Short-term General Hospitals Research Articles

An analysis of state-reported hospital transfer data of urology patients

Background We examined the trends over time of urology patient transfers in rural and urban settings, at the state level, to better characterize transfer trends in the United States. Materials and methods Data were collected from the State Inpatient Database and Emergency Department Database produced by the Healthcare Cost and Utilization Project. We reviewed the data of all the patients who had been transferred 1 or more times between 2014 and 2016. The data reviewed were from all nonfederal, short-term general hospitals in the states of Arkansas, Florida, Iowa, Nebraska, and New York. The transfers were categorized into emergency department (ED)–to–ED transfers, inpatient-to-inpatient transfers, and ED-to-inpatient transfers at the different facilities. Results Overall, 3.33% (17,519/526,126) of all patient transfers were specific to urology. The mean age of the transferred patients specific to urology was 64.7 years, with 55% of these patients being females. Most of the transferred patients resided in nonmetropolitan or small-metropolitan areas (79.2%). Many transfers occurred at night (43.4%) and during weekends (27.3%). In 2014, the more rural states of Arkansas, Iowa, and Nebraska had higher transfer rates (>35 transfers per 100,000 inhabitants) compared with the more urban states of Florida and New York (both <10 transfers per 100,000). Medicare was significantly more likely to be the payer in the rural states (66%–82%) than in the more populated states (52%–58%). Conclusions We found significant differences in hospital transfer patterns between rural and highly populated states. Understanding these key differences may help in the optimization of hospital transfers, potentially lowering costs, improving patient outcomes, and enhancing patient experience of care.

An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019

Attention to 10th Revision of the International Classification of Disease (ICD-10)-CM Z-codes as a mechanism for capturing social risk has grown over the years. However, it remains unclear whether the use of Z-codes has changed over time. This study sought to examine the trends in Z-code use between their introduction in 2015 and the end of 2019 across 2 markedly different states. Using the Healthcare Cost and Utilization Project, all emergency department visits or hospitalizations at short-term general hospitals in Florida and Maryland from 2015 Q4 through 2019 were identified. This study focused on a subset of the Z-codes that are intended to capture social risk to identify the percentage of encounters with a Z-code, percentage of facilities using Z-codes, and facility median of number of encounters with a Z-code per 1000 encounters across quarters, states, and care settings. In total, 495,212 (0.84%) of 58,993,625 encounters had a Z-code. Despite Florida's higher area deprivation, Z-codes were less frequently used and increasing more slowly than when compared with those in Maryland. There were 2.1 times the use of Z-codes in Maryland than in Florida at the encounter level. This difference was also seen when evaluating the median number of encounters with a Z-code, per 1000 encounters (12.1 vs. 3.4). Z-codes were more commonly used at major teaching facilities, and for patients who were uninsured or on Medicaid. The use of ICD-10-CM Z-codes has increased over time, with this increase occurring at nearly all short-term general hospitals. Their use was higher in Maryland than in Florida and among major teaching facilities.

1049-P: Finding Equity: Utilizing Artificial Intelligence to Identify Social and Infrastructural Predictors of Diabetes Mortality in Florida

DM outcomes represent one of the largest avoidable cost burdens with opportunity for improvement in the U.S. health care system. Improving health equity in the context of DM will require targeted community improvements, infrastructure investments, and policy interventions that are designed to maximize the impact of resource allocation through the use of available data and computational resources. By using an Artificial Intelligence approach to evaluate over 2000 socio-economic and infrastructural predictors of DM mortality, this study used a specific series of modeling techniques to identify significant predictors without human selection and compare their predictive ability with all possible factors when passed through artificial neural networks. The final regression model using zip code and county level predictors had an R2 of 0.863. Significant predictors included: Population % White, Population % Householders, Population % Spanish spoken at home, Population % Divorced males, Population % With public health insurance coverage, Population % Employed with private health insurance coverage, Manufacturing-Dependent Designation, Low Education Designation, Population % Medicare Part A and B Female Beneficiaries, Number of Short Term General Hospitals with 50-99 Beds. Using a multi-layered perceptron to predict zip codes at risk the C-statistic for all 2000+ predictors was 0.7938 while the 13 selected predictors was 0.8232. This indicates that these factors are highly relevant for DM mortality in Florida. This process was completed without the need of human variable selection and indicates how AI can be used for informative precision public health analyses for targeted population health management efforts. Disclosure A. Cistola: None.

