Refining a case-mix measure for nursing homes: Resource Utilization Groups (RUG-III)

The impact of hospital-based skilled nursing facility closures on rehospitalizations

OBJECTIVE

To examine the effect of reductions in hospital-based (HB) skilled nursing facility (SNF) bed supply on the rate of rehospitalization of patients discharged to any SNF from zip codes that lost HB beds.

DATA SOURCE

We used Medicare enrollment records, Medicare hospital and SNF claims, and nursing home Minimum Dataset assessments and characteristics (OSCAR) to examine nearly 10 million Medicare fee-for-service hospital discharges to SNFs between 1999 and 2006.

STUDY DESIGN

We calculated the number of HB and freestanding (FS) SNF beds within a 22 km radius from the centroid of all zip codes in which Medicare beneficiaries reside in all years. We examined the relationship between HB and FS bed supply and the rehospitalization rates of the patients residing in corresponding zip codes in different years using zip code fixed effects and instrumental variable methods including extensive sensitivity analyses.

PRINCIPAL FINDINGS

Our estimated coefficients suggest that closure of 882 HB homes during our study period resulted in 12,000-18,000 extra rehospitalizations within 30 days of discharge. The effect was largely concentrated among the most acutely ill, high-need patients.

CONCLUSIONS

SNF patient-based prospective payment resulted in closure of higher cost HB facilities that had served most postacute patients. As other, less experienced SNFs replaced HB facilities, they were less able to manage high acuity patients without rehospitalizing them.

The relationships among licensed nurse turnover, retention, and rehospitalization of nursing home residents

PURPOSE

Individuals receiving postacute care in skilled nursing facilities often require complex, skilled care provided by licensed nurses. It is believed that a stable set of nursing personnel is more likely to deliver better care. The purpose of this study was to determine the relationships among licensed nurse retention, turnover, and a 30-day rehospitalization rate in nursing homes (NHs).

DESIGN AND METHODS

We combined two data sources: NH facility-level data (including characteristics of the facility, the market, and residents) and the Florida Nursing Home Staffing Reports (which provide staffing information for each NH) for 681 Florida NHs from 2002 to 2009. Using a two-way fixed effects model, we examined the relationships among licensed nurse turnover rates, retention rates, and 30-day rehospitalization rates.

RESULTS

Results indicate that an NH's licensed nurse retention rate is significantly associated with the 30-day rehospitalization rate (est. = -.02, p = .04) controlling for demographic characteristics of the patient population, residents' preferences for hospitalization, and the ownership characteristics of the NH. The NHs experiencing a 10% increase in their licensed nurse retention had a 0.2% lower rehospitalization rate, which equates to 2 fewer hospitalizations per NH annually. Licensed nurse turnover is not significantly related to the 30-day rehospitalization rate.

IMPLICATIONS

These findings highlight the need for NH administrators and policy makers to focus on licensed nurse retention, and future research should focus on the measures of staff retention for understanding the staffing/quality relationship.

Direct costs of adult traumatic spinal cord injury in Ontario

STUDY DESIGN

Retrospective economic analysis.

OBJECTIVES

To determine the total direct costs of publicly funded health care utilization for the three fiscal years 2003/04 to 2005/06 (1 April 2003 to 31 March 2004 to 1 April 2005 to 31 March 2006), from the time of initial hospitalization to 1 year after initial acute discharge among individuals with traumatic spinal cord injury (SCI).

SETTING

Ontario, Canada.

METHODS

Health system costs were calculated for 559 individuals with traumatic SCI (C1-T12 AIS A-D) for acute inpatient, emergency department, inpatient rehabilitation (that is, short-stay inpatient rehabilitation), complex continuing care (CCC) (i.e., long-stay inpatient rehabilitation), home care services, and physician visits in the year after index hospitalization. All care costs were calculated from the government payer's perspective, the Ontario Ministry of Health and Long-Term Care.

RESULTS

Total direct costs of health care utilization in this traumatic SCI population (including the acute care costs of the index event and inpatient readmission in the following year after the index discharge) were substantial: $102 900 per person in 2003/04, $100 476 in 2004/05 and $123 674 in 2005/06 Canadian Dollars (2005 CDN $). The largest cost driver to the health care system was inpatient rehabilitation care. From 2003/04 to 2005/06, the average per person cost of rehabilitation was approximately three times the average per person costs of inpatient acute care.

CONCLUSION

The high costs and long length of stay in inpatient rehabilitation are important system cost drivers, emphasizing the need to evaluate treatment efficacy and subsequent health outcomes in the inpatient rehabilitation setting.

Making the investment count: revision of the Minimum Data Set for nursing homes, MDS 3.0

BACKGROUND

The Minimum Data Set (MDS) is a potentially powerful tool for implementing standardized assessment in nursing homes (NHs). Its content has implications for residents, families, providers, researchers, and policymakers, all of whom have expressed concerns about the reliability, validity, and relevance of MDS 2.0. Some argue that because MDS 2.0 fails to include items that rely on direct resident interview, it fails to obtain critical information and effectively disenfranchises many residents from the assessment process.

PURPOSE

Design a major revision of the MDS, MDS 3.0, and evaluate whether the revision improves reliability, validity, resident input, clinical utility, and decreases collection burden.

DESIGN AND METHODS

In the form design phase, we gathered information from a wide range of experts, synthesized existing literature, worked with a national consortium of VA researchers to revise and test eight sections, pilot tested a draft MDS 3.0 and revised the draft based on results from the pilot. In the national validation and evaluation phase, we tested MDS 3.0 in 71 community NHs and 19 VHA NHs, regionally distributed throughout the United States. The sample was selected based on scheduled MDS 2.0 assessments. Comatose residents were excluded. A total 3822 residents of community NHs in eight states were included. The evaluation was designed to test and analyze inter-rater agreement (reliability) between research nurses and between facility staff and research nurses, validity of key sections, response rates for interview items, anonymous feedback on changes from participating nurses, and time to complete the MDS assessment.

