The Impact of Nurse Turnover on Quality of Care and Mortality in Nursing Homes: Evidence from the Great Recession

We estimate the causal effect of nurse turnover on mortality and the quality of nursing home care with a fixed effect instrumental variable estimation that uses the unemployment rate as an instrument for nursing turnover. We find that ignoring endogeneity leads to a systematic underestimation of the effect of nursing turnover on mortality and quality of care in a sample of California nursing homes. Specifically, 10 percentage point increase in nurse turnover results in a facility receiving 2.2 additional deficiencies per annual regulatory survey, reflecting a 19.3 percent increase. Not accounting for endogeneity of turnover leads to results that suggest only a 1 percent increase in deficiencies. We also find suggestive evidence that turnover results in lower quality in other dimensions and may increase mortality. An implication of our mortality results is that turnover may be a mechanism for the procyclicality of mortality rates

Access to Health Insurance and the Use of Inpatient Medical Care: Evidence from the Affordable Care Act Young Adult Mandate

The Affordable Care Act of 2010 expanded coverage to young adults by allowing them to remain on their parent's private health insurance until they turn 26 years old. While there is evidence on insurance effects, we know very little about use of general or specific forms of medical care. We study the implications of the expansion on inpatient hospitalizations. Given the prevalence of mental health needs for young adults, we also specifically study mental health related inpatient care. We find evidence that compared to those aged 27–29 years, treated young adults aged 19–25 years increased their inpatient visits by 3.5 percent while mental illness visits increased 9.0 percent. The prevalence of uninsurance among hospitalized young adults decreased by 12.5 percent; however, it does not appear that the intensity of inpatient treatment changed despite the change in reimbursement composition of patients

Effects of Federal Policy to Insure Young Adults: Evidence from the 2010 Affordable Care Act's Dependent-Coverage Mandate

Using data from the Survey of Income and Program Participation (SIPP), we study the health insurance and labor market implications of the recent Affordable Care Act (ACA) provision that allows dependents to remain on parental policies until age 26. Our comparison of outcomes for young adults aged 19-25 with those who are older and younger, before and after the law, shows a high take-up of parental coverage, resulting in substantial reductions in uninsurance and other forms of coverage. We also find preliminary evidence of increased labor market flexibility in the form of reduced work hours

Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study

This is the publisher's version. To view the original publication, see http://bmjopen.bmj.comThis article aims to examine the between-hospital variation of charges and discounted prices for uncomplicated vaginal and caesarean section deliveries, and to determine the institutional and market-level characteristics that influence adjusted charges. Using data from the California Office of Statewide Health Planning and Development (OSHPD), we conducted a cross-sectional study of all privately insured patients admitted to California hospitals in 2011 for uncomplicated vaginal delivery (diagnosis-related group (DRG) 775) or uncomplicated caesarean section (DRG 766). Hospital charges and discounted prices were adjusted for each patient's clinical and demographic characteristics. We analysed 76,766 vaginal deliveries and 32,660 caesarean sections in California in 2011. After adjusting for patient demographic and clinical characteristics, we found that the average California woman could be charged as little as US$3,296 or as much as US$37,227 for a vaginal delivery and US$8,312–US$70,908 for a caesarean section depending on which hospital she was admitted to. The discounted prices were, on an average, 37% of the charges. We found that hospitals in markets with middling competition had significantly lower adjusted charges for vaginal deliveries, while hospitals with higher wage indices and casemixes, as well as for-profit hospitals, had higher adjusted charges. Hospitals in markets with higher uninsurance rates charged significantly less for caesarean sections, while for-profit hospitals and hospitals with higher wage indices charged more. However, the institutional and market-level factors included in our models explained only 35–36% of the between-hospital variation in charges. These results indicate that charges and discounted prices for two common, relatively homogeneous diagnosis groups—uncomplicated vaginal delivery and caesarean section—vary widely between hospitals and are not well explained by observable patient or hospital characteristics

A bargain at twice the price? California hospital prices in the new millennium.

We use data from California to document and offer possible explanations for the sharp increase in hospital prices charged to private payers after 1999. We find a downward trend in price for private pay patients in the 1990s and a rapid upward trend beginning in 1999, amounting to an annual average increase of 10.6% per year over 1999-2005. Prices in 2006 were almost double prices in 1999. By contrast, there was little discernable trend in prices for Medicare and Medicaid patients, although these prices varied from year-to-year. Surprisingly, the increase in prices is not correlated, geographically, with the change in hospital market concentration. For example, the greatest price rises came from hospitals in monopoly and highly concentrated counties which experienced little or no change over our sample period. Two recent California state hospital regulations, the seismic retrofit mandate and the mandatory nurse staffing ratio affected hospital costs. However, the cost increases due to the nursing staffing regulations are not large enough to account for the price increase, and the price increase is not substantially correlated with the costs of compliance with the seismic retrofit mandate. Therefore, the source of the near-doubling of California hospital prices remains something of a mystery

A Bargain at Twice the Price? California Hospital Prices in the New Millennium

We use data from California to document and offer possible explanations for the sharp increase in hospital prices charged to private payers after 1999. We find a downward trend in price for private pay patients in the 1990s and a rapid upward trend beginning in 1999, amounting to an annual average increase of 10.6% per year over 1999-2005. Prices in 2006 were almost double prices in 1999. By contrast, there was little discernable trend in prices for Medicare and Medicaid patients, although these prices varied from year-to-year. Surprisingly, the increase in prices is not correlated, geographically, with the change in hospital market concentration. For example, the greatest price rises came from hospitals in monopoly and highly concentrated counties which experienced little or no change over our sample period. Two recent California state hospital regulations, the seismic retrofit mandate and the mandatory nurse staffing ratio affected hospital costs. However, the cost increases due to the nursing staffing regulations are not large enough to account for the price increase, and the price increase is not substantially correlated with the costs of compliance with the seismic retrofit mandate. Therefore, the source of the near-doubling of California hospital prices remains something of a mystery.

