Abstract
Objectives
We explore adverse consequences of unmet needs for care among high-need/high-cost (HNHC) older adults.
Method
Interviews with 4,024 community-dwelling older adults with ...ADL/IADL/mobility disabilities from the 2011 National Health and Aging Trends Study (NHATS). Reports of socio-demographics, disability compensatory strategies, and adverse consequences of unmet needs in the past month were obtained from older adults with multiple chronic conditions (MCC), probable dementia (DEM), and/or near end-of-life (EOL) and compared older adults not meeting these criteria.
Results
Older adults with MCC (31.6%), DEM (39.6%), and EOL (48.7%) reported significantly more adverse consequences than low-need older adults (21.4%). Persons with MCC and DEM (53.4%), MCC, and EOL (53.2%), and all three (MCC, DEM, EOL, 65.6%) reported the highest levels of adverse consequences. HNHC participants reported more environmental modifications, assistive device, and larger helper networks. HNHC status independently predicted greater adverse consequences after controlling for disability compensatory strategies in multivariate models.
Discussion
Adverse consequences of unmet needs for care are prevalent among HNHC older adults, especially those with multiple indicators, despite more disability-related compensatory efforts and larger helper networks. Helping caregivers provide better informal care has potential to contain healthcare costs by reducing hospitalization and unplanned readmissions.
Abstract
Background
Patients with serious mental illness (SMI) are vulnerable to medical-surgical readmissions and emergency department visits.
Methods
We studied 1,914,619 patients with SMI ...discharged after medical-surgical admissions in Florida and New York between 2012 and 2015 and their revisits to the hospital within 30 days of discharge.
Results
Patients with SMI from the most disadvantaged communities had greater adjusted 30-day revisit rates than patients from less disadvantaged communities. Among those that experienced a revisit, patients from the most disadvantaged communities had 7.3 % greater 30-day observation stay revisits.
Conclusions
These results suggest that additional investments are needed to ensure that patients with SMI from the most disadvantaged communities are receiving appropriate post-discharge care.
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CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
BACKGROUND: In 2013, New York introduced regulations mandating that hospitals develop pediatric-specific protocols for sepsis recognition and treatment. METHODS: We used hospital discharge data from ...2011 to 2015 to compare changes in pediatric sepsis outcomes in New York and 4 control states: Florida, Massachusetts, Maryland, and New Jersey. We examined the effect of the New York regulations on 30-day in-hospital mortality using a comparative interrupted time-series approach, controlling for patient and hospital characteristics and preregulation temporal trends. RESULTS: We studied 9436 children admitted to 237 hospitals. Unadjusted pediatric sepsis mortality decreased in both New York (14.0% to 11.5%) and control states (14.4% to 11.2%). In the primary analysis, there was no significant effect of the regulations on mortality trends (differential quarterly change in mortality in New York compared with control states: −0.96%; 95% confidence interval CI: −1.95% to 0.02%; P = .06). However, in a prespecified sensitivity analysis excluding metropolitan New York hospitals that participated in earlier sepsis quality improvement, the regulations were associated with improved mortality trends (differential change: −2.08%; 95% CI: −3.79% to −0.37%; P = .02). The regulations were also associated with improved mortality trends in several prespecified subgroups, including previously healthy children (differential change: −1.36%; 95% CI: −2.62% to −0.09%; P = .04) and children not admitted through the emergency department (differential change: −2.42%; 95% CI: −4.24% to −0.61%; P = .01). CONCLUSIONS: Implementation of statewide sepsis regulations was generally associated with improved mortality trends in New York State, particularly in prespecified subpopulations of patients, suggesting that the regulations were successful in affecting sepsis outcomes.
Rates of rural hospital closures have been increasing over the past decade. Closures will almost certainly restrict rural residents’ access to important inpatient services, and they could also be ...related in important ways to the supply of physicians in the local health care system. We used data from the Area Health Resources Files for the period 1997–2016 to examine the relationship between rural hospital closures and the supply of physicians across different specialties in the years leading up to and after a closure. We observed significant annual reductions of up to 8.3 percent in the supply of general surgeons in the years leading up to a closure. We also found that rural hospital closures were associated with immediate and persistent decreases in the supply of surgical specialists and long-term decreases in the supply of physicians across multiple specialties—including an average annual 8.2 percent decrease in the supply of primary care physicians in the six years after a closure and beyond. This dynamic relationship could lead to reduced access to care for rural residents. Future policy efforts must focus on supporting and maintaining health care delivery models that do not depend on hospitals.
Expanding scope of practice (SOP) for nurse practitioners (NPs) may increase NP employment in primary care practices which can help meet the growing demand in primary care. We examined the impact of ...enacting less restrictive NP practice restrictions—NP Modernization Act—in New York State (NYS) on the overall employment of primary care NPs and specifically in underserved areas. We used longitudinal data from the SK&A outpatient database (2012-2018) to identify primary care practices in NYS and in the comparison states (Pennsylvania PA and New Jersey NJ). Using a difference-in-differences design with an event study specification, we compared changes in (1) the presence and (2) total counts of NPs in primary care practices in NYS and neighboring comparison states (ie, PA and NJ) before and after the policy change. The NP Modernization Act was associated with a 1.3 percentage point lower probability of a practice employing at least one NP on average across each of the 3 post-periods (95% CI: −.024, −.002). NP Modernization Act was associated with 0.065 fewer NPs on average across the post-period (95% CI: −.119, −.011). Results were similar in underserved areas. NP employment in primary care practices in NYS was lower after the NP Modernization Act than would have been expected based counterfactual of comparison states. The negative relationship may be explained by gains in provider efficiency which leads to reduced NP hiring in primary care. More research is needed to understand the relationship between SOP regulations, NP supply, and access to care.