Understanding Costs of Care in the Operating Room

ImportanceIncreasing value requires improving quality or decreasing costs. In surgery, estimates for the cost of 1 minute of operating room (OR) time vary widely. No benchmark exists for the cost of OR time, nor has there been a comprehensive assessment of what contributes to OR cost.ObjectivesTo calculate the cost of 1 minute of OR time, assess cost by setting and facility characteristics, and ascertain the proportion of costs that are direct and indirect.Design, Setting, and ParticipantsThis cross-sectional and longitudinal analysis examined annual financial disclosure documents from all comparable short-term general and specialty care hospitals in California from fiscal year (FY) 2005 to FY2014 (N = 3044; FY2014, n = 302). The analysis focused on 2 revenue centers: (1) surgery and recovery and (2) ambulatory surgery.Main Outcomes and MeasuresMean cost of 1 minute of OR time, stratified by setting (inpatient vs ambulatory), teaching status, and hospital ownership. The proportion of cost attributable to indirect and direct expenses was identified; direct expenses were further divided into salary, benefits, supplies, and other direct expenses.ResultsIn FY2014, a total of 175 of 302 facilities (57.9%) were not for profit, 78 (25.8%) were for profit, and 49 (16.2%) were government owned. Thirty facilities (9.9%) were teaching hospitals. The mean (SD) cost for 1 minute of OR time across California hospitals was $37.45 ($16.04) in the inpatient setting and $36.14 ($19.53) in the ambulatory setting (P = .65). There were no differences in mean expenditures when stratifying by ownership or teaching status except that teaching hospitals had lower mean (SD) expenditures than nonteaching hospitals in the inpatient setting ($29.88 [$9.06] vs $38.29 [$16.43]; P = .006). Direct expenses accounted for 54.6% of total expenses ($20.40 of $37.37) in the inpatient setting and 59.1% of total expenses ($20.90 of $35.39) in the ambulatory setting. Wages and benefits accounted for approximately two-thirds of direct expenses (inpatient, $14.00 of $20.40; ambulatory, $14.35 of $20.90), with nonbillable supplies accounting for less than 10% of total expenses (inpatient, $2.55 of $37.37; ambulatory, $3.33 of $35.39). From FY2005 to FY2014, expenses in the OR have increased faster than the consumer price index and medical consumer price index. Teaching hospitals had slower growth in costs than nonteaching hospitals. Over time, the proportion of expenses dedicated to indirect costs has increased, while the proportion attributable to salary and supplies has decreased.Conclusions and RelevanceThe mean cost of OR time is $36 to $37 per minute, using financial data from California’s short-term general and specialty hospitals in FY2014. These statewide data provide a generalizable benchmark for the value of OR time. Furthermore, understanding the composition of costs will allow those interested in value improvement to identify high-yield targets.

Effects of Expanded California Health Coverage on Hospitals: Implications for ACA Medicaid Expansions.

To assess the effects on hospitals of early California actions to expand insurance coverage for low-income uninsured adults after passage of the Affordable Care Act. Data from the California Office of Statewide Health Planning and Development and the California Department of Health were merged with U.S. census data for 294 short-term general hospitals during the period 2009-2012. A difference-in-difference analysis was conducted with hospitals in counties that did not implement insurance expansions used as a comparison group. Variables examined included payer mix, costs of unreimbursed care, and hospital operating margin. Sensitivity analyses were conducted as well as a triple difference analysis. Effects were estimated for hospitals overall and by ownership type. California insurance expansions primarily benefited for-profit hospitals, with these facilities experiencing significant decreases in self-pay patients, increases in county-covered patients, and reductions in charity care. Most models yielded no significant change in payer mix and conflicting changes in unreimbursed care for nonprofit hospitals. California hospitals that treated the most uninsured prior to insurance expansions did not as a group experience substantial benefit in terms of reduced uninsured burden or better financial performance after program expansions occurred.

Stroke Legislation Impacts Distribution of Certified Stroke Centers in the United States.

