Implications For Quality Of Care Research Articles

U.S. Hospital Employment of Foreign-Educated Nurses and Patient Experience: A Cross-Sectional Study

IntroductionFor over half a century, hospitals in the United States have actively recruited foreign-educated nurses (FENs) in response to nurse shortages in hospitals and nursing homes. Little attention has been paid to the quality of care in the United States related to employment of FENs. AimsThe purpose of this retrospective study was to determine whether employment of FENs in U.S. hospitals is associated with patient care experience. MethodThis study used cross-sectional data from three sources in 425 hospitals in four large states to evaluate the relationship between patient perceptions of care and hospital employment of FENs. The study linked data from publicly reported patient experience of care surveys, nurse surveys, and administrative data using unique hospital identifiers common across the data sets. ResultsPatient-reported care experience was found to be more negative in hospitals employing more FENs, after controls for other possible explanations. Each 10% increase in FENs was associated with a decrease in the percentage of patients who would recommend their hospital and a decrease in the percentage of patients giving favorable reports on five nursing-specific aspects of patient experience. ConclusionsThe results of this study suggest that employment of substantial numbers of nurses educated outside the United States may have implications for quality of care. The findings suggest that research on the outcomes of transition programs for FENs would be useful to inform regulatory policies.

Management of bone health in postmenopausal women on aromatase inhibitors (AIs): a single health care system experience.

Aromatase inhibitors (AIs) are the preferred therapy for postmenopausal women with early-stage estrogen receptor-positive breast cancers. However, their use causes bone loss and increased risks of osteoporosis and fractures. This is a retrospective review of all postmenopausal women with breast cancer diagnosed and treated with AI between 2010 and 2015. Of the 564 women identified, 319 were eligible. The median age at AI initiation was 65years (range 51-85years), and the median duration of AI therapy was 28months (1-72months). The median number of DEXA scans per woman was 1 (0-4), performed at a median frequency of 24months (1-48months). Recommendations for calcium and vitamin D were in 66 and 59% of women, respectively. There were 52 (16%) women who received antiresorptive treatments with bisphosphonates (69%), denosumab (25%), or both drugs (6%). Based on guideline recommendations from six societies, starting antiresorptive treatment was unnecessary in 15-54% of women. In this single health system experience, women start antiresorptive drugs that are unnecessary in 15-52%. These results highlight the nonuniformity in guideline recommendations, and this has implications for quality of care, cost-effectiveness, and value-of-care analyses for preventing fractures.

Do public nursing home care providers deliver higher quality than private providers? Evidence from Sweden

BackgroundSwedish nursing home care has undergone a transformation, where the previous virtual public monopoly on providing such services has been replaced by a system of mixed provision. This has led to a rapidly growing share of private actors, the majority of which are large, for-profit firms. In the wake of this development, concerns have been voiced regarding the implications for care quality. In this article, we investigate the relationship between ownership and care quality in nursing homes for the elderly by comparing quality levels between public, for-profit, and non-profit nursing home care providers. We also look at a special category of for-profit providers; private equity companies.MethodsThe source of data is a national survey conducted by the Swedish National Board of Health and Welfare in 2011 at 2710 nursing homes. Data from 14 quality indicators are analyzed, including structure and process measures such as staff levels, staff competence, resident participation, and screening for pressure ulcers, nutrition status, and risk of falling. The main statistical method employed is multiple OLS regression analysis. We differentiate in the analysis between structural and processual quality measures.ResultsThe results indicate that public nursing homes have higher quality than privately operated homes with regard to two structural quality measures: staffing levels and individual accommodation. Privately operated nursing homes, on the other hand, tend to score higher on process-based quality indicators such as medication review and screening for falls and malnutrition. No significant differences were found between different ownership categories of privately operated nursing homes.ConclusionsOwnership does appear to be related to quality outcomes in Swedish nursing home care, but the results are mixed and inconclusive. That staffing levels, which has been regarded as a key quality indicator in previous research, are higher in publicly operated homes than private is consistent with earlier findings. The fact that privately operated homes, including those operated by for-profit companies, had higher processual quality is more unexpected, given previous research. Finally, no significant quality differences were found between private ownership types, i.e. for-profit, non-profit, and private equity companies, which indicates that profit motives are less important for determining quality in Swedish nursing home care than in other countries where similar studies have been carried out.