RESULTS

The reliability for research nurse to research nurse and for research nurse to facility staff was good or excellent for most items. Response rates for the resident interview sections were high: 90% for cognitive, 86% for mood, 85% for preferences, and 87% for pain. Staff survey responses showed increased satisfaction with clinical relevance, validity and clarity compared with MDS 2.0. The test version of the MDS 3.0 took 45% less time for facilities to complete.

IMPLICATIONS

Improving the reliability, accuracy, and usefulness of the MDS has profound implications for NH care and public policy. Enhanced accuracy supports the primary legislative intent that MDS be a tool to improve clinical assessment and supports the credibility of programs that rely on MDS.

Beyond Section Q: prioritizing nursing home residents for transition to the community

Background

Nursing Facility Transition (NFT) programs often rely on self-reported preference for discharge to the community, as indicated in the Minimum Data Set (MDS) Section Q, to identify program participants. We examined other characteristics of long-stay residents discharged from nursing facilities by NFT programs, to “flag” similar individuals for outreach in the Money Follows the Person (MFP) initiative.

Methods

Three states identified persons who transitioned between 2001 and 2009 with the assistance of a NFT or MFP program. These were used to locate each participant’s MDS 2.0 assessment just prior to discharge and to create a control sample of non-transitioned residents. Logistic regression and Automatic Interactions Detection were used to compare the two groups.

Results

Although there was considerable variation across states in transitionees’ characteristics, a derived “Q + Index” was highly effective in identifying persons similar to those that states had previously transitioned. The Index displays high sensitivity (86.5%) and specificity (78.7%) and identifies 28.3% of all long-stayers for follow-up. The Index can be cross-walked to MDS 3.0 items.

Conclusions

The Q + Index, applied to MDS 3.0 assessments, can identify a population closely resembling persons who have transitioned in the past. Given the US Government’s mandate that states consider all transition requests and the limited staffing available at local contact agencies to address such referrals, this algorithm can also be used to prioritize among persons seeking assistance from local contact agencies and MFP providers.

Effect of influenza on functional decline

OBJECTIVES

To examine the relationship between influenza and activity of daily living (ADL) decline and other clinical indicators in nursing home (NH) residents.

DESIGN

Retrospective NH-aggregated longitudinal study.

SETTING

Two thousand three hundred fifty-one NHs in 122 U.S. cities from 1999 to 2005.

PARTICIPANTS

Long-stay (>90 days) NH residents.

MEASUREMENTS

Quarterly city-level influenza mortality and state-level influenza severity. Quarterly incidence of Minimum Data Set-derived ADL decline (≥ 4 points), weight loss, new or worsening pressure ulcers (PUs), and infections. Outcome variables chosen as clinical controls were antipsychotic use, restraint use, and persistent pain.

RESULTS

City-level influenza mortality and state-level influenza severity were associated with higher rates of large (≥ 4 points) ADL decline (mortality β = 0.20, P < .001; severity β = 0.18, P < .001), weight loss (β = 0.19, P < .001; β = 0.24, P < .001), worsening PUs (β = 0.04, P = .08; β = 0.12, P < .001), and infections (β = 0.41, P < .001; β = 0.47, P < .001) but not with restraint use, antipsychotic use, or persistent pain. NH influenza vaccination rates were weakly associated with the outcomes (e.g., β = -0.009, P = .03 for ADL decline, β = 0.008, P = .07 for infections). Compared with the summer quarter of lowest influenza activity, the results for the other quarters translate to an additional 12,284 NH residents experiencing large ADL decline annually, 15,168 experiencing significant weight loss, 6,284 new or worsening PUs, and 29,753 experiencing infections due to influenza.

CONCLUSION

The results suggest a substantial and potentially costly effect of influenza on NH residents. The effect of influenza vaccination on preventing further ADL decline and other clinical outcomes in NH residents should be studied further.

Is it time for a change? A cost-effectiveness analysis comparing a multidisciplinary integrated care model for residential homes to usual care

Objective

The objective of this study was to evaluate the cost-effectiveness of a Multidisciplinary Integrated Care (MIC) model compared to Usual Care (UC) in Dutch residential homes.

Methods

The economic evaluation was conducted from a societal perspective alongside a 6 month, clustered, randomized controlled trial involving 10 Dutch residential homes. Outcome measures included a quality of care weighted sum score, functional health (COOP WONCA) and Quality Adjusted Life-Years (QALY). Missing cost and effect data were imputed using multiple imputation. Bootstrapping was used to analyze differences in costs and cost-effectiveness.

Results

The quality of care sum score in MIC was significantly higher than in UC. The other primary outcomes showed no significant differences between the MIC and UC. The costs of providing MIC were approximately €225 per patient. Total costs were €2,061 in the MIC group and €1,656 for the UC group (mean difference €405, 95% −13; 826). The probability that the MIC was cost-effective in comparison with UC was 0.95 or more for ceiling ratios larger than €129 regarding patient related quality of care. Cost-effectiveness planes showed that the MIC model was not cost-effective compared to UC for the other outcomes.

Interpretation

Clinical effect differences between the groups were small but quality of care was significantly improved in the MIC group. Short term costs for MIC were higher. Future studies should focus on longer term economic and clinical effects.

Trial Registration

Controlled-Trials.com ISRCTN11076857

International casemix and funding models: lessons for rehabilitation

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is ‘An understanding of the different international models for funding of health care services and casemix systems, as exemplified by those in the US, Australia and the UK.’

