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Nurses make decisions about the use of costly resources in countless care delivery settings 24 hours a day. Consequently, nurses are inseparably connected to not only the quality and safety of care, but to the cost-of-care as well. This article is Part 1 of a 6-part series on value-informed nursing practice. It describes the concept of 'value-informed nursing practice'-practice that focuses not only on outcomes, but also on the cost of care-as a new way to envision nursing practice.

ImportanceA better understanding of the association between family structure and sex gaps in physician earnings and hours worked over the life cycle is needed to advance policies addressing persistent sex disparities.ObjectiveTo investigate differences in earnings and hours worked for male and female physicians at various ages and family status.Design, Setting, and ParticipantsThis retrospective, cross-sectional study used data on physicians aged 25 to 64 years responding to the American Community Survey between 2005 and 2019.ExposuresEarned income and work hours.Main Outcomes and MeasuresOutcomes included annual earned income, usual hours worked per week, and earnings per hour worked. Gaps in earnings and hours by sex were calculated by family status and physician age and, in some analyses, adjusted for demographic characteristics and year of survey. Data analyses were conducted between 2019 and 2022.ResultsThe sample included 95 435 physicians (35.8% female, 64.2% male, 19.8% Asian, 4.8% Black, 5.9% Hispanic, 67.3% White, and 2.2% other race or ethnicity) with a mean (SD) age of 44.4 (10.4) years. Relative to male physicians, female physicians were more likely to be single (18.8% vs 11.2%) and less likely to have children (53.3% vs 58.2%). Male-female earnings gaps grew with age and, when accumulated from age 25 to 64 years, were approximately $1.6 million for single physicians, $2.5 million for married physicians without children, and $3.1 million for physicians with children. Gaps in earnings per hour did not vary by family structure, with male physicians earning between 21.4% and 23.9% more per hour than female physicians. The male-female gap in hours worked was 0.6% for single physicians, 7.0% for married physicians without children, and 17.5% for physicians with children.Conclusions and RelevanceIn this cross-sectional study of US physicians, marriage and children were associated with a greater earnings penalty for female physicians, primarily due to fewer hours worked relative to men. Addressing the barriers that lead to women working fewer hours could contribute to a reduction in the male-female earnings gap while helping to expand the effective physician workforce.

Modernizing Scope-of-Practice Regulations Many health care organizations are experimenting with new ways of unleashing their workforce’s potential. Such approaches require reconfiguring of provider...

Supplemental Digital Content is available in the text., Objective: Applied to value-based health care, the economic term “individual productivity” refers to the quality of an outcome attributable through a care process to an individual clinician. This study aimed to (1) estimate and describe the discharge preparation productivities of individual acute care nurses and (2) examine the association between the discharge preparation productivity of the discharging nurse and the patient’s likelihood of a 30-day return to hospital [readmission and emergency department (ED) visits]. Research Design: Secondary analysis of patient-nurse data from a cluster-randomized multisite study of patient discharge readiness and readmission. Patients reported discharge readiness scores; postdischarge outcomes and other variables were extracted from electronic health records. Using the structure-process-outcomes model, we viewed patient readiness for hospital discharge as a proximal outcome of the discharge preparation process and used it to measure nurse productivity in discharge preparation. We viewed hospital return as a distal outcome sensitive to discharge preparation care. Multilevel regression analyses used a split-sample approach and adjusted for patient characteristics. Subjects: A total 522 nurses and 29,986 adult (18+ y) patients discharged to home from 31 geographically diverse medical-surgical units between June 15, 2015 and November 30, 2016. Measures: Patient discharge readiness was measured using the 8-item short form of Readiness for Hospital Discharge Scale (RHDS). A 30-day hospital return was a categorical variable for an inpatient readmission or an ED visit, versus no hospital return. Results: Variability in individual nurse productivity explained 9.07% of variance in patient discharge readiness scores. Nurse productivity was negatively associated with the likelihood of a readmission (−0.48 absolute percentage points, P

Care management programs have become more widely adopted as health systems try to improve the coordination and integration of services across the continuum of care, especially for frail older adults. Several models of care suggest the inclusion of registered nurses (RNs) and social workers to assist in these activities. In a 2018 national survey of 410 clinicians in 363 primary care and geriatrics practices caring for frail older adults, we found that nearly 40 percent of practices had no social workers or RNs. However, when both types of providers did work in a practice, social workers were more likely than RNs to be reported to participate in social needs assessment and RNs more likely than social workers to participate in care coordination. Physicians' involvement in social needs assessment and care coordination declined significantly when social workers, RNs, or both were employed in the practice.

Among the many trends influencing health and health care delivery over the next decade, three are particularly important: the transition to value-based care and increased focus on population health; the shift of care from acute to community-based settings; and addressing the vulnerability of rural health care systems in North Carolina.