Type of oral solid medication packaging and medication preparation time in nursing homes: A direct observation study.

Medication administration is a substantial portion of the workday in nursing homes, with the medication preparation step being the most time-consuming. However, little is known about how medication preparation time is affected by the type of packaging used for oral solid medications (ie, tablets/capsules). We examined the effects of two types of packaging. As fewer steps are associated with strip packaging compared to bingo card packaging, we hypothesized that the increase in medication preparation seconds per resident with each additional oral solid medication would be smaller when strip packaging was used. A total of 430 medication preparations conducted by eight nurses during the regularly scheduled morning medication administration period in two nursing homes-using strip packaging and bingo card packaging, respectively-were observed. Each medication preparation observation was matched to its corresponding medication administration record and observations averaged across resident. Using the resident sample (N=149), we estimated three regression models (adjusting the standard errors for the clustering of resident by nurse). The first model regressed medication preparation seconds on the number of oral solid medications. The second model added the type of packaging used and the control variables (type of unit [long-term care, post-acute care], the number of one-half pills and the dosage form diversity in the preparation). To test our hypothesis, the third model added an interaction term between the number of oral solid medications and the type of packaging used. As hypothesized, all else equal, the number of oral solid medications tended to increase medication preparation time per resident in both nursing homes, but the increase was smaller in the strip packaging nursing home (P<.05). Each additional oral solid medication in the bingo card packaging nursing home increased medication preparation by an average of 13seconds (b=13.077), whereas each oral solid medication administered in the strip packaging nursing home increased medication preparation by an average of only 8seconds (13.077-5.092=7.985). This is a difference on average of about 5seconds per oral solid medication. To our knowledge, we were the first to examine the effect of type of oral solid medication packaging on medication preparation time in nursing homes. Type of packaging matters. The time saved using strip packaging (vs bingo card packaging) has implications for quality of care and the movement towards person-centred care in the nursing home sector. Nurses (or other staff tasked with medication preparation) in nursing homes using strip packaging potentially have more time to devote to nurturing a relationship with the resident. However, time saved in medication preparation by strip packaging is counterproductive if a serious error results. Thus, future studies should investigate the effects of type of packaging on medication preparation errors.

The Shifting Landscape in Utilization of Inpatient, Observation, and Emergency Department Services Across Payers.

Recent policies by public and private payers have increased incentives to reduce hospital admissions. Using data from four states from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, this study compared the payer-specific population-based rates of adults using inpatient, observation, and emergency department (ED) services for 10 common medical conditions in 2009 and in 2013. Patients had an expected primary payer of private insurance, Medicare, Medicaid, or no insurance. Across all four payer populations, inpatient admissions declined, and care shifted toward treat-and-release observation stays and ED visits. The percentage of hospitalizations that began with an observation stay increased. Implications for quality of care and costs to patients warrant further examination. Journal of Hospital Medicine 2017;12:443-446.

Social Dominance Orientation, Dispositional Empathy, and Need for Cognitive Closure Moderate the Impact of Empathy-Skills Training, but Not Patient Contact, on Medical Students' Negative Attitudes toward Higher-Weight Patients.