Background: Payment for treatment in healthcare systems around the world is increasingly based on fixed tariff models to drive up efficiency and contain costs. Casemix classifications, however, must account adequately for the resource implications of varying case complexity. Rehabilitation poses some particular challenges for casemix development.

Objective: The objectives of this educational narrative review are (a) to provide an overview of the development of casemix in rehabilitation, (b) to describe key characteristics of some well-established casemix and payment models in operation around the world and (c) to explore opportunities for future development arising from the lessons learned.

Results: Diagnosis alone does not adequately describe cost variation in rehabilitation. Functional dependency is considered a better cost indicator, and casemix classifications for inpatient rehabilitation in the United States and Australia rely on the Functional Independence Measure (FIM). Fixed episode-based prospective payment systems are shown to contain costs, but at the expense of poorer functional outcomes. More sophisticated models incorporating a mixture of episode and weighted per diem rates may offer greater flexibility to optimize outcome, while still providing incentive for throughput.

Conclusion: The development of casemix in rehabilitation poses similar challenges for healthcare systems all around the world. Well-established casemix systems in the United States and Australia have afforded valuable lessons for other countries to learn from, but have not provided all the answers. A range of casemix and payment models is required to cater for different healthcare cultures, and casemix tools must capture all the key cost-determinants of treatment for patients with complex needs.

Healthcare tariffs for specialist inpatient neurorehabilitation services: rationale and development of a UK casemix and costing methodology

Objective: To describe the rationale and development of a casemix model and costing methodology for tariff development for specialist neurorehabilitation services in the UK.

Rationale for development of a new methodology: Patients with complex needs incur higher treatment costs. Fair payment should be weighted in proportion to costs of providing treatment, and should allow for variation over time

Casemix model and band-weighting: Case complexity is measured by the Rehabilitation Complexity Scale (RCS). Cases are divided into five bands of complexity, based on the total RCS score. The principal determinant of costs in rehabilitation is staff time. Total staff hours/week (estimated from the Northwick Park Nursing and Therapy Dependency Scales) are analysed within each complexity band, through cross-sectional analysis of parallel ratings. A ‘band-weighting’ factor is derived from the relative proportions of staff time within each of the five bands.

Costing methodology: Total unit treatment costs are obtained from retrospective analysis of provider hospitals’ budget and accounting statements. Mean bed-day costs (total unit cost/occupied bed days) are divided broadly into ‘variable’ and ‘non-variable’ components. In the weighted costing model, the band-weighting factor is applied to the variable portion of the bed-day cost to derive a banded cost, and thence a set of cost-multipliers. Preliminary data from one unit are presented to illustrate how this weighted costing model will be applied to derive a multilevel banded payment model, based on serial complexity ratings, to allow for change over time.

Beyond the 'iron lungs of gerontology': using evidence to shape the future of nursing homes in Canada

Institutionalization of the Elderly in Canada suggested that efforts to address the underlying causes of age-related declines in health might negate the need for nursing homes. However, the prevalence of chronic disease has increased, and conditions like dementia mean that nursing homes are likely to remain important features of the Canadian health care system. A fundamental problem limiting the ability to understand how nursing homes may change to better meet the needs of an aging population was the lack of person-level clinical information. The introduction of interRAI assessment instruments to most Canadian provinces/territories and the establishment of the national Continuing Care Reporting System represent important steps in our capacity to understand nursing home care in Canada. Evidence from eight provinces and territories shows that the needs of persons in long-term care are highly complex, resource allocations do not always correspond to needs, and quality varies substantially between and within provinces.

Predictors of low-care prevalence in Florida nursing homes: the role of Medicaid waiver programs

PURPOSE OF THE STUDY

To examine the relationship between county-level Medicaid home- and community-based service (HCBS) waiver expenditures and the prevalence of low-care residents in Florida nursing homes (NHs).

DESIGN AND METHODS

The present study used a cross-sectional design. We combined two data sources: NH facility-level data (including characteristics of the facility and its residents) and county-level market characteristics (including HCBS waiver expenditures) for 653 Florida NHs in 2007. Low-care was defined as residents who require no physical assistance in any of the 4 late-loss activities of daily living (bed mobility, toileting, transferring, and eating). We estimated a 2-level hierarchical linear model (HLM) to examine the relationship between Medicaid HCBS waiver expenditures and the prevalence of low-care residents while accounting for resident assessment, facility-, and county-level covariates.

RESULTS

All Florida counties offered 2 statewide waivers, and 33 counties offered one or more of the 4 regional Medicaid HCBS waivers in 2007. Per-month beneficiary expenditures ranged from $755 to $1,778. The average Florida NH had 120 beds, and 8.0% of its residents were classified as low-care. Results from the HLM model showed that a $10,000 increase in per-enrollee HCBS waiver expenditures was associated with a 3.5 percentage point reduction in low-care resident prevalence (p = .03).

IMPLICATIONS

The findings suggest that Medicaid HCBS waiver programs may reduce the prevalence of low-care residents in NHs. Future studies should evaluate whether Medicaid HCBS waiver programs are effective in promoting community-living among low-care residents and mitigating the growth in long-term care expenditures.

The multiple uses of routine mental health outcome measures in Australia and New Zealand: experiences from the field

OBJECTIVE

The aim of this paper is to describe the way in which particular Australian and New Zealand mental health services are making use of routine outcome data to foster clinical improvements for consumers.

METHOD

We invited individuals who are responsible for implementing outcome data collection across the two countries to describe exemplary practices occurring within their own services, and present the resultant information in the form of case studies.

RESULTS

Outcome measurement is being used to guide clinical decision-making, engage consumers in treatment, foster a collaborative approach to care planning and goal setting, review consumers' progress with treatment, inform questions about consumers' eligibility for given programs, assist with discharge planning, improve the evidence-base on which services are founded, and evaluate particular models of service delivery.

