Higher nurse staffing levels in both intensive care units and in non-ICUs improve patient outcomes but not to the same extent in safety net hospitals that serve more vulnerable populations, according to a study published in the current issue of Medical Care.
The University HealthSystem Consortium study reviewed data from 1.1 million adult patients from 872 units (285 of them ICUs) in 54 hospitals, plus the hours of care that nurses provided to those patients. The study was funded by the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative.
An interdisciplinary team of nurse administrators, health service researchers, and health economists found that while the staffing levels were similar in safety net and non-safety net hospitals, patient outcomes were worse in safety net hospitals.
In non-safety net hospitals, higher nurse staffing rates and a larger number of registered nurses were associated with:
Fewer deaths due to congestive health failure
Fewer incidents in which nurses did not note or initiate treatment in life-threatening situations (failure to rescue)
Lower rates of infection, including infection after operations (postoperative sepsis)
Fewer patients who were required to stay in the hospital for longer than expected
“Higher levels of nursing skill and more nurses providing more hours of care, overall, are correlated with better care–shorter hospital stays, fewer infections and lower rates of failure to rescue,” says lead investigator Mary Blegen, RN, professor in Community Health Systems and director of the Center for Patient Safety at the University of California San Francisco School of Nursing.
“We suspect that the increase in mortality rates due to congestive heart failure in safety net hospitals are a function of patients’ overall health, rather than staffing rates, but more research needs to be done. We also need to know more about how non-RNs affect patient care,” Blegen says.
Earlier this month, a study published in The New England Journal of Medicine found that inpatient mortality goes up significantly when a hospital has greater patient turnover and when it fails to meet its own nurse staffing targets by at least eight hours.
Federal inspectors said they see nothing illegal about a free local transportation arrangement that would shuttle patients from physicians' offices to an adjacent hospital.
The nonprofit hospital, whose name was redacted in the opinion, had asked the Office of Inspector General at the Department of Health and Human Services if the complimentary shuttle service the hospital wants to offer would violate anti-kickback statutes and other federal laws against self-referrals.
The hospital wants to make available a free wheelchair-accessible van, driven by a licensed EMT employed by the hospital, for patients and their families. The van would transport patients needing evaluation and treatment at the hospital and who are unable to transport themselves from the 41 physicians' offices located on or adjacent to the hospital's 108-acre campus,
The hospital said the shuttle is needed because its campus has limited parking far from public entrances; walkways are difficult for feeble, elderly patients to navigate; and there are limited public transportation services.
OIG said that the shuttle service would not violate anti-kickback or self-referral statutes if:
The arrangement would not selectively limit eligibility to targeted populations of federal healthcare program beneficiaries. Patient eligibility would be uniformly determined by the physicians in accordance with the hospital's written policy.
The shuttle service would be reasonable in cost and not include expensive transportation such as limousines.
The arrangement would only be offered locally from the physicians' offices located on or contiguous to the hospital, at a distance of no more than a one-quarter mile.
The service would not be advertised.
The hospital certified that the availability of local public transportation and parking is limited.
The cost of the transportation would not be included on any federal healthcare program cost reports or claims, nor shifted to any federal healthcare program.
A survey of women military veterans has found widespread distrust and dissatisfaction with healthcare services offered by the Department of Veterans Affairs.
The survey of 3,012 U.S. military women veterans worldwide released this week by the American Legion measured 10 attributes of VA service quality, including: reliability, responsiveness, competence, access, courtesy, communication, credibility, security, tangibles and understanding the customer.
The perception of the Veterans Affair healthcare system is dim. "Many women veterans have either chosen not to enroll in VA services, or are unaware of the medical benefits they have earned through their service in the Armed Forces. Other Women Veterans may have negative or ambivalent perceptions of healthcare delivery through the VA Healthcare System," the report says.
"Research on this subject is important, yet it's lacking," said Verna Jones, director of the American Legion's Veterans Affairs & Rehabilitation Division.