Adopting full scope of practice (SOP) for nurse practitioners (NPs) is associated with improved access to care. One possible mechanism for these improvements is increased NP supply. Using ...county-level data, we fit cross-sectional and panel regression models to estimate the association between adopting full NP SOP and NP supply in general, and in rural and health professional shortage area—designated counties in particular. In cross-sectional analyses, we estimated positive associations between NP SOP and NP supply, though these relationships were only statistically significant when analyzing health professional shortage areas. In the panel regression models with county fixed effects, the estimated effects were attenuated toward zero and sometimes switched signs. Our findings suggest that improvements in access to care following adoption of full SOP may not be driven by increased NP supply but rather by increased capacity of NPs and physicians to provide care.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Nurse practitioners (NPs) represent the fastest-growing workforce of primary care clinicians in the United States. Their numbers are projected to grow in the near future. The NP workforce can help ...the country meet the rising demand for care services due to the aging population and increasing chronic disease burden. Yet, increased burnout among these clinicians may affect their ability to deliver high-quality, safe care. We investigated how NP burnout in primary care practices affects patient outcomes, including emergency department (ED) use and hospitalizations, among older adults with chronic conditions. In 2018-2019, we collected survey data from 1244 primary care NPs from 6 geographically diverse states on their burnout and merged the survey data with data from Medicare claims on ED use and hospitalizations among 467 466 older adults with chronic conditions. 26.3% of NPs reported burnout. Using logistic regression models, we found that with a 1-unit increase in the standardized burnout score, the odds of an ED visit increased by 2.8% (OR = 1.028; P-value = .035); Ambulatory Care Sensitive Conditions (ACSC) ED visit by 3.2% (OR = 1.032; P-value = .019); hospitalization by 3.9% (OR = 1.039; P-value = .001); and ACSC hospitalization by 6.2% (OR = 1.062; P-value = .001). Our findings indicate that if chronically ill older adults receive care in primary care practices with higher NP burnout rates they are more likely to use EDs and hospitals. Policy and practice efforts, such as improving NP working conditions, should be undertaken to reduce NP burnout in primary care practices to potentially prevent acute care use.
Studies have established that nurse practitioners (NPs) deliver primary care comparable to physicians in quality and cost, but most focus on Medicare, a program that reimburses NPs less than ...physicians. In this retrospective cohort study, we evaluated the quality and cost implications of receiving primary care from NPs compared to physicians in 14 states that reimburse NPs at the Medicaid fee-for-service (FFS) physician rate (i.e., pay parity). We linked national provider and practice data with Medicaid data for adults with diabetes and children with asthma (2012-2013). We attributed patients to primary care NPs and physicians based on 2012 evaluation & management claims. Using 2013 data, we constructed claims-based primary care quality measures and condition-specific costs of care for FFS enrollees. We estimated the effect of NP-led care on quality and costs using: (1) weighting to balance observable confounders and (2) an instrumental variable (IV) analysis using differential distance from patients’ residences to primary care practices. Adults with diabetes received comparable quality of care from NPs and physicians at similar cost. Weighted results showed no differences between NP- and physician-attributed patients in receipt of recommended care or diabetes-related hospitalizations. For children with asthma, costs of NP-led care were lower but quality findings were mixed: NP-led care was associated with lower use of appropriate medications and higher rates of asthma-related emergency department visits but similar rates of asthma-related hospitalization. IV analyses revealed no evidence of differences in quality between NP- and physician-led care. Our findings suggest that in states with Medicaid pay parity, NP-led care is comparable to physician-led care for adults with diabetes, while associations between NP-led care and quality were mixed for children with asthma. Increased use of NP-led primary care may be cost-neutral or cost-saving, even under pay parity.
Background
Nurse practitioners care for patients with cardiovascular disease, particularly those from racial and ethnic minority groups, and can help assure equitable health outcomes. Yet, nurse ...practitioners practice in challenging care environments, which limits their ability to care for patients.
Objective
To determine whether primary care nurse practitioner care environments are associated with racial and ethnic disparities in hospitalizations among older adults with coronary heart disease.
Design
In this observational study, a cross-sectional survey was conducted among primary care nurse practitioners in 2018–2019 who completed a valid measure of care environment. The data was merged with 2018 Medicare claims data for patients with coronary heart disease.
Participants
A total of 1244 primary care nurse practitioners and 180,216 Medicare beneficiaries 65 and older with coronary heart disease were included.
Main Measures
All-cause and ambulatory care sensitive condition hospitalizations in 2018.
Key Results
There were 50,233 hospitalizations, 9068 for ambulatory care sensitive conditions. About 28% of patients had at least one hospitalization. Hospitalizations varied by race, being highest among Black patients (33.5%). Care environment moderated the relationship between race (Black versus White) and hospitalization (OR 0.93; 95% CI, 0.88–0.98). The lowest care environment was associated with greater hospitalization among Black (odds ratio=1.34; 95% CI, 1.20–1.49) compared to White beneficiaries. Practices with the highest care environment had no racial differences in hospitalizations. There was no interaction effect between care environment and race for ambulatory care sensitive condition hospitalizations. Nurse practitioner care environment had a protective effect on these hospitalizations (OR, 0.96; 95% CI, 0.92–0.99) for all beneficiaries.
Conclusions
Unfavorable care environments were associated with higher hospitalization rates among Black than among White beneficiaries with coronary heart disease. Racial disparities in hospitalization rates were not detected in practices with high-quality care environments, suggesting that improving nurse practitioner care environments could reduce racial disparities in hospitalizations.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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