CONCLUSIONS

A number of mental health services are deriving useful information from routine outcome measurement, and using this to guide clinical practice. The examples provided here may offer some lessons for other services wishing to make better use of outcome data, and there may be some opportunities for the sharing of resources or infrastructure. Services that are already using outcome data to inform their clinical activities, and services that are keen to do so, will need ongoing support.

Using the RUG-III classification system for understanding the resource intensity of persons with intellectual disability residing in nursing homes

Since 1991, the Minimum Data Set 2.0 (MDS 2.0) has been the mandated assessment in US nursing homes. The Resource Utilization Groups III (RUG-III) case-mix system provides person-specific means of allocating resources based on the variable costs of caring for persons with different needs. Retrospective analyses of data collected on a sample of 9707 nursing home residents (2.4% had an intellectual disability) were used to examine the fit of the RUG-III case-mix system for determining the cost of supporting persons with intellectual disability (intellectual disability). The RUG-III system explained 33.3% of the variance in age-weighted nursing time among persons with intellectual disability compared to 29.6% among other residents, making it a good fit among persons with intellectual disability in nursing homes. The RUG-III may also serve as the basis for the development of a classification system that describes the resource intensity of persons with intellectual disability in other settings that provide similar types of support.

Temporal and Geographic variation in the validity and internal consistency of the Nursing Home Resident Assessment Minimum Data Set 2.0

Background

The Minimum Data Set (MDS) for nursing home resident assessment has been required in all U.S. nursing homes since 1990 and has been universally computerized since 1998. Initially intended to structure clinical care planning, uses of the MDS expanded to include policy applications such as case-mix reimbursement, quality monitoring and research. The purpose of this paper is to summarize a series of analyses examining the internal consistency and predictive validity of the MDS data as used in the "real world" in all U.S. nursing homes between 1999 and 2007.

Methods

We used person level linked MDS and Medicare denominator and all institutional claim files including inpatient (hospital and skilled nursing facilities) for all Medicare fee-for-service beneficiaries entering U.S. nursing homes during the period 1999 to 2007. We calculated the sensitivity and positive predictive value (PPV) of diagnoses taken from Medicare hospital claims and from the MDS among all new admissions from hospitals to nursing homes and the internal consistency (alpha reliability) of pairs of items within the MDS that logically should be related. We also tested the internal consistency of commonly used MDS based multi-item scales and examined the predictive validity of an MDS based severity measure viz. one year survival. Finally, we examined the correspondence of the MDS discharge record to hospitalizations and deaths seen in Medicare claims, and the completeness of MDS assessments upon skilled nursing facility (SNF) admission.

Results

Each year there were some 800,000 new admissions directly from hospital to US nursing homes and some 900,000 uninterrupted SNF stays. Comparing Medicare enrollment records and claims with MDS records revealed reasonably good correspondence that improved over time (by 2006 only 3% of deaths had no MDS discharge record, only 5% of SNF stays had no MDS, but over 20% of MDS discharges indicating hospitalization had no associated Medicare claim). The PPV and sensitivity levels of Medicare hospital diagnoses and MDS based diagnoses were between .6 and .7 for major diagnoses like CHF, hypertension, diabetes. Internal consistency, as measured by PPV, of the MDS ADL items with other MDS items measuring impairments and symptoms exceeded .9. The Activities of Daily Living (ADL) long form summary scale achieved an alpha inter-consistency level exceeding .85 and multi-item scale alpha levels of .65 were achieved for well being and mood, and .55 for behavior, levels that were sustained even after stratification by ADL and cognition. The Changes in Health, End-stage disease and Symptoms and Signs (CHESS) index, a summary measure of frailty was highly predictive of one year survival.

Conclusion

The MDS demonstrates a reasonable level of consistency both in terms of how well MDS diagnoses correspond to hospital discharge diagnoses and in terms of the internal consistency of functioning and behavioral items. The level of alpha reliability and validity demonstrated by the scales suggest that the data can be useful for research and policy analysis. However, while improving, the MDS discharge tracking record should still not be used to indicate Medicare hospitalizations or mortality. It will be important to monitor the performance of the MDS 3.0 with respect to consistency, reliability and validity now that it has replaced version 2.0, using these results as a baseline that should be exceeded.

The residential history file: studying nursing home residents' long-term care histories(*)

OBJECTIVE

To construct a data tool, the Residential History File (RHF), that summarizes information from Medicare claims and nursing home (NH) Minimum Data Set (MDS) assessments to track people through health care locations, including non-Medicare-paid NH stays.

DATA SOURCES

Online Survey of Certification and Reporting (OSCAR) data for 202 free-standing NHs, Medicare Denominator, claims (parts A and B), and MDS assessments for 60,984 people who were present in one of these NHs in 2006.

METHODS

The algorithm creating the RHF is outlined and the RHF for the study data are used to describe place of death. The identification of residents in NHs is compared with the reports in OSCAR and part B claims.

PRINCIPAL FINDINGS

The RHF correctly identified 84.8 percent of part B claims with place-of-service in NH, and it identified 18.3 less residents on average than reported in the OSCAR on the day of the survey. The RHF indicated that 17.5 percent non-Medicare NH decedents were transferred to the hospital to die versus 45.6 percent skilled nursing facility decedents.

CONCLUSIONS

The population-based design of the RHF makes it possible to conduct policy-relevant research to examine the variation in the rate and type of health care transitions across the United States.

The effect of state policies on nursing home resident outcomes

OBJECTIVES

To test the effect of changes in Medicaid reimbursement on clinical outcomes of long-stay nursing home (NH) residents.

DESIGN

Longitudinal, retrospective study of NHs, merging aggregated resident-level quality measures with facility characteristics and state policy survey data.