"Women represent a vastly growing portion of U.S. veterans, comprising almost 20% of our armed forces and representing the fastest growing population of the VA healthcare system."
Among the findings of The American Legion Women Veterans Survey Report:
One in three female VA healthcare users reported they were dissatisfied with their most recent experience with VA's Women Veterans Program Manager, who counsels female patients in the system. The survey suggests there is room for significant improvement for VA to provide gender-specific services such as PAP smears and mammograms.
38% of the survey's respondents said they wouldn't use a VA doctor for a second opinion – even if that opinion was offered at no charge.
Nearly 40% of female veterans say they're dissatisfied with the mandatory screening process for military sexual trauma.
About 30% of respondents reported that they were not allowed an appropriate amount of time with their provider to discuss their specific health-related issues.
38% expressed at least some level of dissatisfaction when asked to compare the credibility of healthcare provided by VA against similar services provided by private practitioners – 11% were "very dissatisfied."
Almost 25% of the respondents rated the convenience of VA facilities locations as poor, indicating that gender-specific care is difficult to obtain for a significant number of women.
More than 25% of those surveyed expressed dissatisfaction with VA in security-related issues – especially the degree of sensitivity surrounding a patient's personal information.
Approximately 25% of the respondents said they were dissatisfied with the level of competence demonstrated by VA healthcare providers when compared to private practitioners.
Almost 25% of the respondents gave VA a courtesy rating of less than positive.
The online, 67-question survey was conducted in January by ProSidian Consulting, LLC, based in Charlotte, NC.
Only about 25 percent of the 1.8 million Women Veterans are using the Department of Veterans Affairs (VA) Healthcare System.
"We found in our survey about 66% of the women not only registered for VA healthcare service, but they also maintained their private healthcare service," said Adrian Woolcock, managing principal of ProSidian. "In addition in that subset, only 40% have ever used VA. The women veterans overall do know what their benefits are. It's really a matter of focusing on improving the quality of service provided to women veterans."
Jones said the survey results provided insight about the gap between desired and actual performance of the VA healthcare system for women using it. Of the 2,936 respondents who answered that specific question, 63% were enrolled in the VA healthcare system. Of those, almost 30% were dissatisfied with the "reliability" of healthcare provided by the VA when compared to private healthcare providers, and more than 30% were dissatisfied when they compared the "responsiveness" of VA to that of private healthcare providers.
"The results from this survey will be used to refine The American Legion's outreach efforts (and) enhance its written and oral testimony to Congress and federal agencies," Jones said. "The survey results will also help identify unmet needs among women veterans and guide the development of strategic remedies."
More than one-third of respondents were between ages 52 and 61, and 25% were ages 42-51.
Eighty percent were white, and more than 68% were non-combat veterans.
Some of the veterans who took the survey said they didn't want a separate VA healthcare system for women; rather, they want the same quality healthcare that men receive but tailored to meet gender-specific needs. Others said they hesitate to use VA facilities because they can't get child care on the days of their appointments.
"Changes in culture take time, and VA is starting to change its approach dealing with women veterans," said American Legion National Commander Jimmie L. Foster said. "The American Legion wants to help VA make this important transition. VA health care needs to be more reliable, responsive and competent in its treatment of women."
A copy of the 82-page survey was delivered to VA Secretary Eric Shinseki this week during the Legion's 51st Annual Washington Conference.
Consumers are spending $363 billion -- 14.7% more -- on healthcare than what is conventionally cited in government accounts when unreported costs such as unpaid supervisory care from friends and relatives are factored in, according to a study from the Deloitte Center for Health Solutions.
This unreported spending identified in the Deloitte report, The Hidden Costs of U.S. Health Care for Consumers: A Comprehensive Analysis falls outside of traditionally counted healthcare costs such as doctors, prescriptions, hospitals, and health insurance coverage. Those additional costs identified by Deloitte bump consumer discretionary spending on healthcare from 16.2%, for items traditionally reported by the government, to 19.9%. That makes healthcare spending the largest single household budget item, surpassing housing and utility costs at 18.8%.