Variation in charges for 10 common blood tests in California hospitals: A cross-sectional analysis

Objectives: To determine the variation in charges for 10 common blood tests across California hospitals in 2011, and to analyse the hospital and market-level factors that may explain any observed variation. Design setting and participants: We conducted a cross-sectional analysis of the degree of charge variation between hospitals for 10 common blood tests using charge data reported by all non-federal California hospitals to the California Office of Statewide Health Planning and Development in 2011. Outcome measures: Charges for 10 common blood tests at California hospitals during 2011. Results: We found that charges for blood tests varied significantly between California hospitals. For example, charges for a lipid panel ranged from US$10 to US$10 169, a thousand-fold difference. Although government hospitals and teaching hospitals were found to charge significantly less than their counterparts for many blood tests, few other hospital characteristics and no market-level predictors significantly predicted charges for blood tests. Our models explained, at most, 21% of the variation between hospitals in charges for the blood test in question. Conclusions: These findings demonstrate the seemingly arbitrary nature of the charge setting process, making it difficult for patients to act as true consumers in this era of ‘consumer-directed healthcare.

Microbial Quality of Household Drinking Water in the Sunyani Municipality of Ghana

The health risk associated with the microbial contamination of drinking water has been a major challenge in most households in the developing world. This challenge stems from the fact that water management systems are either inadequate or non-existent. In this study, the microbial quality of household drinking water in the Sunyani Municipality of Ghana was assessed. Thirty water samples were collected from the various households from eight communities for bacteriological analysis using the multiple tube method. The results were recorded as Most Probable Number (MPN) of coliform per 100 ml of water and compared with World Health Organization Guidelines for Drinking water quality. From the study, the mean total coliform of water ranged from 1.75 x 103 to 8.5 x106 cfu/100 ml. Out of the 30 water samples, twenty-two (73.3%) were positive with coliforms. The commonest source of drinking water standpipe had fifty percent of samples contaminated with coliforms. All four samples collected from the borehole were contaminated with coliforms. Out of the 22 coliform-positive samples, 59.1% of them showed positive for faecal coliform, out of which 50% of samples tested positive for the presence of Escherichia coli (E. coli). The study recommends intensive community education on proper water management systems as well as encouraging proper household hygiene practices. Keywords: Total coliforms, E. coli, Most Probable Number, water qualit

Nexus between constructs of social cognitive theory model and diabetes self-management among Ghanaian diabetic patients: A mediation modelling approach

The promotion of Diabetes Self-Management (DSM) practices, education, and support is vital to improving the care and wellbeing of diabetic patients. Identifying factors that affect DSM behaviours may be useful to promote healthy living among these patients. The study assessed the determinants of DSM practices among Type 2 diabetes mellitus (T2DM) patients using a model-based social cognitive theory (SCT). This cross-sectional study comprised 420 (T2DM) patients who visited the Diabetic Clinic of the Komfo Anokye Teaching Hospital (KATH), Kumasi-Ghana. Data was collected using self-structured questionnaires to obtain socio-demographic characteristics, T2DM-related knowledge, DSM practices, SCT constructs; beliefs in treatment effectiveness, level of self-efficacy, perceived family support, and healthcare provider-patient communication. Path analysis was used to determine direct and indirect effects of T2DM-related knowledge, perceived family support, and healthcare provider service on DSM practices with level of self-efficacy mediating the relationships, and beliefs in treatment effectiveness as moderators. The mean age of the participants was 53.1(SD = 11.4) years and the average disease duration of T2DM was 10 years. Most of the participants (65.5 %) had high ( \u3e 6.1mmol/L) fasting blood glucose (FBG) with an average of 6.93 (SD = 2.41). The path analysis model revealed that age (p = 0.176), gender (p = 0.901), and duration of T2DM (p = 0.119) did not confound the relationships between the SCT constructs and DSM specified in the model. A significant direct positive effect of family and friends’ support (Critical ratio (CR) = 5.279, p \u3c 0.001) on DSM was observed. Self-efficacy was a significant mediator in this relationship (CR = 4.833, p \u3c 0.001). There were significant conditional indirect effects (CIE) for knowledge of T2DM and family and friends’ support at medium and high levels of belief in treatment effectiveness (p \u3c 0.05) via level of self-efficacy on DSM practices. However, no evidence of moderated-mediation was observed for the exogenous variables on DSM. Diabetes-related knowledge of T2DM, family and friends’ support, level of self-efficacy, and belief in treatment effectiveness are crucial in DSM practices among Ghanaian T2DM patients. It is incumbent to consider these factors when designing interventions to improve DSM adherence

The Impact of Nurse Turnover and Quality of Care: Evidence from the Great Recession

A large literature finds that high nursing turnover is associated with poor quality of care in nursing homes. This existing evidence is, however, problematic since none of them address the possible endogeneity of job turnover. This research will estimate the causal effect of nurse turnover on the quality of nursing home care by using an instrumental variable estimation that uses employment rate as an instrument for nursing turnover