SETTING

All free-standing NHs in urban counties with at least 20 long-stay residents per quarter (length of stay > 90 days) in the continental United States between 1999 and 2005.

PARTICIPANTS

Long-stay NH residents

INTERVENTIONS

Annual state Medicaid average per diem reimbursement and the presence of case-mix reimbursement in each year.

MEASUREMENTS

Quarterly facility-aggregated, risk-adjusted quality-of-care measures surpassing a threshold for functional (activity of daily living) decline, physical restraint use, pressure ulcer incidence or worsening, and persistent pain.

RESULTS

All outcomes showed an improvement trend over the study period, particularly physical restraint use. Facility fixed-effect regressions revealed that a $10 increase in Medicaid payment increased the likelihood of a NH meeting quality thresholds by 9% for functional decline, 5% for pain control, and 2% for pressure ulcers but not reduced use of physical restraints. Facilities in states that increased Medicaid payment most showed the greatest improvement in outcomes. The introduction of case-mix reimbursement was unrelated to quality improvement.

CONCLUSION

Improvements in the clinical quality of NH care have been achieved, particularly where Medicaid payment has increased, generally from a lower baseline. Although this is a positive finding, challenges to implementing efficient reimbursement policies remain.

Exploring the relationship between private equity ownership and nursing home performance: a review

Private equity has acquired multiple large nursing home chains within the past few years; by 2007, it owned 6 of the 10 largest chains. Despite widespread public and policy interest, evidence on the purported impact of private equity on nursing home performance is limited. In our review, we begin by briefly reviewing the organizational and environmental changes in the nursing home industry that facilitated private equity investments. We offer a conceptual framework to hypothesize the relationship between private equity ownership and nursing home performance. Finally, we offer a research agenda focused on the important parameters of nursing home performance: financial performance, and quality of care.

Medicaid bed-hold policy and Medicare skilled nursing facility rehospitalizations

OBJECTIVE

To analyze the effect of states' Medicaid bed-hold policies on the 30-day rehospitalization of Medicare postacute skilled nursing facility (SNF) residents.

DATA SOURCES

Minimum data set assessments were merged with Medicare claims and eligibility files for all first-time SNF admissions (N = 3,322,088) over the period 2000 through 2005; states' Medicaid bed-hold policies were obtained via survey.

STUDY DESIGN

Regression specification incorporating facility fixed effects to examine changes in Medicaid bed-hold policies on the likelihood of a 30-day SNF rehospitalization.

PRINCIPAL FINDINGS

Using a continuous measure of bed-hold generosity, state Medicaid bed-hold was positively related to Medicare SNF rehospitalization. Specifically, the introduction of a bed-hold policy with average generosity increases Medicare rehospitalizations by 1.8 percent, representing roughly 12,000 SNF rehospitalizations at a cost to Medicare of approximately U.S.$100 million over our study period.

CONCLUSIONS

Although facilities do not receive a Medicaid bed-hold payment for Medicare SNF stays, we found that the adoption of more generous policies led to greater SNF rehospitalizations. This type of spillover is largely ignored in current discussions of Medicare payment reforms such as bundled payment. Neither Medicare nor Medicaid has an incentive to internalize the risks and benefits of its actions as they affect the other.

A RUG-III Case-Mix System for Home Care

Le système de classification de la composition de la clientèle des maisons de soins infirmiers, Resource Utilization Groups Version III (RUG-III), a été éprouvé et raffiné pour les bénéficiaires de soins de longue durée à domicile. Lapos;échantillonnage étudié regroupe 804 personnes recevant des soins à domicile par l'entremise du Michigan Care Management Program ou du Home and Community Based Waiver for the Elderly and Disabled. On a catégorisé les clients et établi des modèles de RUG-III à partir du Minimum Data Set for Home Care (MDS-HC). On a établi un modèle raffiné de soins à domicile, RUG-III/HC, en incorporant les activités instrumentales de la vie quotidienne (AIVQ) à la classification RUG-EH des établissements de soins. Le modèle explique 33,7 pour cent de la variance des coûts quotidiens, à partir de la variable dépendante du coût pondéré des soins structurés ou non. L'utilisation des ressources à l'égard des différents groupes est relativement homogène. Le CMI (case-mix index) du temps pondéré des soins structurés ou non couvre une échelle de 8. Il faudra songer à effectuer des analyses plus poussées du coût de l'inclusion des soins non structurés à l'égard des patients recevant des soins à domicile de longue durée.

Resources and Costs Associated with Disabilities of Elderly People Living at Home and in Institutions

Cette étude a été réalisée auprès d'un échantillon représentatif de sujets âgées vivant à domicile (n = 300), dans des ressources de type familial (RTF) ou des pavilions (n = 271) et dans des institutions d'hébergement (n = 774) de zones métropolitaine, urbaines et rurales du Québec afin de: 1) déterminer le niveau d'incapacité et les ressources consacrés aux soins des personnes âgées vivant à domicile ou en institution; 2) estimer les coûts (publics, privés et bénévoles) de ces ressources; 3) comparer les coûts à autonomie égale; 4) prédire les coûts selon le niveau d'incapacité. Les principaux résultats montrent que les sujets des trois milieux de vie présentent des différences significatives quant au niveau d'incapacité, à l'état cognitif et aux soins requis et fournis, bien que des chevauchements importants étaient notables. Le score d'incapacité explique 85 pour cent de la variance du temps de soins ainsi que, respectivement, 55, 15 et 68 pour cent des coûts à domicile, en RTF et pavilions et en institutions. Les soins infirmiers et d'assistance sont responsables de la majorité des coûts dans tous les milieux de vie. Le coût social total des soins à domicile étaient plus élevé que ceux en RTF et pavilions pour les sujets avec un score d'incapacité de 7,4 et plus et même supérieur à ceux en institutions pour un score au-dessus de 38,7.