“There are two important takeaways from this report,” Paul Keckley, executive director, Deloitte Center for Health Solutions, told HealthLeaders Media. “One is that we have to define healthcare more broadly than doctors, hospitals, prescription drugs, and insurance. We have to define it the way consumers define it. When they are buying an over-the-counter remedy it could be instead of going to a doctor or a hospital.”
“Second, we have to tackle this question of supervisory care, of the lost wages that people are now bearing to take care of medical problems for family members,” he said.
Fifty-five percent in the unreported costs -- $199 billion – identified by Deloitte, were for the estimated value of supervisory care, or care given by unpaid relatives and friends, almost all of which was provided to people living in lower income families. Keckley called the estimate, based on lost wages of $12.60 an hour “very conservative.” The $199 billion also does not reflect the loss of sales and income taxes that would have otherwise been paid, he said.
The other $164 billion in expenditures includes:
15% for “functional foods” and other nutritional products, and vitamin and mineral supplements;
8% for complementary and alternative medicine services and products
8% for mental health services
6% for blood banks and health promotion programs
4% for homes for the elderly
3% for ambulance services
“This is hitting the pocketbook because these are part of the household budget,” Keckley says. “These are not touching insurance programs. The significance of the study is not just the $363 billion, which is a big deal, but that healthcare is now the No. 1 category of expenditures in discretionary spending in the household. It’s above housing costs. You can envision that certain households are having to make everyday decisions about forgoing other things like travel or even food because you have increasing number of dollars going to healthcare.”
Individuals living in families earning less than $10,000 per year accounted for 11% of all healthcare costs in 2009. The shares for families earning $10,000-$25,000, $25,000-$50,000, and $50,000-$100,000 were 21%, 25%, and 26%, respectively. The study also noted that:
Total U.S. healthcare expenditures in 2009 were an estimated $2.83 trillion --a 26% increase from $2.25 trillion in 2005.
U.S. healthcare spending is dominated by big ticket, “necessary expenditure” items of hospital care ($760 billion, or 27% of total expenditures), professional care ($832 billion, or 29%), and prescription drugs ($246.3 billion, or 9%).
Total discretionary costs for direct and indirect healthcare totaled $1,892 per capita in 2009.
One-person family units comprised 24% of total healthcare expenditures, with two-person families accounting for 37%.
Healthcare costs for people 65+ made up 36% of the total ($1.01 trillion). Senior healthcare use concentrates on hospitals, long-term care, supervisory care, and physicians/clinical services.
Keckley says healthcare costs are “feeding on themselves” and growing so quickly that they threaten other vital areas of the economy. “Over 40 years there has been an average [annual] 4.9% increase. Not too many people have seen their wages grow at that level,” he said. “The more impact that healthcare has over the pocketbook, it is clear the economy doesn’t recover as fast. Seventy percent of the economy is built on consumer consumption. If more and more dollars are not spent in retail or travel or in various manufactured items, then the economy doesn’t recover the way people anticipate.”
“It is a conundrum. You have an industry that is a big part of the economy, almost 18%. It creates a lot of jobs. But if more and more of the economy is dependent upon healthcare to make itself affordable, then you’ve put it in conflict with itself,” he said.
To help decelerate healthcare costs, Keckley said, the public must change from passive patients to smart consumers. He said the healthcare reforms enacted last year provide consumers with tools that enhance transparency, rate physician and hospital quality, help select health plans, and explain treatment options and costs. “But you still run up against the question of ‘what is going to motivate a consumer to make better choices?’” he says. “That is probably the big hanging chad here. We don’t see that in the near-term. It is part of healthcare’s biggest challenge -- a transition from a patient-orientation to a consumer market. That is an industry challenge, a government challenge. It is also a personal challenge.”
And that challenge could prove daunting. Keckley says surveys have shown that consumers prefer to have their healthcare decisions made by doctors or others. “It may point back at the lack of will on the part of Americans to really be engaged in their own healthcare,” he says. “It may be easier to say ‘the system is not working than’ it is to say ‘and we are part of the problem.’”