Ensuring and Sustaining a Pandemic Workforce It seems clear that health care delivery organizations, educators, and government leaders all have to be willing to cut through bureaucratic barriers an...

Highlights • MDs report that MDs are their team leaders in most circumstances; NPs are less likely to indicate that MDs lead their teams. • Less than half of MD or NP clinicians agree that they experience excellent team work in their units • Significantly more MDs than NPs agree their role in the care team is clear, Importance The delivery of emergency, trauma, critical and intensive care services requires coordination among all members of the care team. Perceived teamwork and role clarity may vary among physicians (MDs) and nurse practitioners (NPs). Objective To examine differences in perceived roles and responsibilities of NPs and MDs practicing in emergency, trauma, critical and intensive care. Main Outcome(s) and Measure(s) Key clinical activities, perceptions of role clarity, teamwork and preparedness to function as a team in disaster Design Secondary Analysis of the National Survey of Emergency, Intensive and Critical Care Nurse Practitioners and Physicians, a 2015 cross-sectional national survey of clinicians. Setting Mail survey of randomly selected stratified cross-sectional samples of MDs and NPs drawn from national lists of clinicians in eligible specialties working in emergency, trauma, intensive and critical care units in the United States. Participants 814 clinicians (351 NPs and 463 MDs) recruited from national by postal mail survey. Our initial sample included n=2063 clinicians, n=1031 NPs and n=1032 MDs in eligible specialties. Of these, 63.5% of NPs and 70.1% of MDs completed and returned the survey excluding those who were ineligible due to lack of current practice in a relevant specialty Results NPs in ICU/CCU are more likely to be female and report working fewer hours than do MDs and provide direct care to more patients. 55% of NPs and 82% of MDs agree that their individual role in their unit is clear (p

Objective: To describe the members of pediatric intensive care unit interdisciplinary provider teams and labor inputs, working conditions, and clinical practice of pediatric intensive care unit nurse practitioners. Methods: A national, quantitative, crosssectional, descriptive postal survey of pediatric intensive care unit medical directors and nurse practitioners was administered to gather information about provider-team members, pediatric intensive care unit nurse practitioner labor inputs, working conditions, and clinical practice. Descriptive statistics, cross-tabulations, and χ2 tests were used. Results: Responses from 97 pediatric intensive care unit medical directors and 59 pediatric intensive care unit nurse practitioners representing 126 institutions were received. Provider-team composition varied between institutions with and without nurse practitioners. Pediatric intensive care units employed an average of 3 full-time nurse practitioners; the average nurse practitioner-to-patient ratio was 1 to 5. The clinical practice reported by medical directors was consistent with practice reported by nurse practitioners. Conclusion: Nurse practitioners are integrated into interdisciplinary pediatric intensive care unit teams, but institutional variation in team composition exists. Investigating models of care contributes to the understanding of how models influence positive patient and organizational outcomes and may change future role implementation.

The behavioral health workforce, which encompasses a broad range of professions providing prevention, treatment, and rehabilitation services for mental health conditions and substance use disorders, is in the midst of what is considered by many to be a workforce crisis. The workforce shortage can be attributed to both insufficient numbers and maldistribution of workers, leaving some communities with no behavioral health providers. In addition, demand for behavioral health services has increased more rapidly as a result of federal legislation over the past decade supporting mental health and substance use parity and by healthcare reform. In order to address workforce capacity issues that impact access to care, the field must engage in extensive planning; however, these efforts are limited by the lack of timely and useable data on the behavioral health workforce. One method for standardizing data collection efforts is the adoption of a Minimum Data Set. This article describes workforce data limitations, the need for standardizing data collection, and the development of a behavioral health workforce Minimum Data Set intended to address these gaps. The Minimum Data Set includes five categorical data themes to describe worker characteristics: demographics, licensure and certification, education and training, occupation and area of practice, and practice characteristics and settings. Some data sources align with Minimum Data Set themes, although deficiencies in the breadth and quality of data exist. Development of a Minimum Data Set is a foundational step for standardizing the collection of behavioral health workforce data. Key challenges for dissemination and implementation of the Minimum Data Set are also addressed. Supplement information This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

To examine differences in the quality of care provided by primary care nurse practitioners (PCNPs), primary care physicians (PCMDs), or both clinicians.Medicare part A and part B claims during 2012-2013.Retrospective cohort design using standard risk-adjustment methodologies and propensity score weighting assessing 16 claims-based quality measures grouped into 4 domains of primary care: chronic disease management, preventable hospitalizations, adverse outcomes, and cancer screening.Continuously enrolled aged, disabled, and dual eligible beneficiaries who received at least 25% of their primary care services from a random sample of PCMDs, PCNPs, or both clinicians.Beneficiaries attributed to PCNPs had lower hospital admissions, readmissions, inappropriate emergency department use, and low-value imaging for low back pain. Beneficiaries attributed to PCMDs were more likely than those attributed to PCNPs to receive chronic disease management and cancer screenings. Quality of care for beneficiaries jointly attributed to both clinicians generally scored in the middle of the PCNP and PCMD attributed beneficiaries with the exception of cancer screening.The quality of primary care varies by clinician type, with different strengths for PCNPs and PCMDs. These comparative advantages should be considered when determining how to organize primary care to Medicare beneficiaries.

