that included the staffing measure calculated from productive hours by direct-care providers were best, in general. However, the Akaike Information Criterion and Bayesian Information Criterion differences between models were small, indicating that distinguishing nonproductive and indirect-care hours from productive direct-care hours does not substantially affect the approximation of the relationship between nurse staffing and patient outcomes. Conclusions:This study is the first to explicitly evaluate various measures of nurse staffing. Productive hours by direct-care providers are the strongest measure related to patient outcomes and thus should be preferred in research on nurse staffing and patient outcomes.

Job and industry turnover for registered and licensed vocational nurses.

Most studies of nurse turnover focus on job turnover, which could reflect nurse advancement and thus not be detrimental to the workforce. The authors discuss findings from a study that involved 2 cohorts of graduates from registered nursing and licensed vocational nursing community college programs in California. The duration of employment in the healthcare industry, as well as with specific employers, is tracked, lending a more thorough analysis of nursing job and industry turnover than found in other studies.