Anti-fat bias in healthcare providers and medical students has serious implications for quality of care of higher-weight patients. Studies of interventions aimed at reducing anti-fat attitudes in medical students have generally been disappointing, with little enduring effect. It is possible that some students may be more receptive to prejudice-reducing influences than others, due to underlying differences in their personal characteristics. It is also possible that attitudes toward patients, specifically, may differ from anti-fat attitudes in general, and prejudice-reduction effectiveness on patient-specific attitudes has not yet been evaluated. The present study explored the effect on general and patient-specific anti-fat attitudes of (1) contact with higher-weight individuals prior to and during medical school; and (2) training designed to increase medical students' empathy toward patients by encouraging them to take the patient's perspective during clinical encounters. The moderating role of individual difference factors on effectiveness of contact and student-reported hours of empathy training on patient-specific attitudes was assessed. A total of 3,576 students enrolled across 49 US medical schools completed an online survey at the start of their first year of medical school and at the end of their fourth year. Favorable contact experience with higher-weight patients predicted improved attitudes toward heavier patients after 4 years of medical school, and appeared sufficient to partially offset the effects of dislike of higher-weight individuals at baseline. The impact of favorable contact on general anti-fat attitudes was less strong, highlighting the importance of using target-specific outcome measures. The positive effects of favorable contact on attitudes toward higher-weight patients did not differ based on students' baseline levels of social dominance orientation, dispositional empathy, or need for cognitive closure. In contrast, the effectiveness of training did vary by student characteristics, generally being more effective in students who were more egalitarian and empathic at baseline, with little effect, or even adverse effects in students low in these traits. Overall, however, perspective-taking training produced only small improvements in attitudes toward higher-weight patients.

A Multicriteria Model for Optimization of Maintenance in Thermal Energy Production Systems in Hospitals: A Case Study in a Spanish Hospital

Health Care Organizations are large consumers of energy resources. This is due to the large number of services they must offer continuously, the strict requirements of temperature and humidity for patients and comfort for all visitors. Facilities for thermal energy production are critical as they guarantee the proper working of care services by producing primary air, eliminating legionella, and providing air conditioning to theatres, emergency areas, ICUs, neonatology departments, etc. Nonetheless, despite the importance of thermal energy production systems, there is no prior literature analysing the best maintenance to be applied to these systems. This study describes an innovative multicriteria model designed with the Measuring Attractiveness by a Categorical Based Evaluation Technique (MACBETH) approach and Markov chains, in choosing the best combination of maintenance policies to guarantee the best quality of care. The model was created with the co-operation of a decision group made up of those in charge of different areas of a Health Care Organization. This gives the current availability of the thermal energy production systems, and the availability that would be achieved by applying other alternatives. In the system that produces hot water for the air conditioning units, the best alternative is found to be corrective and preventive maintenance. In the cold-water production system for air conditioning, the model recommends the use of corrective, preventive and predictive maintenance, monitored by vibration analysis. For the systems producing hot domestic water and hot and cold water for other systems, corrective and preventive maintenance is recommended. In the legionella treatment system, it is best to apply corrective, preventive and periodic predictive maintenance (quarterly by combustion analysis). Finally, the implications for quality of care of changing the maintenance alternatives are considered. This research was carried out on thermal energy production systems currently operational in the University General Hospital of Ciudad Real (Spain). The methodology used in this study, together with the criteria, descriptors, weightings, etc., may serve as a standard for other Health Care Organizations, with the final goal of improving quality of care.

Current Understandings of the Research–Practice Gap From the Viewpoint of Complementary Medicine Academics: A Mixed-Method Investigation