Introduction Nurse practitioner (NP) prescribing continues to be a contentious policy issue, and studies systematically examining NP prescribing are lacking. The aim of this study was to conduct a descriptive analysis comparing the prescribing services of NPs with those of primary care physicians (PCPs) in providing care to Medicare beneficiaries. Methods Part D drug claims of beneficiaries who saw an NP or a PCP in 2009 and 2010 were examined for differences in the types of medications prescribed, the volume of prescriptions, and the duration of prescriptions across all drug classes in Medicare Part D. Results Data for 164,681 beneficiaries were analyzed. Results showed the same top 20 types of medications and the same share of generic medications for NP and PCP prescriptions. Differences in prescribing patterns were found for the number of prescriptions and for the duration of the prescriptions (days' supply per claim). NP beneficiaries received, on average, approximately one more 30-day prescription per year than PCP beneficiaries. The mean duration for an NP prescription claim was 3 days shorter than that for a PCP prescription claim, indicating that NP beneficiaries need refills sooner than PCP beneficiaries. This pattern existed in most drug classes and was more pronounced in behavioral drug classes, such as antidepressants, antipsychotics, psychotherapeutics, and opioids and in patients with more comorbidities. Differences in state scope of practice laws did not affect these prescribing patterns. Conclusions Key differences were observed in the number and duration of prescriptions written by NPs and PCPs. Further research is needed to understand the impact of differences in NP and PCP patient populations on provider prescribing, such as the higher number of prescriptions issued by NPs for beneficiaries in moderate and high comorbidity groups and the implications of the duration of prescriptions for clinical outcomes, patient-provider rapport, costs, and potential gaps in medication coverage.

Growing Ranks of Advanced Practice Clinicians Nurse practitioners and physician assistants are providing an increasing share of health care services, and education programs have proliferated. These...

Objective This study is designed to assess the cost of services provided to Medicare beneficiaries by nurse practitioners (NPs) billing under their own National Provider Identification number as compared to primary care physicians (PCMDs). Data Source Medicare Part A (inpatient) and Part B (office visit) claims for 2009–2010. Study Design Retrospective cohort design using propensity score weighted regression. Data Extraction Methods Beneficiaries cared for by a random sample of NPs and primary care physicians. Principal Findings After adjusting for demographic characteristics, geography, comorbidities, and the propensity to see an NP, Medicare evaluation and management payments for beneficiaries assigned to an NP were $207, or 29 percent, less than PCMD assigned beneficiaries. The same pattern was observed for inpatient and total office visit paid amounts, with 11 and 18 percent less for NP assigned beneficiaries, respectively. Results are similar for the work component of relative value units as well. Conclusions This study provides new evidence of the lower cost of care for beneficiaries managed by NPs, as compared to those managed by PCMDs across inpatient and office-based settings. Results suggest that increasing access to NP primary care will not increase costs for the Medicare program and may be cost saving.

As the US population ages, primary care is expected to be the health care “home” for older adults, and several initiatives are aimed at helping to transform primary care practice to care for this population. Wide variation in staffing has been observed. Meyers et al proposed ideal models of primary care staffing for a general population and for a frail elderly population (2018). We developed the 2018 Survey of Primary Care and Geriatric Clinicians to measure optimal team configuration in clinical practices caring for older adults. A majority employed NPs, MDs and PAs, with [r = -.53] between % of clinician labor of NPs and physicians). High-NP practices are more likely located in states with full scope of practice, perform well for frail elders and are less expensive. Meyers' models, with fewer physicians, more SW and CHWs, more RNs, perform better for frail elders, and are less expensive.