The number of certified primary stroke centers (PSCs) have increased dramatically during the past decade in the United States We aimed to understand the factors affecting PSC distribution in the United States, including the impact of state stroke legislation. PSCs certified by national organization or state until December 2013 were searched from available databases. The proportion of PSC among short-term general hospitals in each state was calculated and factors affecting its distribution were analyzed. By the end of 2013, the proportion of PSC varied from 4% to 100% among the 50 states and District of Columbia. The 18 states that had legislation in designating stroke centers and regulating stroke triage had higher PSC percentages (median, 43%; range, 13%-100%) than the remaining states (median, 13%; range, 4%-75%; P<0.001). State stroke legislation, urbanization, state economic output, and larger hospital size independently increased the likelihood of a hospital to be stroke certified. From 2009 to 2013, states with stroke legislation had greater increase of PSC percentages when compared with the states without legislation (median increase, 16% versus 6%; P=0.0067). Among the 1505 stroke centers, 74% were certified by the Joint Commission, 20% by state, and 6% by other organizations. Stroke centers certified only by state were smaller in size by hospital bed count compared with those certified by the Joint Commission (P<0.001). State stroke legislation, a generalizable intervention, increased the number of certified stroke centers in the United States, potentially improving accessibility of standardized care for patients with acute ischemic stroke.

Abstract 302: Stroke Legislation Impacts Distribution of Certified Stroke Centers in the United States

Objectives: The Joint Commission (JC) began certifying primary stroke centers (PSC) in 2003 to improve the stroke system of care. Several states passed legislation to designate PSCs and regulate emergent stroke triage. The number of PSCs have increased dramatically over the past decade in the U.S. We aimed to understand the factors affecting PSC distribution in the U.S, especially the impact of state stroke legislation. Methods: PSCs certified by national organization or state until December 2013 were searched from available databases. The proportion of PSC among short-term general hospitals in each state was calculated and factors affecting its distribution were analyzed. Results: By the end of 2013, the proportion of PSC varied from 4% to 100% among the 50 states and District of Columbia (Figure 1). The 18 states with stroke legislation had higher PSC percentages (median 43%, range 13-100%) than the remaining states (median 13%, range 4-75%, p&lt;0.001). Multivariate logistic regression showed that state stroke legislation, urbanization, and larger hospital size independently increased the likelihood of a hospital to be stroke certified. Comparing to states with the lowest GDP (1st quintile), the hospitals in those states of higher GDP were more likely to be PSC certified in univariate analysis, but not in multivariate analysis after adjusting for stroke legislation, urbanization and census region. From 2009 to 2013, states with stroke legislation had greater increase of PSC percentages compared to the states without legislation (median increase of PSC percentage 16% vs 6%, p=0.0067). Among the 1505 stroke centers, 74% were certified by the Joint Commission, 20% by state, and 6% by other organizations. Stroke centers certified only by state were smaller in size by hospital bed count compared to those certified by the JC (median 204 vs 300 beds, IQR 117-339 vs 202-436 beds, p&lt;0.001). Conclusion: State stroke legislation significantly increased the number of certified stroke centers in the United States, potentially improving accessibility of standardized care for patients with acute ischemic stroke.

Hospital Market Structure and Access to Medical Care: The Long-Term Impact of the Hill-Burton Act

Much of the growth in hospital capacity in the United States between World War II and the mid 1970s can be attributed to the Hill-Burton Act of 1946, designed to strengthen the nation's hospital system. Studying the evolution of the hospital industry since, I document evidence of the long-term persistence of short-term general hospitals within the U.S. I further explore the impact of construction of new hospitals under the Hill-Burton Act, finding that Hill-Burton construction significantly altered market structure today, with limited crowd-out of existing hospitals. Using new hospitals constructed using Hill-Burton funds as an exogenous source of variation in present hospital market structure, I find significant increases in the number of hospitals adopting specialized services in markets with greater hospital density, leading to reductions in the distance patients must travel to reach a hospital offering each service. My results imply that government subsidization of firm start-up costs can have significant impact on the long-term competitiveness of industries with highly persistent market structure. I also explore the effect of hospital market structure on utilization of hospital services. My results suggest that the impact of Hill-Burton construction of new hospitals on utilization of hospital services was less than 3% across a broad range of utilization measures.

Hospital financial performance in the recent recession and implications for institutions that remain financially weak.