Office-based physicians contributed $1.4 trillion in economic activity and supported four million jobs nationwide, according to a state-by-state study from the American Medical Association.
The findings show the economic impact of office-based physicians as measured through sales revenue, jobs, wages and benefits, and tax revenue. The report provides information on the economic impact of office-based physicians in all 50 states and the District of Columbia. The median state supported $10.3 billion in economic activity and supported more than 46,400 jobs in 2009.
“Although physicians are primarily focused on providing excellent patient care, physician offices and the jobs and revenue they produce are significant contributors to national and state economies,” said AMA President Cecil B. Wilson, MD. “This study illustrates that office-based physicians contribute to both the health of their patients and also to the economic health of their communities.”
When compared to other industries, office-based physicians almost always contribute more to state economies than each of the following: hospital, legal, nursing home and home health, the study says.
The Institute of Medicine issued two reports on Wednesday that it said will provide an objective and consistent framework for clinical practice guidelines, and standardize systematic reviews of comparative effectiveness.
The eight standards promoted in Clinical Practice Guidelines We Can Trust include recommendations for establishing transparency in the practice, managing conflict of interest, external review, and group composition development.
"These standards are necessary given that there is little documentation to judge the quality and reliability of many of the existing clinical practice guidelines," said Sheldon Greenfield, MD, executive director, Health Policy Research Institute, University of California, Irvine, and chair of the IOM committee on guidelines. "Practice guidelines provide valuable data and guidance that not only inform individual decisions about care but ultimately could also improve overall healthcare quality and outcomes."
IOM's second report, Finding What Works in Health Care: Standards for Systematic Reviews, addresses the myriad and often competing guidelines for clinical recommendations by offering what it said are 21 standards to ensure objective, transparent, and scientifically valid reviews.
"This report presents the 'gold standard' to which those who conduct systematic reviews should aspire to achieve the most reliable and useful products," said Alfred O. Berg, MD, professor of family medicine, University of Washington School of Medicine, Seattle, and chair of the committee that wrote the report on systematic reviews.
"We recognize that it will take an investment of resources and time to achieve such high standards, but they should be adopted to minimize the chances that important health decisions are based on information that may be biased or erroneous," Berg said.
The studies were requested by Congress and sponsored by the Department of Health and Human Services.
Carilion Clinic President and CEO, Edward Murphy, MD, announced Wednesday that on June 30 he will leave the health system he has led for 10 years. Carilion Clinic COO Nancy Howell Agee was named Murphy's replacement by the board of the Roanoke, VA-based not-for-profit health system, effective July 1.
Murphy has taken a job with TowerBrook Capital Partners L.P., a New York- and London-based investment firm, where he will help develop and acquire businesses that deal with physician management and alignment, care coordination, and the development of accountable care organizations.
Murphy will also chair the board of Sound Physicians, a Tacoma, WA-based hospitalist staffing company. He will continue to serve on the board at Carilion and remain on the faculty of the Virginia Tech Carilion School of Medicine, which he helped create.
Since becoming president and CEO of Carilion in 2001, Murphy led Carilion through its transition from a hospital-based system to a multi-specialty clinic, which now includes more than 600 physicians, hospitals, and outpatient centers serving one million people in Virginia. He joined Carilion in 1998 as COO.
Murphy's work on the reorganization is credited with laying the foundation for Carilion's collaboration with Aetna -- announced March 10 -- to build an accountable care organization in southwest Virginia that will feature co-branded insurance plans for individuals and businesses.
"The decision to leave Carilion was difficult, but the time is right," Murphy said. "At Carilion, the building blocks for successful transformation are in place, especially in light of our new relationship with Aetna. The organization is in good position to move forward with excellent, stable leadership. This opportunity with TowerBrook and Sound Physicians will allow me to work on hospital/physician integration and ACO development, nationally."
