Medical Care最新文献

Background: Health care delivery organizations increasingly employ advanced practice professionals (APPs) and participate in alternative payment models such as accountable care organizations (ACOs). Given the former's incentive to constrain spending, APPs' practice patterns may vary in ACO-participating versus non-ACO practices.

Objectives: To compare outpatient care provided by APPs and physicians through ACO participation.

Research design: We used multivariate linear regression to compare measures of workload allocation and billing across ACO-participating and non-ACO practices in 2022, controlling for practice size and market.

Subjects: A total of 91,149 practices, 12,072 in a Medicare Shared Savings Program ACO in 2022.

Measures: We used 100% fee-for-service Medicare claims to identify ACO-participating and non-ACO practices. For every practice, we calculated the share of outpatient encounters provided by APPs rather than physicians and the share of APP-provided encounters billed indirectly to Medicare. We also calculated the share of annual wellness visits, chronic condition care management services, transitional care management services, and postoperative visits provided by APPs.

Results: APPs provided a smaller share of outpatient encounters at ACO-participating versus non-ACO practices, but were more likely to bill indirectly. Among most categories of routine services (eg, annual wellness visits and chronic condition management), APPs provided a smaller share of services at ACO-participating versus non-ACO practices. In the largest quartile of practices, APP practice patterns were more similar across ACO-participation status, and indirect billing was less likely within ACOs.

Conclusions: Findings provide little evidence that ACOs deploy their APP workforce in a more cost-conscious manner than non-ACOs.

Background: Few health care organizations have structured approaches to assimilate and analyze disruptive behavior data. In 2012, Veterans Affairs (VA) developed the Workplace Behavior Risk Assessment (WBRA), a tool that collects behavioral threat data from multiple systems, consolidates it, and tailors staff training based on the frequency and type of events.

Objective: This paper provides an overview of the WBRA and how it can inform nurse training.

Methods: A repeated measures design evaluated trends in workplace violence reporting and event rates across 140 VA health care systems from 2013 to 2024. Data were collected annually using a standardized electronic reporting system and reviewed by multidisciplinary teams. Risk levels were categorized based on the frequency and type of disruptive events, including manual restraint and physical or verbal violence. Descriptive statistics were used to prevalence of incidents and analyze trends, particularly among nursing professionals in high-risk areas.

Results: Four VA workplace settings: acute care (psychiatric and medical/surgical), emergency/urgent care, and Community Living Centers (CLC) were consistently classified as high-risk. In FY 2024, nursing staff accounted for over 90% of reports in inpatient and extended care settings and 73% in emergency/urgent care. From FY 2013 to FY 2024, reports involving nurses increased significantly, with the largest rises in CLCs (289%) and Medical/Surgical Units (271%), whereas the proportion of physical violence reports involving nurses rose from 59% to 83%.

Conclusions: The WBRA enables health care systems to analyze behavioral risk data to align training with risk.

Background: Gulf War illness is a chronic multisymptom illness impacting Veterans of the 1990-1991 Persian Gulf War. Toxic exposures are believed to be associated with the condition, but little is known about how multiple types of exposures can impact the disease. The aim of this study is to determine if a positive association exists between the multiplicity of exposure types and symptom severity score.

Methods: A cross-sectional survey design was used in which Persian Gulf Veterans completed a questionnaire with items related to symptom severity and types of self-reported toxic exposures. Linear regression models were used to examine the association between the number of types of toxic exposures and symptom severity scores. We also examined the association between each type of reported exposure and symptom severity score.

Results: Veterans with a greater number of self-reported toxic exposures reported higher scores on symptom severity. While no individual exposure type reached a statistically significant association with symptom score, radiation and biological agent exposures showed the strongest association.

Discussion: We found a positive association between the number of toxic exposure types and total symptom severity. Veterans who self-reported having Gulf War Illness also reported more types of toxic exposures compared with Veterans who did not report having Gulf War Illness. Radiation and biological agent exposure showed the strongest positive association with symptom scores, yet very few Veterans reported isolated exposure of these types. Our findings suggest that cumulative exposure to multiple types of toxins could be associated with the development and severity of Gulf War Illness symptoms.

