Category Archives: Health Care

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals

Source: Matthew D McHugh, Linda H Aiken, Douglas M Sloane, Carol Windsor, Clint Douglas, Patsy Yates, The Lancet, Vol. 397, issue 10288, May 22, 2021
(subscription required)

From the summary:
Background
Substantial evidence indicates that patient outcomes are more favourable in hospitals with better nurse staffing. One policy designed to achieve better staffing is minimum nurse-to-patient ratio mandates, but such policies have rarely been implemented or evaluated. In 2016, Queensland (Australia) implemented minimum nurse-to-patient ratios in selected hospitals. We aimed to assess the effects of this policy on staffing levels and patient outcomes and whether both were associated.

Methods
For this prospective panel study, we compared Queensland hospitals subject to the ratio policy (27 intervention hospitals) and those that discharged similar patients but were not subject to ratios (28 comparison hospitals) at two timepoints: before implementation of ratios (baseline) and 2 years after implementation (post-implementation). We used standardised Queensland Hospital Admitted Patient Data, linked with death records, to obtain data on patient characteristics and outcomes (30-day mortality, 7-day readmissions, and length of stay [LOS]) for medical-surgical patients and survey data from 17 010 medical-surgical nurses in the study hospitals before and after policy implementation. Survey data from nurses were used to measure nurse staffing and, after linking with standardised patient data, to estimate the differential change in outcomes between patients in intervention and comparison hospitals, and determine whether nurse staffing changes were related to it.

Findings
We included 231 902 patients (142 986 in intervention hospitals and 88 916 in comparison hospitals) assessed at baseline (2016) and 257 253 patients (160 167 in intervention hospitals and 97 086 in comparison hospitals) assessed in the post-implementation period (2018). After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio [OR] 1·07, 95% CI 0·97–1·17, p=0·18), but were significantly lower than at baseline in intervention hospitals (0·89, 0·84–0·95, p=0·0003). From baseline to post-implementation, readmissions increased in comparison hospitals (1·06, 1·01–1·12, p=0·015), but not in intervention hospitals (1·00, 0·95–1·04, p=0·92). Although LOS decreased in both groups post-implementation, the reduction was more pronounced in intervention hospitals than in comparison hospitals (adjusted incident rate ratio [IRR] 0·95, 95% CI 0·92–0·99, p=0·010). Staffing changed in hospitals from baseline to post-implementation: of the 36 hospitals with reliable staffing measures, 30 (83%) had more than 4·5 patients per nurse at baseline, with the number decreasing to 21 (58%) post-implementation. The majority of change was at intervention hospitals, and staffing improvements by one patient per nurse produced reductions in mortality (OR 0·93, 95% CI 0·86–0·99, p=0·045), readmissions (0·93, 0·89–0·97, p<0·0001), and LOS (IRR 0·97, 0·94–0·99, p=0·035). In addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing.

Interpretation
Minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment.

US State Policies, Politics, and Life Expectancy

Source: Jennifer Karas Montez, Jason Beckfield, Julene Kemp Cooney, Jacob M. Grumbach, Mark D. Hayward, Huseyin Zeyd Koytak, Steven H. Woolf, Anna Zajacova, Milbank Quarterly, Vol 98, September 2020

Policy points:

  • Changes in US state policies since the 1970s, particularly after 2010, have played an important role in the stagnation and recent decline in US life expectancy.
  • Some US state policies appear to be key levers for improving life expectancy, such as policies on tobacco, labor, immigration, civil rights, and the environment.
  • US life expectancy is estimated to be 2.8 years longer among women and 2.1 years longer among men if all US states enjoyed the health advantages of states with more liberal policies, which would put US life expectancy on par with other high-income countries.

Related:

Are Conservative Policies Shortening American Lives?
Source: Lola Butcher, Undark, February 1, 2021

Americans have shorter lives than international peers. Some researchers now say conservative policies may be to blame.

Promoting Good Jobs and a Stronger Economy: How Free Collective-Bargaining States Outperform “Right-to-Work” States

Source: Illinois Economic Policy Institute (ILEPI) and the Project for Middle Class Renewal (PMCR) at the University of Illinois at Urbana-Champaign, February 9, 2021

From the press release:
In an eight-year period of national economic expansion that followed the Great Recession of 2008, the 27 U.S. states that had enacted so-called “right-to-work” laws saw slower economic growth, lower wages, higher consumer debt, worse health outcomes, and lower levels of civic participation than states that had not, according to a new study by the Illinois Economic Policy Institute (ILEPI) and the Project for Middle Class Renewal (PMCR) at the University of Illinois at Urbana-Champaign.

