Urban General Hospitals Research Articles

Analysis of hospitalization expenditures and influencing factors for inpatients with chronic bronchitis based on SHA2011 in a central Province of China.

This study compared the hospitalization expenses of patients with chronic bronchitis in a central province (Province A) in China to estimate the direct medical cost of the family. Our data included hospitalization records of 30,341 patients with chronic bronchitis from five urban general hospitals in Province A. Using descriptive statistics and regression analysis, we explored the relevant factors affecting hospitalization expenses. Our study results have indicated that from 2016 to 2020, the medical expenditure of patients with chronic bronchitis increased annually, with an average annual growth rate of 22.65%. Among all kinds of expenses, the hospitalization expenses, drug cost, bed cost, test cost and other cost of UEMI (Urban Employee Medical Insurance) are higher than that of other types of medical insurance. The check-up fees of CMI (Commercial Insurance) are lower than that of other types of insurance. Between 2016 and 2019, the average medical expenses per patient with chronic bronchitis increased by 44%, which is the highest average medical expenses among patients aged 60-70. And the highest average medical expenditure emerged when the number of service days is between 5 and 10 days. The increase in expenditure could be attributed to the rapid development of medical technology and the increasing medical demand of the people. Overall, the results of our study implied a significant increase in medical expenses for patients with chronic bronchitis from 2015 to 2020, indicating that chronic bronchitis could bring heavy economic pressures to patients, their families and society.

Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019

National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood. To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity. This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023. Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals. The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009. The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year. Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.

Personal protective equipment availability and accessibility among nurses and midwives in selected urban general hospitals in Lusaka, Zambia: a cross-sectional study.

the World Health Organization (WHO) declared COVID-19 a pandemic in January 2020, which has spread to many countries, including Zambia. Zambia has had challenges in providing personal protective equipment (PPEs) to nurses and midwives. The study's objective was to assess the availability and accessibility of PPEs among nurses and midwives caring for women in the general hospitals in Lusaka, Zambia. a cross-sectional analytical study design was conducted at five general hospitals in Lusaka on 162 nurses and midwives between February and April 2021, selected by purposive sampling of study sites and simple random sampling to select the participants. Data was collected using a semi-structured self-administered questionnaire and analyzed in STATA version 13. Chi-square and Fisher's exact test were used to test associations between the independent variables and the outcome, and a multivariable logistic regression was used to investigate the predictors of accessing PPEs. out of the 162 who participated in the study, 48.8% were nurses, while 51.2% were midwives. Only 10% (16/160) of the participants reported having enough PPEs at work. Age, marital status, PPE use, employment duration, and protection confidence were associated with accessibility (P<0.05). overall, there was an inadequate provision of PPEs in the health facilities putting the nurses and midwives at a high risk of acquiring COVID-19. Policymakers need a deliberate move to make the availability and accessibility of PPEs a reality during the pandemic.

The Moderating Effect of the Social Deprivation Index (SDI) on the Relationship Between Hospital Strategy and Financial Performance

Background: One of the major tenets of contingency theory is that the appropriate fit between strategy and environmental contingencies results in better financial performance. The purpose of this study was to investigate whether the Social Deprivation Index (SDI) moderates the association between hospital strategy and financial performance. Methods: We used longitudinal data from 2011 to 2016 from US urban general acute care hospitals. Four secondary datasets were used: the American Hospital Association (AHA) Annual Survey, Medicare cost reports (CMS), Area Health Resource File (AHRF), and the Robert Graham Center’s SDI. A generalized estimating equation (GEE) regression model was used to analyze the data. An interaction term was used to test the moderating effect of the SDI on the strategy–financial performance relationship. Results and Discussion: Our results showed that compared to hybrids, the SDI moderates the relationship between strategy and financial performance for cost leaders and hybrids. Increasing market social deprivation increases the hospital operating margin of cost leaders by 0.06%. Similarly, increasing levels of market social deprivation increases the hospital operating margin of hybrids by 0.06% (p < 0.05). As such, our results suggest that social deprivation may affect the viability of hospital strategy.

GIS-Based Medical Resource Evaluation Method

As one of the public service resources, medical and health care has a great guarantee for people’s healthy life and life safety and is an important part of ensuring the normal and orderly operation of urban functions. This paper takes the spatial pattern of urban medical resources in Hohhot as the research object and collects three types of urban medical resources, including clinics (health centers), specialized hospitals, and general hospitals, a total of 1300 sample points, based on GIS spatial analysis methods, using the average nearest neighbor, kernel density estimation method, standard deviation ellipse method, and accessibility measure to analyze the spatial distribution of medical resources. The results show that the medical resources in the urban area of Hohhot are all in a state of agglomeration, but due to the different functions of different types of medical resources, their distribution ranges and distribution directions also show different characteristics. Saihan District, Yuquan District in the southwest, has fewer medical facilities resources, and the distribution of the accessibility of the three types of medical facilities is quite different. Therefore, the spatial balance of comprehensive medical resources in the urban area of Hohhot needs to be further improved. The results of this paper have implications for the layout of medical facilities and planning has important reference significance.