Research plays an important role in advancing health and healthcare. However, much research evidence is not reflected in contemporary complementary and alternative medicine (CAM) practice. Understanding and addressing the reasons for this research-practice gap may have positive implications for quality of care. To shed light on the gap between research and CAM practice. Descriptive cross-sectional, mixed-method study. A total of 126 senior CAM academics across Australasia, Europe, UK, and North America. Participants completed a 30-item online survey and a semi-structured interview; both of which explored the research-practice gap in CAM. A total of 43 (34%) academics completed the survey, with 29 (67%) respondents undergoing an interview. There was general agreement among respondents that CAM research should be informed by practice, and practice informed by research; however, most agreed that this did not reflect the current situation. Translational issues were perceived to be the primary reason for the research-practice gap in CAM. Suggested strategies for closing the gap focussed mostly around improving CAM student/practitioner education and training, and researcher-practitioner engagement and collaboration. Study findings point toward the presence of a research-practice gap in CAM, with several factors likely to be instrumental in sustaining this gap. Attention now needs to focus on understanding the views of CAM clinicians on this issue. Insights gained from this research will help inform the development of a multi-modal strategy that will effectively target the barriers to change in order to bring CAM research and practice closer together.

Contextual Errors in Medical Decision Making: Overlooked and Understudied.

Although it is widely recognized that effective clinical practice requires attending to the circumstances and needs of individual patients-their life context-rather than just treating disease, the implications of not doing so are rarely assessed. What are, for instance, the consequences of prescribing a medication that is appropriate for treating a clinical condition but inappropriate for a particular individual either because she or he cannot afford it, lacks the skills to administer it correctly, or is unable to adhere to the regimen because of competing responsibilities such as working the night shift? Conversely, what are the gains to health and health care when such contextual factors are addressed? Finally, can performance measures be employed and developed for the clinician behaviors associated with contextualizing care to guide improvements in care? The authors have explored these questions through observational and experimental studies to define the parameters of patient context, introduce strategies for measuring clinician attention to patient context, and assess the impact of that attention on care planning, patient health care outcomes, and costs. The authors suggest that inattention to patient context is an underrecognized cause of medical error ("contextual error"), that detecting its presence usually requires listening in on the visit, and that it has significant implications for quality of care. Also described is preliminary work to reduce contextual errors. Evidence suggests that this nascent area of research has significant implications for performance assessment and medical education in addressing deficits in quality of care.

Primary Care Providers Ordered Fewer Preventive Services For Women With Medicaid Than For Women With Private Coverage.

As the number of beneficiaries in the Medicaid program grows under the Affordable Care Act, with over half of the states opting to expand Medicaid eligibility, it is important to understand more about the care provided to Medicaid patients. Using visit-level data for 2006-10 from the National Ambulatory Medical Care Survey, we examined the provision of recommended preventive services to women with Medicaid and those with private insurance at visits to primary care providers in private office-based practices. We found that after patient and provider characteristics were controlled for, Medicaid-insured visits were less likely than privately insured visits to include several preventive services, including clinical breast exams and Pap tests. The differences in provision of services by payer were generally driven by the differences in care at visits classified as preventive and at visits to obstetrician-gynecologists. Further investigation is required to determine what may be driving the differences in content of care across payers and their implications for quality of care.

Complexity of ambulatory care across disciplines

BackgroundComplexity of care has implications for quality of care, health costs, medical errors, and patient and physician satisfaction. The objective was to compare complexity of ambulatory care across 14 medical specialties. MethodsThis secondary analysis uses the 2010 National Ambulatory Medical Care Survey, which used a multistage probability design of primary sampling units throughout U.S. ambulatory practices across 14 specialties. Sampling weights enable results from 29,179 ambulatory visits to represent 878,653,561 visits. Data included symptoms, diagnoses, diagnostic procedures, and treatments provided. Measures of input, output and total encounter complexity and hourly complexity densities were computed. ResultsInternal Medicine leads in total input and total encounter complexity with Family Medicine second in total encounter complexity. When duration-of-visit is considered, Family Medicine is the most complex discipline while Internal Medicine is the second most complex. Pediatrics lacks the complexity of Family Medicine and General Internal Medicine, and OB/GYN bears little similarity to Family Medicine or General Internal Medicine. ConclusionsFamily Medicine and Internal Medicine encounters are the most complex overall, especially when duration-of-visit is considered. ImplicationsRevaluing payments based on complexity could bring better balance to cognitive and procedural services, and better meet the needs of people receiving insurance under the ACA.