The recent recession had a profound effect on all sectors of the US economy, including health care. We examined how private hospitals fared through the recession and considered how changes in their financial health may affect their ability to respond to future industry challenges. We categorized 2,971 private short-term general medical or surgical hospitals (both nonprofit and for-profit) according to their pre-recession financial health and safety-net status, and we examined their operational status changes and operating and total financial margins during 2006-11. We found that hospitals that were financially weak before the recession remained so during and after the recession. The total margins of nonprofit hospitals (both safety-net and other institutions) declined in 2008 but returned to their pre-recession levels by 2011. The recession did not create additional fiscal pressure on hospitals that were previously financially weak or in safety-net roles. However, both groups continue to have notable financial deficiencies that could limit their abilities to meet the growing demands on the industry.

Nonoperating revenue and hospital financial performance

For many years, hospitals have relied on nonpatient care activities to complement patient care revenues and strengthen financial performance. For hospitals that lose money on patient care, nonpatient care revenues may mean the difference between net income and loss. Little is known currently, however, about whether nonpatient care revenues allow hospitals with negative patient care margins to offset their losses. The aims of this study are (a) to examine whether hospitals rely on income from nonpatient care activities to offset losses on patient care and (b) to identify characteristics of hospitals that are able to offset such losses. Data for this study came from the state of California. The sample consisted of not-for-profit and investor-owned short-term general acute care hospitals for the years 2003-2007. Descriptive statistics were used to compare hospitals with negative patient care margins that were able to offset patient care losses to hospitals that were unable to do so. Between 2003 and 2007, approximately 40% of study hospitals lost money on patient care. Of these, only 25% relied on nonpatient care income to offset losses. Hospitals that were able to offset patient care losses tended to be larger, not-for-profit organizations that were able to generate substantial shares of their total revenues from nonpatient care activities, in particular, charitable donations and financial investments. Despite claims that income from nonpatient care activities frequently allows hospitals to offset patient care losses, this study showed that only a small proportion of hospitals were able to do so. The financial viability of hospitals with negative patient care margins will thus depend on their ability to (a) deliver high-quality care profitably, (b) derive income from other operating activities, and (c) generate income from financial investments and engage in active development efforts to increase donations and gifts.

Predicting resource utilization of elderly burn patients in the baby boomer era

BackgroundCensus predictions for Florida suggest a 3-fold increase in the 65 and older population within 20 years. We predict resource utilization for burn patients in this age group. MethodsUsing the Florida Agency for Healthcare Administration admission dataset, we evaluated the effect of age on length of stay, hospital charges, and discharge disposition while adjusting for clinical and demographic factors. Using US Census Bureau data and burn incidence rates from this dataset, we estimated future resource use. ResultsElderly patients were discharged to home less often and were discharged to short-term general hospitals, intermediate-care facilities, and skilled nursing facilities more often than the other age groups (P < .05). They also required home health care and intravenous medications significantly more often (P < .05). Their length of stay was longer, and total hospital charges were greater (P < .05) after adjusting for sex, race, Charleson comorbidity index, payer, total body surface area burned, and burn center treatment. ConclusionsOur data show an age-dependent increase in the use of posthospitalization resources, the length of stay, and the total charges for elderly burn patients.

Can governments do it better? Merger mania and hospital outcomes in the English NHS

The literature on mergers between private hospitals suggests that such mergers often produce little benefit. Despite this, the UK government has pursued an active policy of hospital mergers, arguing that such consolidations will bring improvements for patients. We examine whether this promise is met. We exploit the fact that between 1997 and 2006 in England around half the short term general hospitals were involved in a merger, but that politics means that selection for a merger may be random with respect to future performance. We examine the impact of mergers on a large set of outcomes including financial performance, productivity, waiting times and clinical quality and find little evidence that mergers achieved gains other than a reduction in activity. Given that mergers reduce the scope for competition between hospitals the findings suggest that further merger activity may not be the appropriate way of dealing with poorly performing hospitals.

