The determinants of improvements in health outcomes and of cost reduction in hospital inpatient care

This study aims to address two research questions. First, ‘Can we identify factors that are determinants both of improved health outcomes and of reduced costs for hospitalized patients with one of six common diagnoses?’ Second, ‘Can we identify other factors that are determinants of improved health outcomes for such hospitalized patients but which are not associated with costs?’ The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database from 2003 to 2006 was employed in this study. The total study sample consisted of hospitals which had at least 30 patients each year for the given diagnosis: 954 hospitals for acute myocardial infarction (AMI), 1552 hospitals for congestive heart failure (CHF), 1120 hospitals for stroke (STR), 1283 hospitals for gastrointestinal hemorrhage (GIH), 979 hospitals for hip fracture (HIP), and 1716 hospitals for pneumonia (PNE). This study used simultaneous equations models to investigate the determinants of improvement in health outcomes and of cost reduction in hospital inpatient care for these six common diagnoses. In addition, the study used instrumental variables and two-stage least squares random effect model for unbalanced panel data estimation. The study concluded that a few factors were determinants of high quality and low cost. Specifically, high specialty was the determinant of high quality and low costs for CHF patients; small hospital size was the determinant of high quality and low costs for AMI patients. Furthermore, CHF patients who were treated in Midwest, South, and West region hospitals had better health outcomes and lower hospital costs than patients who were treated in Northeast region hospitals. Gastrointestinal hemorrhage and pneumonia patients who were treated in South region hospitals also had better health outcomes and lower hospital costs than patients who were treated in Northeast region hospitals. This study found that six non-cost factors were related to health outcomes for a few diagnoses: hospital volume, percentage emergency room admissions for a given diagnosis, hospital competition, specialty, bed size, and hospital region.^

An analysis of the shortage of registered nurses (RNs) in acute care hospitals in El Paso, Texas

The purpose of this analysis of the shortage of Registered Nurses (RNs) in acute care hospitals in El Paso, Texas, was to evaluate twenty-two specific organizational and/or patient care unit (nursing unit) characteristics that effect the retention and turnover of professional nurses. Vacancy Rates were used to measure the level of the shortage in each hospital and nursing unit in the study. Vacancy Rates are a function of both RN retention and RN turnover. Seventy-three patient care units in five acute care hospitals were included in the study population.^ Fredrick Herzberg's motivational - hygiene theory was used to explain the types of characteristics or factors that can effect worker dissatisfaction. Dissatisfiers (hygiene factors) are those work place characteristics that influence workers to leave the job. The twenty-two potentially dissatisfying work place characteristics were either organizational or patient care unit specific in nature. The focus of the study was to evaluate high vacancy rates caused by both low retention of RNs and high turnover rates. Retention and turnover are a function of workers (RNs) not staying in their jobs, therefore hygiene factors were appropriate characteristics to study.^ Various multivariate analysis techniques were used to assess both the individual and combined effects of the hygiene factors on Vacancy Rates, Retention and Turnover. Results suggest that certain organizational and patient care unit characteristics are associated with and have a statistically significant effect on vacancy rates, and the retention and turnover of RNs. The type of Hospital was of particular interest in this regards. For-Profit facilities were less effected by most of the study variables than the Not-for-Profits. ^

Prenatal care content and utilization among pregnant women enrolled in managed care programs in Harris County, Texas

This research study was conducted as a descriptive study of prenatal care experiences of women enrolled in public and private managed care programs. The study's aim was to describe the demographic characteristics of the women in the study and to analyze and compare their prenatal care experiences. ^ The objective of this study was to examine the research question: Do pregnant women enrolled in Medicaid Managed Care receive the same level of care as women enrolled in other Managed Care Programs in Harris County, Texas? ^ The study population was a convenience sample of pregnant women enrolled in managed care programs who presented to one of the two hospital study sites for delivery of their infant. The study utilized a self administered survey to measure adequacy and content of prenatal care received by the women during this pregnancy. Adequacy of prenatal care utilization was determined based on the Kessner Index criteria of timing of initiation of care and number of visits. Content of care was measured by the number of different medical services the women reported they had received and the number of health information topics the women reported on which they had received information. Demographic characteristics were described with univariate and bivariate statistics of frequencies and cross tabulations. Associations were evaluated using measures of linear correlations. ^ Results from the study showed there is an association between enrollment in Medicaid Managed Care (public) and prenatal care received compared to women enrolled in other Managed Care Programs (private). The results were derived from statistical tests on data the postpartum women gave when they completed the self-administered survey. Provider type was a moderate predictor of quality and quantity of prenatal care. The results also indicate that in the study population, minority ethnicity, income and lower educational status were associated with intermediate and inadequate prenatal care. ^