Study on Key and Difficult Points and Countermeasures of Traffic Organization in Urban General Hospitals -- Taking Dingjiazhuang District of Nanjing Maternal and Child Health Hospital as an Example

Study on Key and Difficult Points and Countermeasures of Traffic Organization in Urban General Hospitals -- Taking Dingjiazhuang District of Nanjing Maternal and Child Health Hospital as an Example

Development of a Cadre of Evidence-Based Practice Mentors for Nurses: What Works?

Development of a critical mass of evidence-based practice (EBP) mentors for healthcare professionals is pivotal in facilitating and sustaining system-wide implementation of evidence-based care, especially for nurses. Empirical evidence shows that organizational factors are strongly associated with EBP. However, the understanding of organizational support to promote EBP competency is found lacking, especially in Mainland China. The purposes of this study were to (1) establish a baseline assessment of EBP nursing leadership and work environment support as well as EBP competency for EBP mentors of nurses in Western China, and (2) explore how nursing leadership and work environment impact the EBP competencies of mentors. A cross-sectional study was conducted. The study population was 286 EBP mentors for nurses from six urban general hospitals in Xi'an City, Shanxi Province. The EBP Nursing Leadership Scale and the EBP Work Environment Scale were used to evaluate their perceived organizational support. EBP competency was measured by the Evidence-Based Practice Questionnaire. There was insufficient time for EBP mentors of nurses to engage in EBP. Lack of experts in EBP and educational offerings about EBP were identified as the two lowest workplace organizational supports for EBP. The respondents reported themselves as not competent in EBP, especially for the knowledge/skills. EBP nursing leadership and work environment support were key predictors of the self-reported EBP competency in the stepwise multiple linear regression models (β=.211-.345, p<.01). It is imperative to provide EBP mentors for nurses with the knowledge and skills to achieve the expected level of EBP competency. Strategies for developing a cadre of EBP mentors for nurses who have competency in EBP need to be multipronged and target the cultivation of an organizational culture that supports EBP.

Assessing the Attitudes of Greek Nurses Toward Computerized Dementia Screening.

Background:Despite the abundance of research on computerized dementia screening tests, the attitudes of hospital personnel toward this screening method have not been investigated.Objective:1) To conduct a confirmatory factor analysis of the first part of a two-part questionnaire about computerized dementia screening. 2) To assess the attitudes of Greek nurses toward computerized dementia screening. 3) To assess barriers to future implementation of computerized dementia screening in the Greek healthcare system, as reported by nurses.Methods:161 Greek nurses from two urban public general hospitals who participated in a dementia training program were recruited. They were asked to complete a two-part questionnaire about computerized dementia screening. The first part of the questionnaire assesses attitudes toward dementia screening while the second part of the questionnaire assesses barriers to its implementation.Results:Confirmatory factor analysis on the first part of the questionnaire suggested a two-factor structure (feasibility/acceptability). The total score of all items loading on each factor was calculated. For feasibility, scores ranged between 10 and 25 (M = 19.38, SD = 3.80). For acceptability, scores ranged between 6 and 20 (M = 15.27, SD = 2.76). The main barriers to implementation were cost of equipment, insufficient training, lack of a plan for the integration of computerized screening tests in the daily routine of the hospital and time needed for staff training.Conclusion:The positive attitude of nurses supports the implementation of computerized dementia screening in public hospitals as long as identified barriers are addressed.

Acute hospital staff\u2019s attitudes towards dementia and perceived dementia knowledge: a cross-sectional survey in Ireland