Measuring Health Outcomes for Older People Using the Sage Database

Cet article cherche à établir le potentiel d'évaluation des programmes d'une base de données sur les soins de longue durée dans la communauté. Les données proviennent d'un projet-pilote sur la qualité et la clientèle du Health Care Financing Administration, incluant tous les établissements couverts par Medicare/ Medicaid de cinq états américains entre 1992 et 1994. À l'aide du Minimum Data Set, 70 000 résidents de plus de 65 ans souffrant d'insuffisance cardiaque globale ont été identifiés. L'analyse préliminaire de la pharmacothérapie de l'insuffisance cardiaque globale et de ses effets sur le déclin des fonctions physiques est présentée. L'état des fonctions physiques, mesuré par le taux de déclin des activités instrumentales de la vie quotidienne des patients qui suivent une thérapie combinée s'améliore par rapport à ceux qui prennent seulement de la digoxine ou des inhibiteurs de l'enzyme convertissant l'angiotensine. La disponibilité d'un ensemble de donnees sur la population fournit done une méthode d'évaluation des politiques et des pratiques courantes.

Trends in the Utilization of Health Services by Seniors in Alberta

La prestation de services et de programmes exhaustifs et de qualité pour les aîné(e)s canadien(ne)s au cours des prochaines décennies représente un défi de taille pour les responsables des politiques et les professionnels des soins de santé. La présente étude visait à fournir aux décideurs des données actuelles sur l'utilisation des services de santé par les aîné(e)s en Alberta. Nous avons comparé les tendances en utilisation de services hospitaliers actifs (1992/93–1997/98), des services de soins à domicile (1994/95–1997/98), des demandes de règlement de consultations et de soins de médecins (1995/96–1997/98) et, des établissements de soins à long terme (1990–1996) pour les albertains de moins et de plus de 65 ans. Nous avons également évalué les tendances dans l'utilisation des médicaments presents (1992/93–1997/98) chez les albertains de 65 ans et plus. Les données des analyses proviennent des bases de données et des rapports du Alberta Health and Wellness. Dans l'ensemble, les tendances indiquent qu'un moins grand nombre de patients sont soignés en établissement mais qu'ils sont plus malades; aussi, un nombre plus important de patients est soigné dans la communauté. Les reçus de médicaments prescrits remis en dehors des établissements ont augmenté chez les aîné(e)s dans les dernières années. La portée et la pertinence de la substitution des soins en établissement par les soins dans la communauté, la qualité de ses soins et leurs répercussions sur l'amélioration, la détérioration ou le maintien de la santé constituent des thèmes importants d'études ultérieures.

Pain and its Association with Disability in Institutional Long-Term Care in Four Nordic Countries

On a utilisé des données transversales (n = 6 487) de quatre pays nordiques (le Danemark, la Finlande, l'Islande et la Suède) pour établir la prévalence de la douleur quotidienne et de ses effets sur l'invalidité en milieu institutionnel de soins de longue durée. Chaque pensionnaire des établissements examinés a été évalué au moyen de la version 1.0 du Minimum Data Set. L'échantillonnage était représentatif des soins de longue durée donnés en institution à Copenhagen et Reykjavik. De plus, on a utilisé des données recueillies à Stockholm et Helsinki pour tirer des renseignements importants sur les pensionnaires de ces capitales. Les résultats indiquent qu'entre 22 et 24 pour cent des pensionnaires éprouvent des douleurs quotidiennes observables, ce qui est encore plus évident chez les sujets les plus invalides. S'ajoutant à l'invalidité et au sexe féminin, les maladies ou états associés à la douleur étaient un pronostic de maladie terminale, d'ostéoporose, de pneumonie, d'arthrite, de dépression, d'anémie, d'acrosyndrome, de cancer et de défaillance cardiaque. Le lien entre la douleur et la déficience intellectuelle grave était inexistant. Les résultats indiquent clairement que la douleur quotidienne est intimement liée à l'invalidité, celle-ci agissant sur les maladies sous-jacentes pour constituer la cause et l'effet de la douleur. On peut done voir un cercle vicieux entre la douleur et l'invalidité.

Cross-National Comparisons of Antidepressant Use Among Institutionalized Older Persons Based on the Minimum Data Set (MDS)

On a examiné l'usage des antidépresseurs dans des échantillons provenant d'établissements de soins de longue durée de Toronto (Canada), Sapporo et Naie (Japon), Reykjavik (Islande) et Prague (République tchéque). C'est seulement en Islande que la majorité des résidents souffrant de dépression recevaient des antidépresseurs. Le taux de dépression et l'usage des antidépresseurs sont généralement faibles au Japon. On a constaté un écart important entre le diagnostic de dépression et le comportement dépressif en République tchèque. Dans tous les pays examinés, environ la moitié des utilisateurs d'antidépresseurs ne présentent pas de symptômes évidents de dépression. Dans certains pays, l'usage des antidépresseurs était moins élevé chez les résidentes, chez les aîné(e)s plus âgés ou plus handicapés. La dépression est clairement sous-diagnostiqué en République tchèque mais les faibles taux de dépression au Japon sont plus difficiles à interpréter. Étant donné l'opinion largement répandue voulant que la dépressione passe souvent inaperçue et soit done mal soignée, les résultats de l'étude laissent entendre que l'on pourrait améliorer les mesures prises dans les cas de dépression grâce à des outils comme le MDS.

Incremental cost of postacute care in nursing homes

OBJECTIVES

To determine whether the case mix index (CMI) based on the 53-Resource Utilization Groups (RUGs) captures all the cross-sectional variation in nursing home (NH) costs or whether NHs that have a higher percent of Medicare skilled care days (%SKILLED) have additional costs. DATA AND SAMPLE: Nine hundred and eighty-eight NHs in California in 2005. Data are from Medicaid cost reports, the Minimum Data Set, and the Economic Census.