State Employee Health Insurance: Assessing the Scale of State Purchasing Power

Source: John Kaelin, Jim DeWan, Rockefeller Institute of Government, December 2020

From the introduction: https://rockinst.org/issue-area/state-employee-health-insurance-assessing-the-scale-of-state-purchasing-power/
Across the nation, state governments are major purchasers of health insurance for their employees. According to the US Census Bureau, 100 percent of state governments offered health insurance benefits to their employees in 2018. The Census Bureau further reported that state governments provided health insurance benefits to 67.6 percent of their 5.4 million employees in 2018. This total of approximately 3.7 million employees does not include the number of dependents, retirees, or enrollees of local governments, and other public employers that also participate in states’ health insurance programs. In 2012, based on a report published by Pew Charitable Trusts and MacArthur Foundation, total spending exceeded $30 billion covering 2.7 million households.

Between employee benefits and Medicaid programs, states’ spending on health insurance represents a major budgetary item. In 2018, the federal Center for Medicare and Medicaid Services (CMS) reported that health insurance spending for all state and local governments totaled $433.6 billion and that spending has experienced an average annual increase of 3.9 percent over the past five years. In Fiscal Year 2019-20, the state of New York itself spent $22.1 billion on Medicaid and $4.3 billion on employee and retiree health insurance costs. To alleviate these escalating costs, some states have examined options to coordinate purchasing across state programs in an attempt to achieve economies of scale. Recently, California proposed policies to leverage their purchasing of prescription drugs by combining employee health insurance programs with other state programs such as Medicaid and Correctional Health.

The purpose of this policy brief is to examine the extent to which the states in their role of purchasers drive the evolution of the healthcare delivery system. This brief examines the availability of basic financial and cost data relating to state employee insurance programs. It assesses the scale of state health insurance purchasing using existing data and presents results from a preliminary survey of states. We also review the degree to which employee purchasing decisions are coordinated with other state health policy purchasing goals such as Medicaid and the Affordable Care Act (ACA) insurance marketplaces.

Health Benefits In 2020: Premiums In Employer-Sponsored Plans Grow 4 Percent; Employers Consider Responses To Pandemic

Source: Gary Claxton, Anthony Damico, Matthew Rae, Gregory Young, Daniel McDermott, and Heidi Whitmore, Health Affairs, Vol. 39 no. 11, 2020
(subscription required)

From the abstract:
The annual Kaiser Family Foundation Employer Health Benefits Survey is the benchmark survey of the cost and coverage of employer-sponsored health benefits in the United States. The 2020 survey was designed and largely fielded before the full extent of the coronavirus disease 2019 (COVID-19) pandemic had been felt by employers. Data collection took place from mid-January through July, with half of the interviews being completed in the first three months of the year. Most of the key metrics that we measure—including premiums and cost sharing—reflect employers’ decisions made before the full impacts of the pandemic were felt. We found that in 2020 the average annual premium for single coverage rose 4 percent, to $7,470, and the average annual premium for family coverage also rose 4 percent, to $21,342. Covered workers, on average, contributed 17 percent of the cost for single coverage and 27 percent of the cost for family coverage. Fifty-six percent of firms offered health benefits to at least some of their workers, and 64 percent of workers were covered at their own firm. Many large employers reported having “very broad” provider networks, but many recognized that their largest plan had a narrower network for mental health providers.

COVID-19 Projected to Worsen Racial Disparities in Health Coverage

Source: Chris Sloan, Robin Duddy-Tenbrunsel, Samantha Ferguson, Angel Valladares, Thomas Kornfield, Avalere, September 16, 2020

From the summary:
The COVID-19 pandemic is exacerbating existing economic and healthcare inequalities between racial groups in the US. Nationally, employment decreased 13% from February to April 2020; this effect was disproportionately greater among Asian (-18%), Black (-15%), and Hispanic (-17%) workers compared to White (-11%) workers. Avalere analysis suggests that, because of these job losses, at least 1 million Asian, 2 million Black, and 3 million Hispanic people are likely to lose their employer-sponsored health insurance in 2020.