Background: Prior work has shown that Medicaid coverage offset reductions in employer-sponsored insurance after COVID-19-related job loss in Medicaid expansion states. However, the effect of Medicaid expansion on health care access is not fully understood.

Objective: To estimate the association of unemployment during COVID-19 with health insurance coverage and health care access in Medicaid expansion versus nonexpansion states.

Study design: We used restricted, longitudinal National Health Interview Survey (NHIS) data from 2019 to 2020, focusing on working-age adults (N=5156). Using triple-difference models, we estimated changes in outcomes for respondents becoming unemployed between 2019 and 2020 (after COVID-19) relative to continuously employed respondents, in Medicaid expansion versus nonexpansion states.

Principal findings: Compared with continuously employed respondents, there was a statistically significant increase in Medicaid coverage among the newly unemployed in expansion states (6.1 percentage points (pp), 95% CI: 1.0 to 11.3, P=0.019) but not in nonexpansion states (3.9 pp, 95% CI: -3.9 to 11.8, P=0.324); however, the triple difference was nonsignificant. Uninsurance increased among the newly unemployed in expansion states by only 4.9 pp (95% CI: 0.9 to 8.9, P=0.016) versus 12.4 pp in nonexpansion states (95% CI: 0.2 to 24.6, P=0.047), but the triple difference was statistically nonsignificant. There was a significant increase in delaying or skipping medical care among newly unemployed respondents in nonexpansion states, but not in expansion states and the triple difference was statistically significant (-15.5 pp, 95% CI: -26.9 to -4.0, P=0.008).

Conclusion: Our results suggest that Medicaid expansion prevented disruptions in health care access for the newly unemployed during COVID-19.

Background: Inpatient nurse staffing affects patient outcomes. Less is known about the mechanism of this relationship and how lower overall staffing in a unit affects individual RN activities at the bedside.

Objectives: Estimate the relationship between the number of patients assigned to an RN and time spent on medication administration at the peak-time medication pass (PTM), a common nursing task.

Research design: Estimate the association using multivariable linear regression to adjust for patient severity and staff and unit fixed effects.

Subjects: All 9272 RNs administering medications during the PTM on 243 inpatient units in 113 VHA hospitals in 2019.

Measures: Number of assigned patients to an RN at PTM; PTM duration.

Results: After adjusting for staff and unit fixed effects and average patient severity of illness, the PTM duration for an RN assigned 3 patients is 20.67 (95% CI: 20.31, 21.03) minutes longer than when they are assigned 2 patients. The adjusted difference between 4 and 2 patients is 35.42 (95% CI: 35.01, 35.83). PTM duration per patient declines. Relative to 2 patients, RNs assigned 3 patients spend 0.78 (95% CI: 0.63, 0.93) fewer minutes per patient delivering medications during the PTM (3% reduction), and RNs assigned 4 patients spend 2.52 (95% CI: 2.37, 2.68) fewer minutes (11% reduction).

Conclusion: Individual nurses spend more time overall delivering medications when assigned more patients. Nurses compensate for the increased patient load by only marginally reducing time spent with each patient, even after controlling for patient severity and other factors.

Background: The employee experience of clinical personnel, especially nurses, is increasingly vital for health care organizations and is now part of health care's quintuple aim, which includes improving patient experience, population health, cost, and health equity. Nurse burnout and turnover intentions have heightened since the COVID-19 pandemic, with high workload and inadequate staffing as key organizational drivers. Flexible work schedules, such as 72/80 (where one works three 12-h shifts per week but receives the pay equivalent of 80 h), have been a longstanding countermeasure, but postpandemic data on their impact are limited.

Objective: This national evaluation investigates the impact of the 72/80 work schedule on Veterans Health Administration (VHA) nurses. We hypothesized that nurses on a 72/80 schedule experience less burnout, higher job satisfaction, greater work engagement, and lower turnover intentions.