RESEARCH DESIGN

We estimate hybrid cost functions, which include in addition to outputs, case mix, ownership, wages, and %SKILLED. Two-stage least-square (2SLS) analysis was used to deal with the potential endogeneity of %SKILLED and CMI.

RESULTS

On average 11 percent of NHs days were due to skilled care. Based on the 2SLS model, %SKILLED is associated with costs even when controlling for CMI. The marginal cost of a one percentage point increase in %SKILLED is estimated at U.S.$70,474 or about 1.2 percent of annual costs for the average cost facility. Subanalyses show that the increase in costs is mainly due to additional expenses for nontherapy ancillaries and rehabilitation.

CONCLUSION

The 53-RUGs case mix does not account completely for all the variation in actual costs of care for postacute patients in NHs.

Performing well on nursing home report cards: does it pay off?

OBJECTIVE

To examine whether high performance or improvement on quality measures leads to economic rewards for nursing homes in the presence of public reporting.

DATA SOURCES

Data from 6,286 freestanding Medicare-certified nursing homes between 1999 and 2005 were identified in Medicare Cost Reports, Minimum Data Set, and Online Survey and Certification Reporting System.

STUDY DESIGN

Using a facility-level fixed-effects model, the effect of public reporting on financial performance was measured by comparing each of four financial outcomes (revenues, expenses, operating, and total profit margins) before (1999-2002) to after (2003-2005) public reporting was initiated. The effects were estimated separately by level of performance and improvement over time.

PRINCIPAL FINDINGS

Facilities that improved on publicly reported performance had increased revenues and higher profit margins after public reporting, mainly through increased Medicare admissions. High-scoring facilities showed similar patterns, though differences were not statistically significant.

CONCLUSIONS

Providers that improve their performance under public reporting may receive a return on their investment in quality improvement. This supports the business case for public reporting.

Screening cognitive impairment among institutionalized older Chinese men in Taiwan: a new minimum data set-based dementia screening tool is needed

Dementia screening is of great importance in various health settings for older people, long-term care facilities are no exception. The need for an effective dementia screening tool being culture sensitive is important. Minimum data set (MDS) is a population instrument for health care management in the world, which also covers dementia screening. The main purpose of this study was to evaluate the effectiveness of the MDS-based dementia screening tools among older Chinese men in the Veteran Home in Taiwan. Overall, 576 participants (mean age: 80.9±5.3 years, all males, 92.7% physically independent), 18.6% had cognitive impairment according to the mini-mental state examination (MMSE) (mean score: 26.7±3.9). However, the prevalence of cognitive impairment was 5.5% by MDS cognitive performance scale (CPS) and 18.9% by MDS cognition scale (MDS-COGS). The screening results of CPS and MDS-COGS were highly interrelated (γ=0.93, p<0.001), and MMSE scores were also significantly associated with CPS and MDS-COGS status (γ=-0.50, p<0.001 and γ=-0.52, p<0.001, respectively). Although the prevalence of cognitive impairment by MMSE and MDS-COGS are similar, the results are significantly inconsistent (p<0.001). In conclusion, both MDS-COGS and CPS were significantly correlated with MMSE scores, but significant inconsistence was noted between screening results of MMSE, CPS and MDS-COGS. Further study is needed to develop MDS-based dementia screening tools for older Chinese men in Taiwan.

The impact of opioids, anticholinergic medications and disease progression on the prescription of laxatives in hospitalized palliative care patients: a retrospective analysis

Definitive risk factors for constipation in palliative care remain poorly defined. A retrospective analysis of 211 admissions to a palliative care unit was undertaken, with the main aim being to identify some factors, which influence laxative prescription. On univariate analysis, significant unadjusted associations were found between two or more prescribed laxatives and a diagnosis of malignancy, morphine equivalent dose, type of illness phase and the subsequent phase type, length of phase, anticholinergic load imposed by medications, symptom severity and functional status. Multiple ordinal logistic regressions revealed the prescription of one laxative to be significantly associated with oral morphine-equivalent dose, total anticholinergic load (odds ratio [OR] 1.4, 95% CI = 1.0-2.0), disease progression to terminal phase and death (OR 0.1, 95% CI = 0.0-0.3), and length of phase (OR 1.1, 95% CI = 1.0-1.2). Similar results were obtained for the prescription of two or more laxatives. Two additional measures of function, toileting (OR 3.6, 95% CI = 1.6-8.2) and transfer (OR 0.4 95% CI = 0.2-0.9), also became significant. Total anticholinergic load was significantly associated with the prescription of a single laxative (OR 1.4, 95% CI = 1.0-2.0) and two or more laxatives (OR 1.8, 95% CI = 1.3-2.5) for each unit increase in anticholinergic load. Opioids and in particular opioids prescribed at higher doses, the total anticholinergic load associated with prescribed medications, the degree of impaired physical function of a person, their length of stay in a palliative care unit and their proximity to death were all strongly related to the prescription of laxatives.

Adjustment of nursing home quality indicators

Background

This manuscript describes a method for adjustment of nursing home quality indicators (QIs) defined using the Center for Medicaid & Medicare Services (CMS) nursing home resident assessment system, the Minimum Data Set (MDS). QIs are intended to characterize quality of care delivered in a facility. Threats to the validity of the measurement of presumed quality of care include baseline resident health and functional status, pattern of comorbidities, and facility case mix. The goal of obtaining a valid facility-level estimate of true quality of care should include adjustment for resident- and facility-level sources of variability.

Methods

We present a practical and efficient method to achieve risk adjustment using restriction and indirect and direct standardization. We present information on validity by comparing QIs estimated with the new algorithm to one currently used by CMS.