Mortality Rates From COVID-19 Are Lower In Unionized Nursing Homes

Source: Adam Dean, Atheendar Venkataramani, and Simeon Kimmel, Health Affairs, Ahead of Print, September 10, 2020
(subscription required)

From the abstract:
More than 40% of all reported coronavirus disease 2019 (COVID-19) deaths in the United States have occurred in nursing homes. As a result, health care worker access to personal protective equipment (PPE) and infection control policies in nursing homes have received increased attention. However, it is not known if the presence of health care worker unions in nursing homes is associated with COVID-19 mortality rates. Therefore, we used cross-sectional regression analysis to examine the association between the presence of health care worker unions and COVID-19 mortality rates in 355 nursing homes in New York State. Health care worker unions were associated with a 1.29 percentage point mortality reduction, which represents a 30% relative decrease in the COVID-19 mortality rate compared to facilities without health care worker unions. Unions were also associated with greater access to PPE, one mechanism that may link unions to lower COVID-19 mortality rates. [Editor’s Note: This Fast Track Ahead Of Print article is the accepted version of the peer-reviewed manuscript. The final edited version will appear in an upcoming issue of Health Affairs.]

US racial inequality may be as deadly as COVID-19

Source: Elizabeth Wrigley-Field, Proceedings of the National Academy of Sciences (PNAS), first published August 24, 2020

From the abstract:
The COVID-19 pandemic is causing a catastrophic increase in US mortality. How does the scale of this pandemic compare to another US catastrophe: racial inequality? Using demographic models, I estimate how many excess White deaths would raise US White mortality to the best-ever (lowest) US Black level under alternative, plausible assumptions about the age patterning of excess mortality in 2020. I find that 400,000 excess White deaths would be needed to equal the best mortality ever recorded among Blacks. For White mortality in 2020 to reach levels that Blacks experience outside of pandemics, current COVID-19 mortality levels would need to increase by a factor of nearly 6. Moreover, White life expectancy in 2020 will remain higher than Black life expectancy has ever been unless nearly 700,000 excess White deaths occur. Even amid COVID-19, US White mortality is likely to be less than what US Blacks have experienced every year. I argue that, if Black disadvantage operates every year on the scale of Whites’ experience of COVID-19, then so too should the tools we deploy to fight it. Our imagination should not be limited by how accustomed the United States is to profound racial inequality.

Transgender Status, Gender Identity, and Socioeconomic Outcomes in the United States

Source: Christopher S. Carpenter, Samuel T. Eppink, Gilbert Gonzales, Volume 73 Issue 3, May 2020
(subscription required)

From the abstract:
This article provides the first large-scale evidence on transgender status, gender identity, and socioeconomic outcomes in the United States, using representative data from 35 states in the Behavioral Risk Factor Surveillance System (BRFSS), which asked identical questions about transgender status and gender identity during at least one year from 2014 to 2017. More than 2,100 respondents, aged 18 to 64 years, identified as transgender. Individuals who identify as transgender are significantly less likely to be college educated and less likely to identify as heterosexual than are individuals who do not identify as transgender. Controlling for these and other observed characteristics, transgender individuals have significantly lower employment rates, lower household incomes, higher poverty rates, and worse self-rated health compared to otherwise similar men who are not transgender.

Impacts of Public Health Insurance on Occupational Upgrading

Source: Ammar Farooq, Adriana Kugler, IRL Review, OnlineFirst, Published June 5, 2020
(subscription required)

From the abstract:
Using data from the Current Population Survey’s Merged Outgoing Rotation Groups, the authors examine whether greater Medicaid generosity encourages people to switch toward better quality occupations. Exploiting variation in Medicaid eligibility expansions for children across states during the 1990s and early 2000s, they find that a one standard deviation increase in Medicaid infant income thresholds increased the likelihood that working parents move to a new occupation by 1.6 percentage points or 3.3%. Findings show that these effects are larger for those below 150% of the poverty line and for married parents who were not benefiting from Medicaid prior to the expansions. In addition, findings indicate that Medicaid generosity also increased mobility toward occupations with higher average wages and higher educational requirements. This article contributes to the literature on job lock by showing that access to public health insurance not only increases employment and job switches but also encourages occupational upgrading.