Agee began her career in nursing at Carilion, serving in various management roles over the past 20 years. In 1996 she was appointed vice president medical education. In 2000 she became senior vice president of the organization, advancing to executive vice president/COO in 2001. At the beginning of 2011, Agee was appointed president/CEO of Carilion Medical Center.
"This is a unique organization, with truly remarkable people, and I am honored to have this opportunity," Agee said. "I still remember the faces of my patients back in 1973 and as I see our patients today I know that even with new technology, new facilities and a new medical school our core mission remains the same – providing high-quality, coordinated, compassionate care tailored to meet the individual needs of our patients every day."
Agee's successor as COO of Carilion Clinic has yet to be named.
Despite the high costs and heavy demand for atrial fibrillation services, states aren't providing their residents with the resources to address and manage the chronic disease, research suggests.
AFib in America: State Impact Reports identifies key state-by-state statistics, resources and state health department programs related to the impact of AFib. It was written by The George Washington University School of Public Health and Health Services.
AFib is the most common form of heart arrhythmia, affecting 2.5 million Americans, and its prevalence is expected to increase as the population ages. AFib increases risk for stroke by five times, worsens other heart diseases, and doubles the risk of death. Patients with AFib tend to use more healthcare services than patients without AFib, including time in the hospital, the report says.
Medicare payments where AFib was the primary diagnosis totaled almost $2.3 billion in 2007, of which nearly half of the costs were related to hospital inpatient stays, according to the report.
"Atrial fibrillation is costly and can become debilitating as it worsens, yet it does not share the same priority on the public health agenda that other chronic diseases have," said Prof. Christy Ferguson, of the Department of Health Policy, School of Public Health and Health Services, GWU. "This report calls attention to the lack of resources about AFib, alerting policymakers, state health officials, and other health leaders to better educate residents about this common but misunderstood disease."
Despite the health and economic burden of AFib, no state has a public health program specifically dedicated to educating or supporting patients with AFib. State-level public health programs generally include AFib as a part of stroke and heart disease prevention efforts, rather than focusing on the specific risks and consequences of AFib, the report says.
"Just as patients need to comprehensively manage their AFib, health leaders need to develop and implement comprehensive programs that address the impact of AFib in their home states," said Bill Frist, MD, former U.S. Senate Majority Leader and policy advisor for AF Stat.
Frist said there is an incorrect assumption at the state level that Medicare will absorb much of the costs associated with AFib. "Individual states feel AFib's impact on their residents' health, productivity, and quality of life. Local hospitals and providers often assume the burden of repeated hospitalizations and care for AFib patients. As health leaders work to lower the costs of expensive chronic diseases, AFib must be a part of the discussion," Frist said.
Connecticut is the state with the highest percentage (8.8) of Medicare recipients who have used healthcare services because of AFib. Hawaii is the state with the least (3.3%).
The research was financed by drugmaker Sanofi-Aventis U.S., LLC.
Coupling electronic prescription drug ordering with computer reporting of adverse events can dramatically reduce medication errors in psychiatric units, Johns Hopkins researchers say.
"Medication errors are a leading cause of adverse events in hospitals," says study leader Geetha Jayaram, MD, an associate professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. "With the use of electronic ordering, training of personnel and standardized information technology systems, it is possible to eliminate dangerous medication errors."
The findings, published in the March issue of The Journal of Psychiatric Practice, detail how the 88-bed psychiatric unit at The Johns Hopkins Hospital in Baltimore went from a medication error rate of 27.89 per 1,000 patient days in 2003 to 3.43 per 1,000 patient days in 2007. During the study period there were no medication errors that caused death or serious, permanent harm, the study said.
Potentially lethal medication errors can be caused by illegible handwriting, misinterpretation of orders, caregiver fatigue, pharmacy dispensing errors and administration mistakes. "Having something typed eliminates bad writing — and most errors — immediately," Jayaram said. "It's a good reason for going electronic."
The computer program used in the psychiatric department, and hospital-wide at Johns Hopkins, includes integrated decision support for drug dosage selection, drug allergy alerts, drug interactions, patient identifiers and monitoring — data that can be lost with a manual system that relies on layers of human beings, Jayaram said, adding that the more the number of steps involved in the process, the greater the likelihood of mistakes.