Key Points Question Is the growth of accountable care organizations associated with changes in physician work hours, probability of being self-employed, and probability of working in a hospital? Findings In this cross-sectional study including 49 582 physicians, a 10–percentage point increase in accountable care organization enrollment in a hospital referral region was associated with a statistically significant reduction of 0.82 work hours per week among male physicians. In addition, the 10–percentage point increase was associated with a decrease of 2% in the probability of all physicians being self-employed. Meaning These results suggest that accountable care organizations may affect physician employment patterns., Importance The share of the population covered by accountable care organizations (ACOs) is growing, but the association between this increase and physician employment is unknown. Objective To investigate the association between the growth of ACOs and changes in physician work hours, probability of being self-employed, and probability of working in a hospital. Design, Setting, and Participants A fixed-effects design was used in this cross-sectional study to compare changes in physician employment in hospital referral regions with high vs low ACO growth. A nationally representative 1% sample of all working US physicians obtained annually from 2011 through 2015 from the American Community Survey (N = 49 582) was included. Data analysis was conducted from March 28, 2017, to April 10, 2018. Main Outcomes and Measures Physician hours worked per week, probability of being self-employed, and probability of working in a hospital. Results Of the 49 582 physicians included in the study, 63.5% were men; the mean (SD) age of sampled physicians was 46.01 (11.59) years. In 2011, sampled physicians worked a mean (SD) of 52.2 (16.1) hours per week, 24.43% were self-employed, and 42.03% worked in a hospital. A 10–percentage point increase in ACO enrollment in a hospital referral region was associated with a statistically significant reduction of 0.82 (95% CI, −1.52 to −0.13; P = .02) work hours in men and a decrease of 2% (95% CI, −3.8% to −0.1%; P = .04) in the probability of all physicians being self-employed. The association with self-employment was strongest (−5.0%; 95% CI, −8.7% to −1.4%; P = .006) in physicians aged 50 to 69 years, who were also more likely (4.0%; 95% CI, 1.0% to 6.9%; P = .009) to work in a hospital. Conclusions and Relevance The growth of ACOs within hospital referral regions appears to be associated with a reduction in hours of work and self-employment among physicians. These results suggest that ACOs may affect physician employment patterns., This cross-sectional study evaluates the association between the expansion of accountable care organizations throughout the United States and changes in physician work hours, self-employment, and employment in hospitals.

Objective: This study explores the interactions among phases of team coordination, patient-related information, decision-making levels, and role holders in intensive care units (ICUs). Background: The effects of communication improvement initiatives on adverse patient events or improved outcomes have been difficult to establish. Conceptual inconsistencies and methodological shortcomings suggest insufficient understanding about clinical communication and care coordination. Method: Data were collected by shadowing a charge nurse, fellow, resident, and nurse in each of eight ICUs and recording each of their conversations during 12 hrs (32 role holders during 350 hrs). Results: Hierarchical log linear analyses show statistically significant three-way interactions between the patient information, phases of team coordination, and decision levels, χ2( df = 75) = 212, p < .0001; between roles, phases of team coordination, and decision levels, χ2( df = 60) = 109, p < .0001; and between roles, patient information, and decision levels, χ2( df = 60) = 155, p < .0001. Differences among levels of the variables were evaluated with the use of standardized parameter estimates and 95% confidence intervals. Conclusion: ICU communication and care coordination involve complex decision structures and role interactions across two information spaces. Different role holders mediate vertical and lateral process flows with goals and directions representing an important conceptual transition. However, lateral isolation within decision levels (charge nurses) and information overload (residents) are potential communication and care coordination vulnerabilities. Results are consistent with and extend the findings of previous studies. Application: The profile of ICU communication and care coordination provides a systemic framework that may inform future interventions and research.

Monitoring quality of care across institutions and over time and examining the correlates of quality are critical to pursuing effective policy to improve quality (Institute of Medicine Committee on Quality of Health Care in America 2001; Kohn et al. 2000). Medical record abstraction has been the “gold standard” for constructing quality measures but the costs associated with abstracting data from the patient's chart makes its use infeasible in monitoring quality and overall health system performance and examining the factors that influence quality. Researchers wishing to conduct analysis on large samples of hospitals have turned to less expensive and more readily available administrative data, primarily patient discharge abstracts, to construct measures of hospital quality (Agency for Healthcare Research and Quality 2000; Ball et al. 1998; Geraci 2000; Iezzoni, Daley, Heeren, Foley, Hughes et al. 1994; Iezzoni, Daley, Heeren, Foley, Fisher et al. 1994; Johantgen et al. 1998; Kuykendall et al. 1995; Silber and Rosenbaum 1997). Over 40 states now collect discharge abstracts on all hospitalized patients in acute care hospitals. These data vary in completeness, number of primary and secondary diagnoses and procedures reported, presence of other patient information, such as race/ethnicity and insurer, years available, and cost. The Centers for Medicare and Medicaid Services' (CMS) MedPAR system contains information on hospital discharges for all Medicare patients. These data are relatively inexpensive, consistently coded, available for virtually all acute care hospitals in the United States, and have been used in many studies (Lawthers et al. 2000; Romano et al. 1994; Romano et al. 1995; Weingart et al. 2000). There are, however, important differences between the state and national discharge data on Medicare patients. For example, the public-use MedPAR data do not include information on dates for procedures and have fewer coded secondary diagnoses and procedures than most state datasets. Nevertheless, the quality of patient care based on Medicare data is often regarded as a surrogate measure of the quality of care for all hospitalized patients. Although the data on Medicare patients contained within all-patient state datasets are generally consistent with information on Medicare patients in the CMS Medicare data (Medstat Group Research and Policy Division 2000), and there is some evidence that hospital admission patterns for all patients can be predicted from the admission patterns of Medicare patients (Radany and Luft 1993), it is an empirical question whether Medicare data can be used as a close substitute for all-patient data for hospital quality studies. Quality measures have been used in studies to assess quality in specific hospitals and in studies of hospital characteristics associated with quality care. We focus on the second type of study and assess whether all-patient and Medicare data provide the same results in regression-based studies of correlates of quality across a range of measures. We analyze data from a sample of all-patient discharge abstracts for hospitals in 11 states, and patients in a national sample drawn from MedPAR data, examining three samples of patients: the 11-state all-patient sample, the Medicare patients in the 11-state data (11-state Medicare sample), and national MedPAR sample. Our quality indicators were developed and tested in a larger study that examined the association of patient outcomes and nurse staffing in acute care hospitals (Needleman et al. 2002; Needleman et al. 2001). Our analytic strategy is first to compare rates of adverse outcomes and results from regression analysis of outcomes on nurse staffing in the 11-state all-patient sample to those from analysis of the 11-state Medicare sample. This comparison allows us to draw conclusions on how closely Medicare patients are a surrogate for all patients in the same sample of hospitals using consistently coded discharge data and identical measures of nurse staffing. Because researchers working with Medicare data will likely use data from the CMS national MedPAR files, and because less information is available on these abstracts than in most state discharge abstracts, we compare adverse outcome rates and regression results in the national MedPAR sample with those from our 11-state Medicare and 11-state all-patient samples to determine if the results from the MedPAR and state data are consistent. We find some differences in regression results between the MedPAR and two 11-state samples and conduct additional analyses to determine the source of these differences.