Who is looking after Mom and Dad? Unregulated workers in Canadian long-term care homes.

Older adults living in residential long-term care or nursing homes have increasingly complex needs, including more dementia than in the past, yet we know little about the unregulated workforce providing care. We surveyed 1,381 care aides in a representative sample of 30 urban nursing homes in the three Canadian Prairie provinces and report demographic, health and well-being, and work-related characteristics. Over 50 per cent of respondents were not born in Canada and did not speak English as their first language. They reported moderately high levels of burnout and a strong sense of their work's worth. Few respondents reported attending educational sessions. This direct caregiver workforce is poorly understood, has limited training or standards for minimum education, and training varies widely across provinces. Workplace characteristics affecting care aides reflect factors that precipitate burnout in allied health professions, with implications for quality of care, staff health, and staff retention.

Task shifting in the provision of home and social care in Ontario, Canada: implications for quality of care.

Growing healthcare costs have caused home-care providers to look for more efficient use of healthcare resources. Task shifting is suggested as a strategy to reduce the costs of delivering home-care services. Task shifting refers to the delegation or transfer of tasks from regulated healthcare professionals to home-care workers (HCWs). The purpose of this paper is to explore the impacts of task shifting on the quality of care provided to older adults from the perspectives of home healthcare workers. This qualitative study was completed in collaboration with a large home and community care organisation in Ontario, Canada, in 2010-2011. Using a purposive sampling strategy, semi-structured telephone interviews were conducted with 46 home healthcare workers including HCWs, home-care worker supervisors, nurses and therapists. Study participants reported that the most common skills transferred or delegated to HCWs were transfers, simple wound care, exercises, catheterisation, colostomies, compression stockings, G-tube feeding and continence care. A thematic analysis of the data revealed mixed opinions on the impacts of task shifting on the quality of care. HCWs and their supervisors, more often than nurses and therapists, felt that task shifting improved the quality of care through the provision of more consistent care; the development of trust-based relationships with clients; and because task shifting reduced the number of care providers entering the client's home. Nurses followed by therapists, as well as some supervisors and HCWs, expressed concerns that task shifting might compromise the quality of care because HCWs lacked the knowledge, training and education necessary for more complex tasks, and that scheduling problems might leave clients with inconsistent care once tasks are delegated or transferred. Policy implications for regulating bodies, employers, unions and educators are discussed.

A multicentre survey of acute hospital nursing staff training in dementia care

Purpose: This paper reports on results of a study to identify education needs of nurses in acute care environments regarding dementia care in Ireland. Method: As part of a multicentre study of dementia prevalence and in-hospital course, a survey was conducted with nurses (n=151) in six acute hospitals in the south of Ireland. Data were analysed using descriptive statistics. Findings: Despite the availability of a national dementia education programme across all care services, 83% of acute hospital nursing staff perceived that they had insufficient training in dementia care, reflecting the known poor uptake of offered dementia education in acute hospitals. Over two thirds of nurses felt that education on dementia specific communication strategies was insufficient or unavailable. Nurses also reported insufficient knowledge with regard to pain assessment in patients with dementia, or alternatives to physical or chemical restraint. This lack of knowledge has implications for quality of care and may have consequences for safety of patients with dementia in acute hospitals in Ireland. Conclusion: With the expected growth in prevalence of dementia worldwide, more people with dementia will access acute hospital care. Education and training to improve dementia care needs to be prioritised in acute hospitals at senior level.