Evaluation of environmental contamination of Clostridium difficile associated diarrhea in hospital rooms at St. Luke's Episcopal Hospital (SLEH) and review of literature on environmental sampling

The study was carried out at St. Luke's Episcopal Hospital to evaluate environmental contamination of Clostridium difficile in the infected patient rooms. Samples were collected from the high risk areas and were immediately cultured for the presence of Clostridium difficile . Lack of microbial typing prevented the study of molecular characterization of the Clostridium difficile isolates obtained led to a change in the study hypothesis. The study found a positivity of 10% among 50 Hospital rooms sampled for the presence of Clostridium difficile. The study provided data that led to recommendations that routine environmental sampling be carried in the hospital rooms in which patients with CDAD are housed and that effective environmental disinfection methods are used. The study also recommended molecular typing methods to allow characterization of the CD strains isolated from patients and environmental sampling to determine their type, similarity and origin.^

Variation in hospital inpatient charges by payer in Houston, Texas

An analysis of variation in hospital inpatient charges in the greater Houston area is conducted to determine if there are consistent differences among payers. Differences in charges are examined for 59 Composite Diagnosis Related Groups (CDRGs) and two regression equations estimating charges are specified. Simple comparison of mean charges by diagnostic categories are significantly different for 42 (71 percent) of the 59 categories examined. In 41 of the 42 significant categories, charges to Medicaid were less than charges to private insurers. Meta-analytic statistical techniques yielded a weighted average effect size of $-$0.7198 for the 59 diagnostic categories, indicating an overall effect that Medicaid charges were less than private insurance charges. Results of a multiple regression estimating charges showed that private insurance was a significant independent variable, along with age, length of stay, and hospital variables. Results indicated consistent differential charges in the present analysis. ^

Cross-culture perspectives on fear of HIV disease and AIDS in health care workers

Health care workers have been known to carry into the workplace a variety of judgmental and negative attitudes towards their patients. In no other area of patient care has this issue been more pronounced as in the management of patients with AIDS. Health care workers have refused to treat or manage patients with AIDS and have often treated them more harshly than identically described leukemia patients. Some health care institutions have simply refused to admit patients with AIDS and even recent applicants to medical colleges and schools of nursing have indicated a preference for schools in areas with low prevalence of HIV disease. Since the attitudes of health care workers do have significant consequences on patient management, this study was carried out to determine the differences in clinical practice in Nigeria and the United States of America as it relates to knowledge of a patient's HIV status, determine HIV prevalence and culture in each of the study sites and how they impact on infection control practices, determine the relationship between infection control practices and fear of AIDS, and also determine the predictors of safe infection control practices in each of the study sites.^ The study utilized the 38-item fear of AIDS scale and the measure of infection control questionnaire for its data. Questionnaires were administered to health care workers at the university teaching hospital sites of Houston, Texas and Calabar in Nigeria. Data was analyzed using a chi-square test, and where appropriate, a student t-tests to establish the demographic variables for each country. Factor analysis was done using principal components analysis followed by varimax rotation to simple structure. The subscale scores for each study site were compared using t-tests (separate variance estimates) and utilizing Bonferroni adjustments for number of tests. Finally, correlations were carried out between infection control procedures and fear of AIDS in each study site using Pearson-product moment correlation coefficients.^ The study revealed that there were five dimensions of the fear of AIDS in health care workers, namely fear of loss of control, fear of sex, fear of HIV infection through blood and illness, fear of death and medical interventions and fear of contact with out-groups. Fear of loss of control was the primary area of concern in the Nigerian health care workers whereas fear of HIV infection through blood and illness was the most important area of AIDS related feats in United States health care workers. The study also revealed that infection control precautions and practices in Nigeria were based more on normative and social pressures whereas it was based on knowledge of disease transmission, supervision and employee discipline in the United States, and thus stresses the need for focused educational programs in health care settings that emphasize universal precautions at all times and that are sensitive to the cultural nuances of that particular environment. ^