BackgroundLittle is known about staff’s attitudes in Irish acute hospital settings towards people living with dementia and their perceived dementia knowledge. The aim of this study was to understand the general level of dementia knowledge and attitudes towards dementia in different types of hospital staff, as well as to explore the potential influence of previous dementia training and experience (having a family member with dementia) and the potential moderating effects of personal characteristics. This data was required to plan and deliver general and targeted educational interventions to raise awareness of dementia throughout the acute services.MethodsA cross-sectional survey was carried out among a diverse range of hospital staff (n = 1795) in three urban acute general hospitals in Ireland, including doctors, nurses, healthcare attendants, allied professionals, and general support staff. Participants’ perceived dementia knowledge and attitudes were assessed as well as their previous dementia training and experience. To measure participant’s attitude towards dementia, the validated Approaches to Dementia Questionnaire (ADQ) was used.ResultsHospital staff demonstrated positive attitudes towards people living with dementia, and believed they had a fair to moderate understanding of dementia. Both ‘having previous dementia training’ and ‘having a relative living with dementia’ predicted attitude towards dementia and perceived dementia knowledge. Interestingly, certain personal staff characteristics did impact dementia training in predicting attitude towards dementia and perceived dementia knowledge.ConclusionThis study provides a baseline of data regarding the attitudes towards dementia and perceived dementia knowledge for hospital staff in Irish acute hospitals. The results can inform educational initiatives that target different hospital staff, in order to increase awareness and knowledge to improve quality of dementia care in Irish hospitals.

The Association Between Strategic Group Membership and Hospital Financial Performance

The health care industry is facing constant changes from health care reform; demanding consumers; new expensive forms of treatment. These changes put more pressure on hospitals and their ability to remain profitable. Understanding how to improve hospital financial performance by applying an appropriate strategy remains a key concern to managers and researchers. The overall purpose of this study was to identify the strategic group structure of the hospital industry and to examine the effect of strategic group membership on hospital financial performance. We used longitudinal data from 2006 to 2016 related to US urban general acute care hospitals. We used three secondary datasets in the study: the American Hospital Association (AHA) Annual Survey, Medicare cost reports (CMS), and Area Health Resource File (AHRF). We used cluster analysis and multiple regression models with control for time and state fixed effect to analyze data. Our results suggest that on average about 37 percent of hospitals pursue a cost-leadership strategy, and about 5 percent of hospitals pursue the differentiation strategy. Hospitals with hybrid strategy outperform hospitals with cost-leadership strategy and stuck-in-the-middle. The absence of a coherent strategy (i.e., stuck- in-the-middle) is likely to lead to poor performance. The results demonstrate the usefulness of strategic group studies like this study as a method for managers to assess their current strategic situations.

Spatial Equilibrium Allocation of Urban Large Public General Hospitals Based on the Welfare Maximization Principle: A Case Study of Nanjing, China

This study aims to utilize the new gravity P-median model to conduct an empirical study for the spatial equilibrium layout of general hospitals in the urban area of Nanjing City, based on multiple requirements for spatial equilibrium, involving spatial equity-efficiency, service utility fairness, and utilization efficiency. The major results are as follows: (1) the new layout can achieve the goal of obtaining a proximate, high-quality medical service in 30 min even for those who reside on the outskirts, which is less than the current 65.6 min. Moreover, the new layout corresponds better to the population distribution and traffic network layout. (2) When compared with several typical characteristics of accessibility to hospitals, including severe gradient variation, five high-value centers, and the efficiency orientation in the current layout, the new demonstrates distinctive ones: comparatively moderate accessibility variation; more relatively high-value areas scattered in different parts of the city; more convenient accessibility on the outskirts; a better balance of the equitable appeal from the inhabitants residing in different areas. (3) The new layout can attain spatial equilibrium at a higher level, the representative indices to measure spatial equity, spatial efficiency, chance fairness, and utilization efficiency have been ameliorated by 54%, 13%, 63%, 14%, respectively. The study reveals that: (1) The new gravity P-median model has the validity and practicability in solving facility location and scale configuration problems with high time complexity, under complicated situations due to multiple targets and multi-agent competition. (2) The model can be applied to decision making related to public infrastructure planning in different types of development areas, by setting concerning parameters or making some minor adjustments to the model in different scenarios. Such research can provide some reference for the location-allocation problem of high-grade facilities in metropolises, and support the decision-making basis for urban infrastructure planning.

2) Role of the Generalist Physicians in Urban General Hospitals

2) Role of the Generalist Physicians in Urban General Hospitals

The proliferation of elective services in U.S. urban hospitals.

Although adding convenience for both patients and providers, the proliferation of elective services and equipment in U.S. general hospitals contributes to higher costs and raises concerns about quality and overuse. We assess the relationship of two forces-health system membership and market competition-with the diffusion of elective services and equipment. The sample consists of all urban U.S. nonfederal general acute hospitals in 2010 (n = 2,467). Elective equipment and services are defined by 25 services offered by less than 33% of urban general hospitals. We relate the number of elective services to environmental and organizational conditions, adopting a contingency theory perspective. Ordinary least squares regression is used to estimate the associations among the key variables. Market competition is positively associated with numbers of elective services. The effect of health system membership varies by system type, with the most developed integrated systems showing a positive relationship with the quantity of elective services, relative to freestanding hospitals. Members of less-developed integrated systems, however, have fewer elective services than freestanding hospitals. The evidence on market competition is consistent with a medical arms race scenario in which hospitals pursue elective services and equipment to compete with each other. Membership in highly integrated systems does not act as a constraint on the pursuit of elective services and equipment but instead may independently promote it. It may be unrealistic to expect hospitals to resist offering elective services in the face of competitive and organizational considerations that encourage proliferation.