Presentismo en Enfermería. Implicaciones en seguridad del paciente. Posibilidades de control y reducción

We begin to find studies and research oriented towards the idea that poorer health and welfare of health care workers may have important implications for quality of care and safety that patients receive. The emerging phenomenon of presenteeism, referred to those employees who despite being sick or injury that would force them to absent, report to work, serves as an example to try to explain this reality.Objectives: Try to answer the following questions: Is nursing a presentist profession?, Why nurses do not call in sick? What implications does have this behaviour for Patient Safety? What chance have nursing supervisors and managers of health institutions to control and reduce presenteeism in their organizations?Methodology: A review of the available scientific evidence literature in Castilian and English between 1995 and 2011 was conducted in order to try to answer the following questions: Database used were Medline, Pubmed, Scopus, Cuiden, CSIC- ISOC y PsycINFO. Search was completed with references and intuitive search in Google. We found 57 items of which 48 were selected.Results: The nursing profession, with care-and-welfare and education sector at the primary level are one of the professional groups with significantly higher rates of presenteeism compared with other professions. A large number of variables, both organizational and individual have been described as presenteeism predictors, i.e. facilitate and increase the likelihood that a sick nurse go to work. Conclusions: There is still a small number of research focused on presenteeism in the field of health institutions. Experts in occupational health, health management or quality or care should include this new phenomenon in their agendas, designing research to try to find a better scientific evidence.

Health Information Technology in Urologic Care: Current Status and Implications for Quality of Care

Health information technology (HIT) is expected to transform the delivery of health care in the United States, but implementation and adoption vary widely across settings, specialties, and geographies. Significant barriers to high-level adoption persist despite federal incentives to hospitals and health-care providers. This article will review the current status and future impact of HIT in the specialty of urology, with emphasis on the intersection of HIT and quality measurement.

Extremity soft tissue tumor surgery by surgical specialty: A comparison of case volume among oncology and non-oncology-designated surgeons

We sought to characterize the extent of extremity soft tissue tumor (ESTT) resections among surgical specialties, hypothesizing that substantial variation exists in the number of ESTT resections performed by specialty. We queried the UHC-AAMC database for data from 85 institutions for years 2007-2009. We abstracted data on total number of musculoskeletal (MSK) procedures, number of subcutaneous (SQ), deep, and malignant ESTT resections, and anatomic site of resection. Data were available for 4,682 practitioners including the following specialties: general surgery (GS, N = 2,195), plastic surgery (PS, N = 792), surgical oncology (SO, N = 533), general orthopedics (GO, N = 1,079), and orthopedic oncology (OO, N = 83). The mean number of all MSK procedures performed per year was 19.0 ± 2.3 GS, 179.6 ± 3.0 PS, 32.4 ± 6.2 SO, 798.6 ± 115.4 GO, and 482.9 ± 6.5 OO (P = 0.001). SQ ESTT resections per year were similar among specialties (1.7 ± 0.3 GS, 2.7 ± 0.3 PS, 2.4 ± 0.4 SO, 1.7 ± 0.5 GO, 4.7 ± 0.2 OO), while deep and malignant resections were more likely performed by OO (combined deep and malignant: 0.9 ± 0.1 GS, 2.0 ± 0.4 PS, 9.9 ± 0.6 SO, 5.8 ± 0.3 GO, and 63.6 ± 8.1 OO, P = 0.001). Adjusting for number of physicians in the database, of the total deep and malignant ESTT resections, 9.4% were performed by GS, 7.7% by PS, 26.0% by SO, 30.8% by GO, and 26.0% by OO. Nearly 50% of deep and malignant ESTT resections are performed by non-oncology-designated surgeons. Approximately 17% are performed by practitioners who complete an average of one to two of these procedures per year. These findings may have significant implications for quality of care in soft tissue tumor surgery.

