Survival Models of Community Tenure and Length of Hospital Stay for the Seriously Mentally Ill: A 10-year Perspective

Objective: To examine the effects of personal and community characteristics, specifically race and rurality, on lengths of state psychiatric hospital and community stays using maximum likelihood survival analysis with a special emphasis on change over a ten year period of time. Data Sources: We used the administrative data of the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) from 1982- 1991 and the Area Resources File (ARF). Given these two sources, we constructed a history file for each individual who entered the state psychiatric system over the ten year period. Histories included demographic, treatment, and community characteristics. Study Design: We used a longitudinal, population-based design with maximum likelihood estimation of survival models. We presented a random effects model with unobserved heterogeneity that was independent of observed covariates. The key dependent variables were lengths of inpatient stay and subsequent length of community stay. Explanatory variables measured personal, diagnostic, and community characteristics, as well as controls for calendar time. Data Collection: This study used secondary, administrative and health planning data. Principal Findings: African-American clients leave the community more quickly than whites. After controlling for other characteristics, however, race does not affect hospital length of stay. Rurality does not affect length of community stays once other personal and community characteristics are controlled for. However, people from rural areas have longer hospital stays even after controlling for personal and community characteristics. The effects of time are significantly smaller than expected. Diagnostic composition effects and a decrease in the rate of first inpatient admissions explain part of this reduced impact of time. We also find strong evidence for the existence of unobserved heterogeneity in both types of stays and adjust for this in our final models. Conclusions: Our results show that information on client characteristics available from inpatient stay records is useful in predicting not only the length of inpatient stay but also the length of the subsequent community stay. This information can be used to target increased discharge planning for those at risk of more rapid readmission to inpatient care. Correlation across observed and unobserved factors affecting length of stay has significant effects on the measurement of relationships between individual factors and lengths of stay. Thus, it is important to control for both observed and unobserved factors in estimation.community tenure, length of psychiatric inpatient stay, survival analysis, state psychiatric hospital, maximum likelihood estimation

Diagnosis Measurement Error and Corrected Instrumental Variables

Health diagnosis indicators used as explanatory variables in econometric models often suffer from substantial measurement error. This measurement error can lead to seriously biased inferences about the effects of health conditions on the outcome measure of interest, and the bias generally spills over into inferences about the effects of policy/treatment variables. We generalize an existing instrumental variables (IV) method to make it compatible with the types of instruments typically available in large datasets containing health diagnoses. In particular, we relax the classical IV assumption that the instruments must have uncorrelated measurement errors. We identify and estimate the covariance matrix of the measurement errors and then use this information to derive a correction term to mitigate or eliminate the bias associated with classical IV. Our Monte Carlo simulations suggest that this corrected IV method can produce estimates far superior to those produced by OLS or classical IV.

Shortages of Rural Mental Health Professionals

This study presents a conceptual model of the supply and demand for mental health professionals. It uses national data to profile differences in the supply of mental health professionals in different types of rural and urban areas. It contrasts the availability of general health and mental health professionals. It examines shortage areas identified in 2000 and their related community characteristics. Because of the absence of data on a national level to describe many types of mental health professionals state licensure data for one state were used to show the volume and distribution of these practitioners. To improve rural mental health service delivery it will be necessary to implement system changes to promote the increased availability, competency, and support of rural health professionals.mental health, rural

The Lengths of Psychiatric Hospital Stays and Community Stays

We use advanced survival analysis methods to estimate the parameters affecting the joint distribution of exit dates from psychiatric hospitals and return dates to those hospitals. Data comes from Virginia state psychiatric hospital administrative records. We find that sex, marital status, employment status, diagnosis, and age help explain durations. We also find that there is significant duration dependence and unobserved heterogeneity which suggest that earlier analyses in this field that used simpler estimation methods were flawed.

Supply, Demand, and Equilibrium in the Market for CRNAs

This study determined the current trends in supply, demand and equilibrium (ie, the level of employment where supply equals demand) in the market for Certified Registered Nurse Anesthetists (CRNAs). It also forecasts future needs for CRNAs given different possible scenarios. The impact of the currect availablity of CRNAs, projected retirements, and changes in the demand for surgeries are considered in relation to CRNAs needed for the future. The study used data from many sources to estimate models associated with the supply and demand for CRNAs and the relationship to relevant community and policy characteristics such as per capita income of the community and managed care. These models were used to forecast changes in surgeries and in the supply of CRNAs in the future. The supploy of CRNAs has increased in recent years, stimulated by shortages of CRNAs and subsequent increases in the number of CRNAs trained. However, the increases have not offset the number of retiring CRNAs to maintain a constant age in the CRNA population. The average age will continue to increase for CRNAs in the near future despite increases in CRNAs trained. The supply of CRNAs in relation to surgeries will increase in the near future.Anesthesia manpower, CRNA, demand, nursing workforce, supply