Design: We conducted a web-based survey including self-reported 72/80 work status and employee experience measures, alongside existing administrative data on employee outcomes. We analyzed the data using Mann-Whitney U tests, mixed effects, and linear regression models.

Sample: Eight thousand five hundred forty-five VHA nurses from 170 Veterans Affairs Medical Centers nationwide working in 24/7 bedded units completed the survey.

Results: The 72/80 schedule was significantly associated with lower emotional exhaustion and depersonalization, and greater personal accomplishment. In addition, 72/80 status correlated with higher workplace engagement, job satisfaction, organizational satisfaction, and lower turnover intention.

Conclusions: The 72/80 work schedule shows significant potential as a transformative workforce strategy, providing substantial benefits in recruitment, retention, and employee satisfaction.

Background: Despite nursing being the largest US health profession, only 16% of registered nurses (RNs) practice in rural areas, where health care access is limited. This significantly impacts rural residents, including over 2.7 million rural veterans receiving care at the Veterans Health Administration, leading to compromised health outcomes. Nurses are vital in primary care, improving coordination and management of chronic conditions.

Objectives: Identify recruitment and retention programs for rural nurses (licensed vocational nurses/licensed practical nurses and RNs), including strategy characteristics and location.

Research design: We conducted a scoping review of published and gray literature. Eligible studies targeted US rural nurse recruitment and retention strategies.

Measures: Data were extracted for program characteristics, including strategy type (eg, financial incentive), focus (recruitment, retention, or both), and collaboration levels (single or multi-institutional).

Results: Of 1179 unique articles identified, only 60 met the inclusion criteria. An additional 42 programs were identified from gray literature, totaling 102 programs. Twenty-two programs used a multipronged approach (2-14 strategies), totaling 180 strategies. Education (n=85) and personal and professional support (n=54) were the most frequently used recruitment and retention strategies.

Conclusions: Of the 102 programs, only 22 used a multipronged approach, with education as the most frequently used strategy. More programs should use a multipronged approach and provide additional incentives and support (eg, financial incentives) to rural nurses beyond education. Only 4 strategies were regulatory, shedding light on the need for more nurse recruitment and retention support at the policy level.

Background: Prior literature has shown that favorable selection of enrollees in Medicare Advantage (MA) that is not accounted for under the Hierarchical Condition Category (HCC) risk adjustment model can result in significant overpayments to MA plans. Detailed data from the Veterans Health Administration's (VHA) Nosos risk score can measure previously undetected favorable selection in a unique cohort of patients.

Objective: To analyze characteristics associated with Veteran enrollment in MA versus Traditional Medicare (TM) and quantify previously undetected favorable selection.

Research design: Pooled, cross-sectional study using nationally representative VHA survey data and VHA administrative data, 2016-2019.

Subjects: Dual VHA-Medicare enrollees.

Measures: Enrollee characteristics, risk scores, and VHA inpatient and outpatient costs.

Results: Compared with VHA-TM enrollees, VHA-MA enrollees were older [73.8 (8.5) vs. 72.2 (8.2) y; SMD=0.19], more likely to have Medicaid coverage (13.7% vs. 4.7%; SMD=0.31), less likely to use VHA care (67.4% vs. 74.3%; SMD=0.26), and more likely to be in the lowest priority group (facing VHA copays) (21.4% vs. 17.6%; SMD=0.15). However, in 2019, MA enrollees had Nosos scores that were 25.6 percentage points lower (95% CI: -35.7, -15.5) than TM enrollees, signaling a healthier population. In adjusted comparisons, MA enrollees had $453.79 lower VHA costs (95% CI: $832.30, $75.27) than TM enrollees.

Conclusions: MA plans enroll Veterans who are healthier and less costly than TM-enrolled Veterans. Our findings underscore plans' potential selection of enrollees based on characteristics unobservable in the HCC risk adjustment model. Policymakers may consider opportunities to adopt additional risk-adjustment factors specifically for dual VHA-MA enrollees.