Cost-effectiveness of a health-social partnership transitional program for post-discharge medical patients

BackgroundReadmissions are costly and have implications for quality of care. Studies have been reported to support effects of transitional care programs in reducing hospital readmissions and enhancing clinical outcomes. However, there is a paucity of studies executing full economic evaluation to assess the cost-effectiveness of these transitional care programs. This study is therefore launched to fill this knowledge gap.MethodsCost-effectiveness analysis was conducted alongside a randomized controlled trial that examined the effects of a Health-Social Transitional Care Management Program (HSTCMP) for medical patients discharged from an acute regional hospital in Hong Kong. The cost and health outcomes were compared between the patients receiving the HSTCMP and usual care. The total costs comprised the pre-program, program, and healthcare utilization costs. Quality of life was measured with SF-36 and transformed to utility values between 0 and 1.ResultsThe readmission rates within 28 (control 10.2%, study 4.0%) and 84 days (control 19.4%, study 8.1%) were significantly higher in the control group. Utility values showed no difference between the control and study groups at baseline (p = 0.308). Utility values for the study group were significantly higher than in the control group at 28 (p < 0.001) and 84 days (p = 0.002). The study group also had a significantly higher QALYs gain (p < 0.001) over time at 28 and 84 days when compared with the control group. The intervention had an 89% chance of being cost-effective at the threshold of £20000/QALY.ConclusionsPrevious studies on transitional care focused mainly on clinical outcomes and not too many included cost as an outcome measure. Studies examining the cost-effectiveness of the post-discharge support services are scanty. This study is the first to examine the cost-effectiveness of a transitional care program that used nurse-led services participated by volunteers. Results have shown that a health-social partnership transitional care program is cost-effective in reducing healthcare costs and attaining QALY gains. Economic evaluation helps to inform funders and guide decisions for the effective use of competing healthcare resources.

Will the NP Workforce Grow in the Future?

The nurse practitioner (NP) workforce has been a focus of considerable policy interest recently, particularly as the Patient Protection and Affordable Care Act may place additional demands on the healthcare professional workforce. The NP workforce has been growing rapidly in recent years, but fluctuation in enrollments in the past decades has resulted in a wide range of forecasts. To forecast the future NP workforce using a novel method that has been applied to the registered nurse and physician workforces and is robust to fluctuating enrollment trends. An age-cohort regression-based model was applied to the current and historical workforce, which was then forecasted to future years assuming stable age effects and a continuation of recent cohort trends. A total of 6798 NPs who were identified as having completed NP training in the National Sample Survey of Registered Nurses between 1992 and 2008. The future workforce is projected to grow to 244,000 in 2025, an increase of 94% from 128,000 in 2008. If NPs are defined more restrictively as those who self-identify their position title as "NP," supply is projected to grow from 86,000 to 198,000 (130%) over this period. The large projected increase in NP supply is higher and more grounded than other forecasts and has several implications: NPs will likely fulfill a substantial amount of future demand for care. Furthermore, as the ratio of NPs to Nurse Practitioners to physicians will surely grow, there could be implications for quality of care and for the configuration of future care delivery systems.

Differences between non-profit and for-profit hospices: patient selection and quality

This research compares the behavior of non-profit organizations and private for-profit firms in the hospice industry, where there are financial incentives created by the Medicare benefit. Medicare reimburses hospices on a fixed per diem basis, regardless of patient diagnosis. Because under this system patients with lower expected costs are more profitable, hospices can selectively enroll patients with longer lengths of stay. While it is illegal for hospices to reject potential patients explicitly, they can influence their patient mix through referral networks. A fixed per diem rate also creates an incentive shirk on quality and to substitute lower skilled for higher skilled labor, which has implications for quality of care. By using within-market variation in hospice characteristics, the empirical evidence suggests that for-profit hospices differentially take advantage of these incentives. The results show that for-profit hospices engage in patient selection through significantly different referral networks than non-profits. They receive more patients from long-term care facilities and fewer patients through more traditional paths, such as physician referrals. This mechanism of patient selection is supported by the result that for-profits have fewer cancer patients and more patients with longer lengths of stay. While non-profit and for-profit hospices report similar numbers of staff visits per patient, for-profit firms make significantly less use of skilled nursing providers. We also find some weak evidence of lower levels of quality in for-profit hospices.