Do inter-hospital comparisons of in-hospital, acute myocardial infarction case-fatality rates serve the purpose of fostering quality improvement? An evaluative study

BackgroundIn-hospital case-fatality rates in patients, admitted for acute myocardial infarction (AMI-CFRs), are internationally used as a quality indicator. Attempting to encourage the hospitals to assume responsibility, the Belgian Ministry of Health decided to stimulate initiatives of quality improvement by means of a limited set of indicators, among which AMI-CFR, to be routinely analyzed. In this study we aimed, by determining the existence of inter-hospital differences in AMI-CFR, (1) to evaluate to which extent Belgian discharge records allow the assessment of quality of care in the field of AMI, and (2) to identify starting points for quality improvement.MethodsHospital discharge records from all the Belgian short-term general hospitals in the period 2002-2005. The study population (N = 46,287) included patients aged 18 years and older, hospitalized for AMI. No unique patient identifier being present, we tried to track transferred patients. We assessed data quality through a comparison of MCD with data from two registers for acute coronary events and through transfer and sensitivity analyses. We compared AMI-CFRs across hospitals, using multivariable logistic regression models. In the main model hospitals, Charlson's co-morbidity index, age, gender and shock constituted the covariates. We carried out two types of analyses: a first one wherein transferred-out cases were excluded, to avoid double counting of patients when computing rates, and a second one with exclusion of all transferred cases, to allow the study of patients admitted into, treated in and discharged from the same hospital.ResultsWe identified problems regarding both the CFR's numerator and denominator.Sensitivity analyses revealed differential coding and/or case management practices. In the model with exclusion of transfer-out cases, the main determinants of AMI-CFR were cardiogenic shock (ORadj 23.0; 95% CI [20.9;25.2]), and five-year age groups ORadj 1.23; 95% CI [1.11;1.36]). Sizable inter-hospital and inter-type of hospital differences {(ORcomunity vs tertiary hospitals1.36; 95% CI [1.34;1.39]) and (ORintermediary vs tertiary hospitals1.36; 95% CI [1.34;1.39])}, and nonconformities to guidelines for treatment were observed.ConclusionsDespite established data quality shortcomings, the magnitude of the observed differences and the nonconformities constitute leads to quality improvement. However, to measure progress, ways to improve and routinely monitor data quality should be developed.

Implementation of a center for drug policy across a system of hospitals

The past decade has witnessed the growth of multihospital or diversified single-hospital systems.[1][1] Data from the American Hospital Association’s 2007 survey show that some 56% of non-federal, short-term general, and other special hospitals belong to a system.[1][1] Hospital systems provide

Managed care competition and the adoption of hospital technology: The case of cardiac catheterization

The diffusion of health care technology is influenced by both the total market share of managed care organizations as well as the level of competition among them. This paper differentiates between HMO penetration and competition and examines their relationship to the adoption of cardiac catheterization laboratories in all non-federal, short-term general community hospitals in the U.S. between 1985 and 1995. Results show that a hospital is less likely to adopt the technology if HMO market penetration increases but more likely to adopt if HMO competition increases. Further, the latter effect is non-linear in the number of adopters. In markets where fewer than a critical number of neighboring hospitals have already adopted, the probability of adoption increases with the number of HMOs, but in markets where more than the critical number of neighbors have already adopted, the probability of adoption decreases with the number of HMOs. Thus, in markets where technology is rare, HMO penetration and competition have countervailing effects on the diffusion of technology such that the net effect could be small.

Development and preliminary validation of a Greek-language outpatient satisfaction questionnaire with principal components and multi-trait analyses

BackgroundIn the recent years there is a growing interest in Greece concerning the measurement of the satisfaction of patients who are visiting the outpatient clinics of National Health System (NHS) general acute hospitals. The aim of this study is therefore to develop a patient satisfaction questionnaire and provide its preliminary validation.MethodsA questionnaire in Greek has been developed by literature review, researchers' on the spot observation and interviews. Pretesting has been followed by telephone surveys in two short-term general NHS hospitals in Macedonia, Greece. A proportional stratified random sample of 285 subjects and a second random sample of 100 outpatients, drawn on March 2004, have been employed for the analysis. These have resulted in scale creation via Principal Components Analysis and psychometric testing for internal consistency, test-retest and interrater reliability as well as construct validity.ResultsFour summated scales have emerged regarding the pure outpatient component of the patients' visits, namely medical examination, hospital environment, comfort and appointment time. Cronbach's alpha coefficients and Pearson, Spearman and intraclass correlations indicate a high degree of scale reliability and validity. Two other scales -lab appointment time and lab experience- capture the apparently distinct yet complementary visitor experience related to the radiographic and laboratory tests. Psychometric tests are equally promising, however, some discriminant validity differences lack statistical significance.ConclusionThe instrument appears to be reliable and valid regarding the pure outpatient experience, whereas more research employing larger samples is required in order to establish the apparent psychometric properties of the complementary radiographic and laboratory-testing process, which is only relevant to about 25% of the subjects analysed here.