The success of efforts to bolster the primary care workforce rests in part on how these clinicians view their professions and their willingness to recommend their careers to others. The authors sought to examine career and job satisfaction, perceptions of workforce shortages, and willingness to make career recommendations among primary care physicians (PCPs) and primary care nurse practitioners (PCNPs).In 2012, the authors mailed a national survey concerning the issues above to 1,914 randomly chosen clinicians found on national databases: 957 PCPs and 957 PCNPs.A total of 972 eligible clinicians (505 PCPs, 467 PCNPs) returned the survey. Using standard opinion research procedures, the authors estimated there were approximately 1,589 eligible clinicians in their sample (response rate, 61.2%). PCNPs and PCPs were more likely to recommend a career as a PCNP than as a PCP, despite the perception among all clinicians of a serious shortage of PCPs nationally and in their own communities. This finding held among PCNPs who reported low workplace autonomy and among PCPs reporting that they were satisfied with their own careers.Efforts to solve the primary care workforce shortage that ignore the significant dissatisfaction of PCPs with their own careers are unlikely to be successful. Simply adding training slots and increasing reimbursement rates will do little to solve the problem if PCPs continue to view their own careers as ones they cannot recommend to others.

The size of the registered nurse (RN) workforce has surpassed forecasts from a decade ago, growing to 2.7 million in 2012 instead of peaking at 2.2 million. Much of the difference is the result of a surge in new nursing graduates. However, the size of the RN workforce is particularly sensitive to changes in retirement age, given the large number of baby-boomer RNs now in the workforce. We found that in the period 1969-90, for a given number of RNs working at age fifty, 47 percent were still working at age sixty-two and 9 percent were working at age sixty-nine. In contrast, in the period 1991-2012 the proportions were 74 percent at age sixty-two and 24 percent at age sixty-nine. This trend, which largely predates the recent recession, extended nursing careers by 2.5 years after age fifty and increased the 2012 RN workforce by 136,000 people. Because many RNs tend to shift out of hospital settings as they age, employers seeking RNs for nonhospital roles may welcome (and seek to capitalize on) the growing numbers of experienced RNs potentially able to fill these positions.

The U.S. health care system is facing a projected nursing shortage of unprecedented magnitude. Although military nursing services recently have been able to meet their nursing recruitment quotas, national studies have predicted a long-term nursing shortage that may affect future recruitment for the Nurse Corps of the three military services. Data are needed to plan for recruitment incentives and the impact of those incentives on targeted populations of likely future nurses.Data are drawn from three online surveys conducted in 2011-2012, including surveys of 1,302 Army, Navy, and Air Force personnel serving on major military bases, 914 nursing students at colleges with entry Bachelor of Science in Nursing programs located nearby major military bases, and a qualitative survey of 1,200 young adults, age 18-39, in the general public.The three populations are different in several demographic characteristics. We explored perceptions of military careers, nursing careers and barriers, and incentives to pursue military nursing careers in all populations. Perceptions differ among the groups.The results of this study may help to inform strategies for reaching out to specific populations with targeted messages that focus on barriers and facilitators relevant to each to successfully recruit a diverse Nurse Corps for the future.