A comparative assessment of the awareness of danger signs and practice of birth preparedness and complication readiness among pregnant women attending rural and urban general hospitals in Lagos State

Background: Nigeria still experiences a high burden of unsafe motherhood. The knowledge of obstetric danger signs and the effective application of the principles of birth preparedness and complication readiness (BPACR) have the potential to significantly reduce the high maternal and perinatal morbidity and mortality rates. However, rural-urban differences may exist in the knowledge and practice of BPACR among women, and these may limit its potential benefit. We set out to assess and compare the knowledge of obstetric danger signs and practice of BPACR among pregnant women attending Rural (Agbowa) and Urban (Gbagada) Hospitals in Lagos State. Materials and Methods: In this cross-sectional comparative study, pregnant women attending antenatal clinics in each health facility were recruited into the study using a systematic sampling method. A structured interviewer administered questionnaire adapted from the safe motherhood John Hopkins Program for International Education in Gynecology and Obstetrics prototype questionnaire was used for data collection. Data were analyzed using SPSS version 17.0. Results: Awareness of obstetric danger signs during pregnancy was good among rural and urban study participants accounting for 62.4% and 68.4%, respectively. The most commonly identified danger sign in pregnancy, labor, and after delivery was bleeding from the genital tract. The awareness of danger signs during labor and after delivery identified by the women was low in both settings, though relatively higher in the urban area. The level of BPACR was low in both groups of women but was higher among women attending the urban center (31.6%) compared with the rural center (13.2%) P-value < 0.001. Conclusion and Recommendations: Activities aimed at improving birth preparedness practices particularly among rural women should be considered.

Physicians’ perceptions and attitudes toward clinical pharmacy services in urban general hospitals in China

To provide better patient care, it is very important for the physicians to be willing to accept clinical pharmacy services (CPSs). To explore physicians' perceptions and overall attitudes toward CPSs in China, to determine the dimensions of factors underlying the physicians' perceptions of different types of CPSs, and to analyze the determinants of physicians' overall attitudes. Inpatient units of urban general hospitals in China. Self-administered questionnaires were distributed to 990 physicians in the inpatient units of 22 general hospitals in seven cities between June and October 2012. Descriptive statistical analysis, factor analysis, and logistic regression were used. The physicians' comfort levels and their overall attitudes toward CPSs, as well as the dimensions of factors underlying their perceptions of CPSs. The predictors of overall attitudes included demographics, the characteristics of self-perceived workload, the frequency of communication with clinical pharmacists, and the perception variables for the different types of CPSs. Amongst the 646 questionnaires retrieved, 81.3 % of the physicians had positive overall attitudes. Factor analysis resulted in four factors, with a cumulative explained variance of 69.0 %, as follows: clinical pharmacists' support of physicians' decisions; auxiliary work; prescribing; and independent decision-making activities. The results of logistic regression showed that the degree of comfort with clinical pharmacists' support of physicians' decisions had the greatest influence on physicians' overall attitudes toward CPSs. From the perspective of improving physicians' overall attitudes, the prioritization strategy of developing CPSs in China should focus on the role of clinical pharmacists within the decision support system for medication management, thus encouraging clinical pharmacists to interact more frequently with physicians at the ward level.

Predictions and measurements of the stack effect on indoor airborne virus transmission in a high-rise hospital building

As the viral diseases such as Severe Acute Respiratory Syndrome (SARS) and Influenza A (H1N1) occur in many countries recently, the epidemic of those influenza viruses causes many human casualties. Moreover, the second infection from infected patients particularly within general hospitals frequently takes places due to improperly hospitalized and/or quarantined patients. Accordingly, it becomes a great concern to accommodate safer ventilation system in general hospital wards against such airborne transmitted viruses. It is also a recent trend that many urban general hospitals are designed and constructed as high-rises. If a virus is transmitted through uncontrolled air movement within a hospital and then infected other patients or healthy visitors, it might be impossible to control the spread of the disease. Thus research has been preceded scrutinizing stack effect on the indoor airborne virus transmission in large hospitals by conducting both the field measurement and numerical analysis according to the outdoor temperature and the releasing vertical points of the tracer gas assumed as a viral contaminant. In the field measurement of a high-rise hospital, the indoor airflow was affected by the stack effect of vertical chute of the building. The numerical simulation was verified by comparing its prediction results and the field measurement data. In result, very high possibility has witnessed that the airborne contaminant emitted from the infected patients in the lower floors could be transported to the higher floors through the airflow driven by the stack effect.