THE MEASUREMENT OF HUMANISTIC AND DEHUMANISTIC BEHAVIORS IN HOSPITAL NURSING ENVIRONMENTS

The purpose of this investigation was to develop a reliable scale to measure the social environment of hospital nursing units according to the degree of humanistic and dehumanistic behaviors as perceived by nursing staff in hospitals. The study was based on a conceptual model proposed by Jan Howard, a sociologist. After reviewing the literature relevant to personalization of care, analyzing interviews with patients in various settings, and studying biological, psychological, and sociological frames of reference, Howard proposed the following necessary conditions for humanized health care. They were the dimensions of Irreplaceability, Holistic Selves, Freedom of Action, Status Equality, Shared Decision Making and Responsibility, Empathy, and Positive Affect.^ It was proposed that a scale composed of behaviors which reflected Howard's dimensions be developed within the framework of the social environment of nursing care units in hospitals. Nursing units were chosen because hospitals are traditionally organized around nursing care units and because patients spend the majority of their time in hospitals interacting with various levels of nursing personnel.^ Approximately 180 behaviors describing both patient and nursing staff behaviors which occur on nursing units were developed. Behaviors which were believed to be humanistic as well as dehumanistic were included. The items were classified under the dimensions of Howard's model by a purposively selected sample of 42 nurses representing a broad range of education, experience, and clinical areas. Those items with a high degree of agreement, at least 50%, were placed in the questionnaire. The questionnaire consisted of 169 items including six items from the Marlowe Crowne Social Desirability Scale (Short Form).^ The questionnaire, the Social Environment Scale, was distributed to the entire 7 to 3 shift nursing staff (603) of four hospitals including a public county specialty hospital, a public county general and acute hospital, a large university affiliated hospital with all services, and a small general community hospital. Staff were asked to report on a Likert type scale how often the listed behaviors occurred on their units. Three hundred and sixteen respondents (52% of the population) participated in the study.^ An item analysis was done in which each item was examined in relationship to its correlation to its own dimension total and to the totals of the other dimensions. As a result of this analysis, three dimensions, Positive Affect, Irreplaceability, and Freedom of Action were deleted from the scale. The final scale consisted of 70 items with 26 in Shared Decision Making and Responsibility, 25 in Holistic Selves, 12 in Status Equality, and seven in Empathy. The alpha coefficient was over .800 for all scales except Empathy which was .597.^ An analysis of variance by hospital was performed on the means of each dimension of the scale. There was a statistically significant difference between hospitals with a trend for the public hospitals to score lower on the scale than the university or community hospitals. That the scale scores should be lower in crowded, understaffed public hospitals was not unexpected and reflected that the scale had some discriminating ability. These differences were still observed after adjusting for the effect of Social Desirability.^ In summary, there is preliminary evidence based on this exploratory investigation that a reliable scale based on at least four dimensions from Howard's model could be developed to measure the concept of humanistic health care in hospital settings. ^

Comparison of two strategies for the treatment of acute myocardial infarction: In-hospital outcomes analysis