Over the past year, published research has drawn increased attention to issues of hospital nurse staffing and adverse patient outcomes. Among the published articles that have appeared are those by Aiken et al . [1], Kovner et al . [2], and Needleman et al . [3]. The article by Aiken et al . focused on post-surgical mortality, and received substantial attention because of its conclusion that, controlling for patient and hospital characteristics, the addition of one patient to a registered nurse's workload was associated with a 7% increase in mortality. Research examining the association between nurse staffing and mortality has reached mixed conclusions. Needleman et al . found an association between nurse staffing levels and ‘failure to rescue’, defined in that study as death among patients who had one of five complications (pneumonia, sepsis, shock or cardiac arrest, upper gastrointestinal bleeding, and deep vein thrombosis), in surgical patients and to a lesser extent in medical patients. While Needleman et al . measured nurse staffing in a different way to Aiken et al ., reanalysis of the study generates an estimate of the magnitude of the impact of nurse staffing on failure to rescue similar to that reported by Aiken and colleagues. Needleman et al . did not, however, find an association with overall in-hospital mortality and nurse staffing. At least four other studies have found an association between nurse staffing and hospital mortality [4–7], while others have not [8–10]. How should these conflicting findings be viewed? Firstly, it must be recognized that because many factors influence hospital mortality, it can be difficult to tease out the effect of an individual factor. Many of these studies have used administrative data, including the three studies cited that were …

As health care delivery organizations react to the changes brought about by public and private sector reform initiatives, RNs can anticipate that, in addition to intended outcomes, there will be unpredictable pressures and unintended consequences arising from reform. Biennial national surveys of RNs conducted over the past decade have explored various changes in the nursing workforce, quality of the workplace environment, staffing and payment policies, and RNs' views of health policy, including their expectations of health reform. The latest survey results offer a picture of RNs' capacity to practice successfully in a care delivery environment that, over the current decade, is expected to emphasize teams, care coordination, and become driven increasingly by payment incentives that reward quality, safety, and efficiency. If RNs are provided with strong clinical leadership, participate in developing an achievable vision of the future, and if supported to take risks and innovate to improve the quality and efficiency of care delivery, then the profession is likely to thrive rather than struggle during the health reform years that lie ahead. Increasing the education and preparation of nursing leaders, and particularly unit-level managers, will be increasingly vital for nursing to prosper in the future.

Estimates of physician supply in the United States have been based on data that may overestimate the number of older physicians in the workforce.To compare physician workforce estimates and supply projections using the American Medical Association Physician Masterfile (Masterfile) data with estimates and projections using data from the US Census Bureau Current Population Survey (CPS).Parallel retrospective cohort analyses of employment trends of the number of active physicians by age and sex using annual data from the Masterfile and the CPS between 1979 and 2008. Recent workforce trends were used to project future physician supply by age.Annual number of physicians working at least 20 hours per week in 10-year age categories.In an average year in the sample period, the CPS estimated 67,000 (10%) fewer active physicians than did the Masterfile (95% confidence interval [CI], 57,000-78,000; P.001), almost entirely due to fewer active physicians aged 55 years or older. The CPS estimated more young physicians (ages 25-34 years) than did the Masterfile, with the difference increasing to an average of 17,000 (12%) during the final 15 years (95% CI, 13,000-22,000; P.001). The CPS estimates of more young physicians were consistent with historical growth observed in the number of first-year residents, and the CPS estimates of fewer older physicians were consistent with lower Medicare billing by older physicians. Projections based on both the CPS and the Masterfile data indicate that the number of active physicians will increase by approximately 20% between 2005 and 2020. However, projections for 2020 using CPS data estimate nearly 100,000 (9%) fewer active physicians than projections using the Masterfile data (957,000 vs 1,050,000), and estimate that a smaller proportion of active physicians will be 65 years or older (9% vs 18%). The increasing proportion of female physicians had little effect on physician supply projections because, unlike male physicians, female physicians were found to maintain their work activity after age 55 years.Compared with the Masterfile data, estimates using the CPS data found more young physicians entering the workforce and fewer older physicians remaining active, resulting in estimates of a smaller and younger physician workforce now and in the future.

A clear link has been demonstrated between lower nurse staffing levels in hospitals and adverse patient outcomes, but the results of studies of such relationships in long-term care facilities haven't been as clear. This study explored the time nurses spent in direct care and how it affected outcomes in long-stay (two weeks or longer) nursing home residents.In a retrospective study of data collected as part of the National Pressure Ulcer Long-Term Study (NPULS), we analyzed data on 1,376 residents of 82 long-term care facilities whose lengths of stay were 14 days or longer, who were at risk of developing pressure ulcers but had none at study entry, and who had a Braden Scale score of 17 or less. Primary data came from residents' medical records during 12-week periods in 1996 and 1997. Dependent variables included development of pressure ulcer or urinary tract infection (UTI), weight loss, deterioration in the ability to perform activities of daily living (ADLs), and hospitalization. Independent variables included resident demographics, severity of illness, nutritional and incontinence interventions, medications, and nurse staffing time.More RN direct care time per resident per day (examined in 10-minute increments up to 30 to 40 minutes per resident per day) was associated with fewer pressure ulcers, hospitalizations, and UTIs; less weight loss, catheterization, and deterioration in the ability to perform ADLs; and greater use of oral standard medical nutritional supplements. More certified nursing assistant and licensed practical nurse time was associated with fewer pressure ulcers but did not improve other outcomes.The researchers controlled for important variables in long-stay nursing home residents at risk for pressure ulcers and found that more RN direct care time per resident per day was strongly associated with better outcomes. There's an urgent need for further research to confirm these findings and, if confirmed, for improving RN staffing in nursing homes to decrease avoidable adverse outcomes and suffering.