Exploring pharmacists' perceptions of the feasibility and value of pharmacist prescribing of antimicrobials in secondary care in Scotland

The introduction of non-medical prescribing in the UK has provided opportunities and challenges for pharmacists to help ensure prudent use of antimicrobials. The objective of this research was to explore pharmacists' perceptions of the feasibility and value of pharmacist prescribing of antimicrobials in secondary care in Scotland. Pharmacists' perceptions were explored using focus groups in five Scottish regions representing (a) urban and rural areas and (b) district general hospitals and large teaching centres. Senior hospital pharmacists, both prescribers and non-prescribers, working in specialities where antimicrobials are crucial to patient management, were invited to participate. A topic guide was developed to lead the discussions, which were audio-recorded and transcribed. The framework approach to data analysis was used. Six focus groups took place and some emerging themes and issues are presented. Pharmacists believed that the feasibility of antimicrobial prescribing is dependent upon the patient's clinical condition and the area of clinical care. They identified potential roles and opportunities for pharmacist prescribing of antimicrobials. Perceived benefits included giving patients quicker access to medicines, reducing risk of resistance and better application of evidence-based medicine. Pharmacists feel they have a good knowledge base to prescribe and manage antimicrobial treatment, identifying possible opportunities for intervention. Roles within a multidisciplinary antimicrobial team need to be clearly defined.

Emerging from the shadow of medicine: allied health as a ‘profession community’ subculture

The authority relationship between medicine and the allied health professions has been conceptualised as one of subordination. The research that underpinned the subordination thesis was largely based on pre-1980 studies of interprofessional interaction and struggle. This article presents data from a comparative longitudinal case study analysis of Australian allied health professions employed in three distinct organisational models in urban acute care general hospitals during the 1990s. The article discusses the emergence of a distinct allied health ‘profession community’ subculture associated with the emergence of new organisational structures in Australia. A model to account for subculture development under different organisational conditions is proposed. A key concern is the way in which a ‘profession community’ is created, structured and maintained in the complex organisational settings of the acutecare hospital. The findings challenge the notion that subordination is an inevitable consequence of medical dominance and calls for a re-formulation of our understanding of the relationship between medicine and allied health professions in light of contemporary health service reforms.

Glycemic chaos (not glycemic control) still the rule for inpatient care

Diabetes is one of the most common diagnoses in hospitalized patients. A third of all persons admitted to urban general hospitals have glucose levels qualifying them for the diagnosis of diabetes, and a third of these hyperglycemic patients have not previously been diagnosed with diabetes. The impact of hyperglycemia on the mortality rate of hospitalized patients has been increasingly appreciated. Extensive evidence from observational studies indicates that hyperglycemia in patients with or without a history of diabetes is a marker of a poor clinical outcome. In addition, the results of prospective randomized trials in patients with critical illness or those undergoing coronary bypass surgery suggest that aggressive glycemic control improves clinical outcomes including reductions in: a) shortand long-term mortality, b) multiorgan failure and systemic infection, and c) length of hospitalization. The importance of glycemic control is not limited to patients in critical care areas but may also apply to patients admitted to general surgical and medical wards. The development of hyperglycemia in such patients with or without a history of diabetes has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death. In general-surgical patients, serum glucose 220 mg/dL on postoperative day 1 has been shown to be a sensitive, albeit nonspecific, predictor of the development of serious postoperative hospital-acquired infection. A retrospective review of 1886 admissions to a community hospital in Atlanta, Georgia, found an 18-fold increase in mortality in hyperglycemic patients without a history of diabetes and a 2.5-fold increase in mortality in patients with known diabetes compared with controls. A meta-analysis of 26 studies identified an association of admission glucose 110 mg/dL with the increased mortality of patients hospitalized for acute stroke. More recently, hyperglycemia on admission was also shown to be independently associated with adverse outcomes in patients with community acquired pneumonia. In view of the increasing evidence supporting better glycemic control in the hospital, the American Association of Clinical Endocrinologists (AACE) in late 2003 convened a consensus conference on the inpatient with diabetes, cosponsored or supported by other prominent professional organizations, including the Society of Hospital Medicine (SHM). An expert panel agreed on and pubE D I T O R I A L

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.