Clinical Faculty: Major Contributors to the Education of New CRNAs

This study examines the important contributions of clinical faculty toward the education of the future workforce of Ceertified Registered Nurse Anesthetists (CRNAs). Differences in workload, work activities and income amoung clinical faculty, academic faculty and nonfaculty are examined.crnas, labor makret

The E¤ect of Rurality on Mental and Physical Health

Any time researchers choose to conduct a study on any aspect of rural health care, they are faced with a di¢ cult methodological choice regarding the oper- ational de?nition of rural to use in their study. While this seems to many who are not familiar with rural research to be a straightforward question (and often naive rural researchers expect to ?nd a single answer that is commonly agreed upon by experts in rural research), to date there is no single answer that is based on a consensus and supported by scienti?c evidence. Coburn, et al. (2007) states that ?there is no single, universally preferred de?nition of rural that serves all policy purposes.? One goal of this paper is to provide a method useful in informing the choice of rural de?nitions for a speci?c research study. This methods paper presents a systematic evaluation of the impact of the choice of rural de?nition on results. It was stimulated by the need to select a rural de?nition to use in related papers on the impact of community resources on mental and general health outcomes in other research by the authors. A na- tional dataset, the Community Tracking Survey, 2000-2001, includes individual level observations from household interviews. We merge it with county level data re?ecting community resources, and we use econometric methods to ana- lyze this multi-level data, accounting for individuals from the same family being included in the dataset. The e¤ect of using four di¤erent de?nitions of rural available for use in county level analysis is presented. A statistical analysis of the impact of the choice of a rural de?nition on outcomes and on the esti- mates and signi?cance of explanatory variables in the model is presented and is used to inform the selection of the de?nition to use in other research. Dif- ferences in results for mental health, physical health, and utilization of health care variables are evaluated. The choice of a rural definition is presented and justi?ed using the methodological analyses presented in this paper. Strengths and weaknesses of using county-level community characteristics as compared to data from larger geographic areas, such as Health Services Areas, or from smaller geographic areas, such as census tracts or zip codes, are discussed. Fi- nally, the need for a methods study to guide the use of multi-level geographic data to re?ect community characteristics within health care studies is proposed.rural, mental health, physical health, testing

New Estimates for CRNA Vacancies

A national survey to estimate vacancy rates of Certified Registered Nurse Anestheists (CRNAs) in hospital and ambulatory surgical centers was conducted in 2007. Poisson regression methods were used to improve the precision of the estimates. A significat increase in the estiamted vacancy rate was reported for hospitals relative to an earlier study from 2002, although it is important to note that there were some methodologial differences between the 2 surveys explaining the part of the increase. Results from this study found the vacancy rate was higher in rural hospitals than in nonrural hospitals, and it was lower in ambulatory surgical centers. A number of simulations were run to predict the effects of relevant changes in the market for surgeries and nuber of CRNAs, which were compared to the predicitons from the previous survey. The remarkable factor since the last survey was the unusually large rate of new CRNAs entering the market, yet the vacancy rates remain relatively high.Certified Registered Nurse Anesthetist, demand, labor market, vacancies, workforce

Engaging Healthcare Users through Gamification in Knowledge Sharing of Continuous Improvement in Healthcare

Knowledge management systems are key for capturing, retaining, and communicating results from projects and presenting information to staff. The purpose of a knowledge management system is to tap into the vast wisdom from projects and experts across an organization. This research focuses on the knowledge management system within the Veterans Health Administration that was developed as a repository of information on continuous improvement tools such as flowcharts, value stream mapping, 5S, and the application of these in healthcare projects. The use of social network analysis and gamification improves website organization, user participation, and dissemination of shared knowledge related to continuous improvement of operations. The purpose of gamification is to engage, teach, entertain, measure, and improve the ease of use of information systems. The goal of this research is to utilize gamification theory within the knowledge management system to drive behaviors in a targeted audience and engage users in aspects such as writing, contributing, getting the feedback, which will create a more robust, cohesive system. A thorough review of the current knowledge management system was conducted, and a gap analysis was performed comparing the goals and objectives for the system to the current results. Next, gamification techniques with the potential to improve performance were identified and strategies to implement these were developed