Few topics evoke more heightened emotions and controversy at academic medical centers than resident physician work hour limits. From first year intern to seasoned hospital administrator, the policy change instituted on a nationwide basis in July 2003 by the Accreditation Council on Graduate Medical Education (ACGME) has impacted trainees, reshaped residency training programs, and demanded shifts in hospital resources to compensate for the reduction in resident work hours. A primary goal of these work hour limits is an improvement in patient safety.1 This goal arose largely from publicity about errors at teaching institutions (eg, the Libby Zion case in New York) and public reaction to controversial reports of increased medical errors possibly linked to provider fatigue.2–4 Empirical evaluation of far-reaching policy changes, such as resident work hour limits, is critical to appraising the predicted and unforeseen consequences that inevitably accompany such interventions. Being the first state to enact and enforce resident work hour limits, examination of the New York experience provides a unique opportunity to evaluate this policy that now affects the entire nation. Although important in their own scope, most evaluations of resident work hour limits have been limited to nonstandardized surveys or single institutions.5–7 Furthermore, recent statewide evaluations have not focused on the groups most impacted by work hour regulations, namely, surgical specialties.8 In this study, we test the hypothesis that resident work hour limits are associated with surgical patient safety measure improvement in New York teaching hospitals. In addition, we use standardized Patient Safety Indicators (PSIs) developed by the Agency for Healthcare Research and Quality (AHRQ) as outcome measures sensitive to surgical training or technical performance.9 This study provides critical, timely data in the appraisal of resident work hour limits and gives a measure of PSI effect sizes to design further evaluations at the state and national levels.

Background Administrative data are an attractive data source for the construction of quality indicators to assess and monitor quality of nursing care in hospitals. Current approaches to constructing measures from discharge abstracts apply substantial restrictions to exclude patients at high risk or with preexisting conditions. This study evaluates whether broader sample definitions combined with risk adjustment would allow for larger samples and increase analytic power. Methods Eight indicators were constructed from discharge abstracts of major surgical and medical patients from 799 hospitals in 11 states using existing definitions: pneumonia, urinary tract infection, decubitus ulcers, central nervous system complications, shock, sepsis, pulmonary failure, and upper gastrointestinal bleeding. We tested the effect of broadening the samples in 4 ways: comparing indicator rates in the broader and restrictive samples; assessing correlations of hospital ranks in the broader and restrictive samples; performing clinical reviews of cases in the added samples; and using different samples in regressions of indicators on nurse staffing variables, adjusting for patient risk. Results Indicator rates in the broader samples tended to be higher but did not change hospital rankings significantly. Clinical review suggested that many sample restrictions could be dropped. Using indicators based on broader definitions, coefficients on staffing variables increased in magnitude. Conclusion Less restrictive sample definitions were shown to be feasible and increased the sensitivity of the indicators and thus the power of the analysis. Particularly in surgical patients, the samples could be broadened, although more conservative definitions appeared appropriate for medical patients.

To assess whether adverse outcomes in Medicare patients can be used as a surrogate for measures from all patients in quality-of-care research using administrative datasets.Patient discharge abstracts from state data systems for 799 hospitals in 11 states. National MedPAR discharge data for Medicare patients from 3,357 hospitals. State hospital staffing surveys or financial reports. American Hospital Association Annual Survey.We calculate rates for 10 adverse patient outcomes, examine the correlation between all-patient and Medicare rates, and conduct negative binomial regressions of counts of adverse outcomes on expected counts, hospital nurse staffing, and other variables to compare results using all-patient and Medicare patient data.Coding rules were established for eight adverse outcomes applicable to medical and surgical patients plus two outcomes applicable only to surgical patients. The presence of these outcomes was coded for 3 samples: all patients in the 11-state sample, Medicare patients in the 11-state sample, and Medicare patients in the national Medicare MedPAR sample. Logistic regression models were used to construct estimates of expected counts of the outcomes for each hospital. Variables for teaching, metropolitan status, and bed size were obtained from the AHA Annual Survey.For medical patients, Medicare rates were consistently higher than all-patient rates, but the two were highly correlated. Results from regression analysis were consistent across the 11-state all-patient, 11-state Medicare, and national Medicare samples. For surgery patients, Medicare rates were generally higher than all-patient rates, but correlations of Medicare and all-patient rates were lower, and regression results less consistent.Analyses of quality of care for medical patients using Medicare-only and all-patient data are likely to have similar findings. Measures applied to surgery patients must be used with more caution, as those tested only in Medicare patients may not provide results comparable to those from all-patient samples or across different samples of Medicare patients.