Hospital Demand for Licensed Practical Nurses

Despite evidence that hospital use of licensed practical nurses (LPNs) declined in the 1990s, the current registered nurse (RN) shortage has prompted interest in LPNs as substitutes for RNs. Hospitals, being the dominant employer of RNs, have an economic incentive to use less expensive LPNs as substitutes. Beside wages, there are several forces underlying hospital demand for LPNs. In this article, the authors model and estimate hospital demand for LPNs as a function of nurse wages and hospital, market, and patient characteristics using a longitudinal data set of short-term general hospitals in the United States. The authors find evidence that higher RN wages increase hospital demand for LPNs, both in levels and relative to RNs, suggesting that hospitals at least partially substitute RNs with LPNs.

Hospital Competition, Managed Care, and Mortality after Hospitalization for Medical Conditions in California

To assess the effect of hospital competition and health maintenance organization (HMO) penetration on mortality after hospitalization for six medical conditions in California. Linked hospital discharge and vital statistics data for short-term general hospitals in California in the period 1994-1999. The study sample included adult patients hospitalized for one of the following conditions: acute myocardial infarction (N=227,446), hip fracture (N=129,944), stroke (N=237,248), gastrointestinal hemorrhage (GIH, N=216,443), congestive heart failure (CHF, N=355,613), and diabetes (N=154,837). The outcome variable was 30-day mortality. We estimated multivariate logistic regression models for each study condition with hospital competition, HMO penetration, hospital characteristics, and patient severity measures as explanatory variables. Higher hospital competition was associated with lower 30-day mortality for three to five of the six study conditions, depending on the choice of competition measure, and this finding was robust to a variety of sensitivity analyses. Higher HMO penetration was associated with lower mortality for GIH and CHF. Hospitals that faced more competition and hospitals in market areas with higher HMO penetration provided higher quality of care for adult patients with medical conditions in California. Studies using linked hospital discharge and vital statistics data from other states should be conducted to determine whether these findings are generalizable.

Timely Referral of Potential Organ Donors

Timely Referral of Potential Organ Donors

The Effect of Changes in Hospital Reimbursement on Nurse Staffing Decisions at Safety Net and Nonsafety Net Hospitals

The financial savings from the Balanced Budget Act (BBA) are attractive to policy makers, but such savings come at a cost. We measure changes in nurse staffing at hospitals related to potential declines in reimbursement through the BBA. Following Hadley, Zuckerman, and Feder (1989), we define a fiscal pressure index (FPI) to measure the differential effect of the BBA. We estimate the effect of the FPI on the number of full-time equivalent registered nurses (RN) and licensed practical nurses (LPN) per adjusted patient day using American Hospital Association (AHA) data of a panel of hospitals from 1996 to 2001. The AHA data are combined with the Area Resource Files and health maintenance organizations penetration data. We control for hospital heterogeneity using fixed effects. All urban short-term general hospitals that responded to the staffing and uncompensated care questions in the AHA survey between 1996 and 2001. We define safety net hospitals as those with a high ratio of uncompensated costs to total hospital expenses (see, e.g., Zuckerman et al. 2001). We find that the nonsafety net hospitals that were most susceptible to the provisions of the BBA experienced a decline in RN staffing ratios about twice the rate of the nonsafety net hospitals that were least susceptible to the BBA. We are unable to detect an effect of the BBA on staffing at safety net hospitals. RN and LPN staffing levels per adjusted patient day declined, on average, between 1996 and 2001. Within the context of the general decline, we find that RN staffing per adjusted patient day declined even more at nonsafety net hospitals that were most susceptible to lower reimbursement related to the BBA. Thus, there was a small but statistically significant incremental effect of potential BBA losses on RN staffing at hospitals that were expected to be affected most. This incremental decline represented about a 6 percent increase in nurse workload that in isolation might not affect quality. Nevertheless, the BBA contributed to the contemporaneous trends toward higher nurse workloads that could have deleterious effects on quality. In contrast, safety net hospitals did not respond to the provisions of the BBA by reducing staffing ratios. This conclusion is tempered by the fact that we have few safety net hospitals in the sample.