At the time that the drug ordering system was installed, Hopkins began using the Patient Safety Net error reporting system, a Web-based reporting tool. When a mistake is made it is to be reported on the PSN. This system allows for follow up, corrective action, and the ability to learn from common mistakes. It also categorizes unsafe conditions and near-miss events.
Jayaram says the HIT programs have helped to create a "culture of safety" in the psychiatry department, along with annual safety training, reporting of all adverse events as they occur, and feedback that focuses not by blaming, but on how to prevent a reoccurrence through education and corrective action.
While medication mistakes involving psychotropic drugs are rarely deadly, Jayaram said psychiatric patients also take other kinds of medication — insulin, blood thinners, and others that can be lethal if given in the wrong doses or in the wrong combination. In a psychiatric department some nonpsychotropic medications are considered high-risk and, as a precaution, two nurses must check them off before they are administered.
Even with computerized backstops, Jayaram said complacency can be a problem and new problems can arise so the system is constantly evolving. "You have to be vigilant for new problems that might come up," she said.
Trauma patients who've been hurt in car or bike crashes, shot, stabbed, or suffered other injuries are more likely to live if they arrive at the hospital on the weekend than during the week, according to a study from the University of Pennsylvania School of Medicine.
The research, published in the current issue of Archives of Surgery, also shows that trauma patients who present to the hospital on weeknights are no more likely to die than those who present during the day, contrasting previous studies showing a so-called "weekend effect" in which patients with emergent illnesses such as heart attacks and strokes fare worse when they're hospitalized at night or on weekends.
The study found that the trauma system's unique organization and staffing appears to serve as a built-in protection for these critically injured patients, and may provide a roadmap for restructuring and coordinating emergency care.
"Whether patients have an emergent illness or a severe injury, the common denominator is time. Patients must rely on the system to quickly get them to the place that's best prepared to save their lives," said Brendan G. Carr, MD, an assistant professor in the departments of Emergency Medicine and Biostatistics and Epidemiology, and a lead author of the study. "Trauma systems have been designed to maximize rapid access to trauma care, and our results show that the system also offers special protection for patients injured during periods that are known to be connected to worse outcomes among patients with time-sensitive illnesses."
The researchers studied 90,461 patients who were treated from 2004 to 2008 at Pennsylvania's 32 accredited trauma centers. About 25% of the patients presented to the hospital on weeknights -- defined as 6 p.m. to 9 a.m. Monday through Friday -- and about 40% arrived on weekends -- 6 p.m. Friday to 9 a.m. on Monday. Neither the weekend or night patient groups experienced delays for crucial brain or abdominal surgeries often required for trauma patients, compared to weekday patients, the study found.
Unlike most other medical and surgical specialties – in which staffing and resources vary on nights and weekends – trauma centers are required to have round-the-clock resources for emergency medicine, radiology, surgery, and post-operative intensive care immediately available 24 hours a day, seven days a week, 365 days a year.
The report suggests that the greater odds of survival on weekends may be influenced by hospital scheduling. Since elective surgeries are typically not performed on weekends, there is less competition for practitioners' time, operating rooms, blood bank, pharmacy and other hospital resources.
Despite the indication that trauma patients may, overall, be safer during off hours, the findings revealed that both weeknight and weekend presentation was associated with longer ICU stays, and those who came to the hospital on weeknights were more likely to have a longer hospital stay overall than those who were admitted on a weekday. The report said this may be due to hospital factors not entirely related to the patient's condition, including greater bed availability because few elective admissions and surgeries occur on weekends.
"It is unrealistic to think that all hospitals can be fully staffed to provide optimal care for all time-sensitive conditions all of the time, so our challenge is to develop an integrated system of emergency care for unplanned -- but inevitable -- critical illness," Carr said. "The trauma system has a plan of care in place long before we ever need it, and it offers many lessons for the remainder of emergency care."