Recent trends in hours worked by physicians may affect workforce needs but have not been thoroughly analyzed.To estimate trends in hours worked by US physicians and assess for association with physician fees.A retrospective analysis of trends in hours worked among US physicians using nationally representative workforce information from the US Census Bureau Current Population Survey between 1976 and 2008 (N = 116,733). Trends were estimated among all US physicians and by residency status, sex, age, and work setting. Trends in hours were compared with national trends in physician fees, and estimated separately for physicians located in metropolitan areas with high and low fees in 2001.Self-reported hours worked in the week before the survey.After remaining stable through the early 1990s, mean hours worked per week decreased by 7.2% between 1996 and 2008 among all physicians (from 54.9 hours per week in 1996-1998 to 51.0 hours per week in 2006-2008; 95% confidence interval [CI], 5.3%-9.0%; P.001). Excluding resident physicians, whose hours decreased by 9.8% (95% CI, 5.8%-13.7%; P.001) in the last decade due to duty hour limits imposed in 2003, nonresident physician hours decreased by 5.7% (95% CI, 3.8%-7.7%; P.001). The decrease in hours was largest for nonresident physicians younger than 45 years (7.4%; 95% CI, 4.7%-10.2%; P.001) and working outside of the hospital (6.4%; 95% CI, 4.1%-8.7%; P.001), and the decrease was smallest for those aged 45 years or older (3.7%; 95% CI, 1.0%-6.5%; P = .008) and working in the hospital (4.0%; 95% CI, 0.4%-7.6%; P = .03). After adjusting for inflation, mean physician fees decreased nationwide by 25% between 1995 and 2006, coincident with the decrease in physician hours. In 2001, mean physician hours were less than 49 hours per week in metropolitan areas with the lowest physician fees, whereas physician hours remained more than 52 hours per week elsewhere (P.001 for difference).A steady decrease in hours worked per week during the last decade was observed for all physicians, which was temporally and geographically associated with lower physician fees.

This study was guided by the economic theory of the decision to work, with secondary survey data (N = 16,880) derived from the National Sample Survey of the Population of Registered Nurses, November 1984, used to analyze the effects of economic and sociodemographic variables on the number of hours worked annually by registered nurses (RNs). When separate analyses were performed for the entire sample and for unmarried RNs alone, regression coefficients estimated for the RN's wage indicated that raising wages would result in modest increases in the number of annual hours worked. This effect was not present when either married RNs or those who were widowed, divorced, or separated were used in regression analyses. Male RNs worked 11 weeks more than married, female RNs, and nonwhite RNs worked almost 7 weeks more per year than white, married RNs. RNs with an associate degree in nursing worked more hours than those with a diploma certificate, and the presence of young children at home had a substantial negative effect on the number of hours RNs worked.

ContextThe average age of registered nurses (RNs), the largest group of health care professionals in the United States, increased substantially from 1983 to 1998. No empirically based analysis of the causes and implications of this aging workforce exists.ObjectivesTo identify and assess key sources of changes in the age distribution and total supply of RNs and to project the future age distribution and total RN workforce up to the year 2020.Design and SettingRetrospective cohort analysis of employment trends of recent RN cohorts over their lifetimes based on US Bureau of the Census Current Population Surveys between 1973 and 1998. Recent workforce trends were used to forecast long-term age and employment of RNs.ParticipantsEmployed RNs aged 23 to 64 years (N = 60,386).Main Outcome MeasuresAnnual full-time equivalent employment of RNs in total and by single year of age.ResultsThe average age of working RNs increased by 4.5 years between 1983 and 1998. The number of full-time equivalent RNs observed in recent cohorts has been approximately 35% lower than that observed at similar ages for cohorts that entered the labor market 20 years earlier. Over the next 2 decades, this trend will lead to a further aging of the RN workforce because the largest cohorts of RNs will be between age 50 and 69 years. Within the next 10 years, the average age of RNs is forecast to be 45.4 years, an increase of 3.5 years over the current age, with more than 40% of the RN workforce expected to be older than 50 years. The total number of full-time equivalent RNs per capita is forecast to peak around the year 2007 and decline steadily thereafter as the largest cohorts of RNs retire. By the year 2020, the RN workforce is forecast to be roughly the same size as it is today, declining nearly 20% below projected RN workforce requirements.ConclusionsThe primary factor that has led to the aging of the RN workforce appears to be the decline in younger women choosing nursing as a career during the last 2 decades. Unless this trend is reversed, the RN workforce will continue to age, and eventually shrink, and will not meet projected long-term workforce requirements.