A strategy of pre-hospital reduced dose fibrinolytic administration coupled with urgent coronary intervention (PCI) for patients with STEMI (FAST-PCI) has been found to be superior to primary PCI (PPCI) alone. A coordinated STEMI system-of-care that includes FAST-PCI might offer better outcomes than pre-hospital diagnosis and STEMI team activation followed by PPCI alone. We compared the in-hospital outcomes for patients treated with the FAST-PCI approach with outcomes for patients treated with the PPCI approach during a pause in the FAST-PCI protocol. In-hospital data for 253 STEMI patients (03/2003–12/2009), treated with FAST-PCI protocol were compared to 124 patients (12/2009–08/2011), treated with PPCI strategy alone. In-hospital mortality was the primary endpoint. Stroke, major bleeding, and reinfarction during index hospitalization were secondary endpoints. Comparing the strategies used during the two time intervals, in-hospital mortality was significantly lower with FAST-PCI than with PPCI (2.77% vs. 10.48%, p = 0.0017). Rates of stroke, reinfarction and major bleeding were similar between the two groups. There was a lower frequency of pre- PCI TIMI 0 flow (no patency) seen in patients treated with FAST-PCI compared to the PPCI patients (26.7% vs. 62.7%, p<0.0001). Earlier infarct related artery patency in the FAST-PCI group had a favorable impact on the incidence of cardiogenic shock at hospital admission (FAST-PCI- 3.1% vs. PPCI- 20.9%, p<0.0001). The FAST-PCI strategy was associated with earlier infarct related artery patency and the lower incidence of cardiogenic shock on hospital arrival, as well as with reduced in-hospital mortality among STEMI patients.^

A Time-Motion Study of Registered Nurses’ Workflow in Intensive Care Unit Remote Monitoring

Utilizing advanced information technology, Intensive Care Unit (ICU) remote monitoring allows highly trained specialists to oversee a large number of patients at multiple sites on a continuous basis. In the current research, we conducted a time-motion study of registered nurses’ work in an ICU remote monitoring facility. Data were collected on seven nurses through 40 hours of observation. The results showed that nurses’ essential tasks were centered on three themes: monitoring patients, maintaining patients’ health records, and managing technology use. In monitoring patients, nurses spent 52% of the time assimilating information embedded in a clinical information system and 15% on monitoring live vitals. System-generated alerts frequently interrupted nurses in their task performance and redirected them to manage suddenly appearing events. These findings provide insight into nurses’ workflow in a new, technology-driven critical care setting and have important implications for system design, work engineering, and personnel selection and training.

Grandparents in Kinship Care: Help or Hindrance to Family Preservation

The phenomenon of grandparents and other relatives raising children is a tradition rooted in the African American culture. However, a substantial increase in the number of relatives raising children has drawn attention to the child welfare system. Many of the biological parents are incarcerated for drugs or suffering from other social ills. Kinship care is an important component of family preservation and prevents court intervention based on child protection concerns and avoids formal placement of children in the child welfare system (Wilkerson, 1999). The child welfare system, however, is not conducive to this phenomenon. Placing children with grandparents and relatives allows them to live with people they know and trust; reduces the initial trauma of living with unknown persons; supports the transmission of identity, culture, and ethnicity; facilitates connections with brothers and sisters, and strengthens a family’s ability to provide the support they need.

Partnering with Parents: Promising Approaches to Improve Reunification Outcomes for Children in Foster Care

Family reunification is one of the central tenents of the child welfare system, yet research supporting effective practices to promote safe reunifications is limited. As a departure from previous initiatives, the Parent Partner (PP) program enlists as staff mothers and fathers who have experienced child removal, services, and reunification. This study examines outcomes for children served by the PP program. The experimental group includes 236 children whose parents were served by a Parent Partner and a matched comparison group of 55 children whose parents were served by the public child welfare agency in 2004, before the Parent Partner program was established. Cases were examined 12 months following case opening to determine reunification status. Results from the outcome study indicate that reunification may be more likely for children whose parents were served by Parent Partners. Although there are limitations to the data, findings from this study suggest that the Parent Partner model may hold promise as a child welfare intervention designed to support reunification.

Commentary on "Partnering with Parents: Promising Approaches to Improve Reunification Outcomes for Children in Foster Care"

In “Partnering with Parents: Promising Approaches to Improve Reunification Outcomes for Children in Foster Care,” authors J. D. Berrick, Edward Cohen and Elizabeth Anthony describe promising outcomes from a quasi-experimental study of reunification outcomes associated with the Parent Partner program in one western county

Commentary on "Grandparents in Kinship Care: Help or Hindrance to Family Preservation"

Invited commentary on "Grandparents in Kinship Care: Help or Hindrance to Family Preservation."