Results

More than half of the new QIs achieved a "Moderate" validation level.

Conclusions

Given the comprehensive approach and the positive findings to date, research using the new quality indicators is warranted to provide further evidence of their validity and utility and to encourage their use in quality improvement activities.

Targeting residents for transitions from nursing home to community

OBJECTIVE

To analyze nursing home utilization patterns in order to identify potential targeting criteria for transitioning residents back to the community.

DATA SOURCES

Secondary data from minimum data set (MDS) assessments for an annual cohort of first-time admissions (N=24,648) to all Minnesota nursing homes (N=394) from July 2005 to June 2006.

STUDY DESIGN

We conducted a longitudinal analysis from admission to 365 days. Major MDS variables were discharge status; resident's preference and support for community discharge; gender, age, and marital status; pay source; major diagnoses; cognitive impairment or dementia; activities of daily living; and continence.

PRINCIPAL FINDINGS

At 90 days the majority of residents showed a preference or support for community discharge (64 percent). Many had health and functional conditions predictive of community discharge (40 percent) or low-care requirements (20 percent). A supportive facility context, for example, emphasis on postacute care and consumer choice, increased transition rates.

CONCLUSIONS

A community discharge intervention could be targeted to residents at 90 days after nursing home admission when short-stay residents are at risk of becoming long-stay residents.

Who determines the rehabilitation needs of care home residents? An observational survey

Determining the rehabilitation needs is of great importance in long-term care setting, but the perception of rehabilitation needs may vary extensively between service provider and recipients. The purpose of this study was to assess the differences between the self-perceived and carer-evaluated rehabilitation needs among care home residents. Data of Longitudinal Older Veterans (LOVE) study were sorted for study. Overall, this study enrolled 581 (mean age=80.9±5.4 years) male participants. Among them, 539 (92.8%) were physically independent, and 463 (79.7%) were cognitively intact. Of these participants, 367 (63.2%) believed they would be physically improved by certain rehabilitation services, but only 57 (9.8%) residents were considered to have rehabilitation potential by their carers. Over half of physically dependent, but only 16.7% of physically independent residents were considered to have positive rehabilitation potential by their carer. Similarly, carers considered that residents with cognitive deficits were more likely to be improved by rehabilitation (24.6% vs. 6.0%, p<0.001) but cognitively intact residents considered themselves more likely to benefit from rehabilitation (67.6% vs. 45.8%, p<0.001). In conclusion, a significant disagreement in rehabilitation potential was noted between residents' self-perception and carer assessment. Residents with physical dependence and intact cognition may be more likely to receive rehabilitation. An intervention study is needed to develop practice guidelines to provide cost-effective rehabilitation for care home residents.

Pain and health-care utilization among older men in a veterans care home

Pain is a common health-care issue, and the prevalence increases with advancing age. Although it is often assumed that people with chronic pain are associated with a higher consumption of health care, evidence supporting this assertion is insufficient. Data from the Longitudinal Older VEterans (LOVE) study were stratified to explore the prevalence of pain and its relationship with health-care utilization. In total, data from 574 residents (mean age: 80.9+/-5.4 years, all male) were obtained. Among them, 92.8% were physically independent and 20.2% of them had mild to moderate cognitive impairment. Overall, 153 (26.3%) subjects reported pain; 114 (74.5%) subjects with mild pain and the remaining 39 (25.5%) subjects with moderate pain. The most commonly reported pain was lower back pain (40.5%, 62/153), which was followed by joint pain (29.4%, 45/153). Subjects with pain were more likely to have higher scores on the Geriatric Depression Scale (2.4+/-2.4 vs. 1.8+/-2.2, p = 0.023) and care-complexity problems (4.7+/-2.0 vs. 3.9+/-1.9, p < 0.001), despite being similar in age (81.3+/-5.0 vs. 80.8+/-5.5, p = 0.271), cognitive status and physical independence. Compared with pain-free subjects, subjects with pain were more likely to be hospitalized in the 12-month study period (0.71+/-1.20 vs. 0.46+/-1.00, p = 0.010), but the utilization of emergency department treatment (1.74+/-1.23 vs. 1.88+/-1.63, p = 0.560) was not statistically significant. In conclusion, the prevalence of pain among residents in a Taiwanese veterans care home was 26.3%; subjects with pain having more depressive symptoms, higher clinical-care complexity, and more likely to be hospitalized during the 12-month follow-up.

Public policy and the dependency of nursing home residents in Australia: 1968-69 to 2006-07

OBJECTIVE

The purpose of this paper is to derive annual estimates of the aggregate dependency of the nursing home population in Australia, and to use these data to consider the impact of Government policies to target nursing home services to those with high care-needs/dependency. Two related tools, the 'Aggregate Dependency Value' and 'Aggregate Dependency Index', have been constructed using the principles of case-mixed based systems, to quantify the aggregate dependency of residents. Data on all residents 1968-1969 to 2006-2007, and on newly admitted residents 1992-1993 to 2006-2007 have been derived and analysed.

METHODS

To construct the tools, the percent of residents classified into various dependency categories were weighted by proxy measures of their dependency. These were summed, and converted into index numbers to estimate rates of change in the aggregate dependency of residents. The derived data were used to consider possible impacts of the policies.

RESULTS

The data indicate that the dependency of residents has, for the most part, increased over recent decades but that the rate of the increase has varied. An increase in the dependency of residents corresponds with the policies' objectives.

CONCLUSIONS

The tools extend the ways the dependency of nursing home residents in Australia can be assessed. The estimates support the effectiveness of the Government's targeting policies but causal relationships have not been estimated.

Staffing characteristics, turnover rates, and quality of resident care in nursing facilities

Despite substantial spending and considerable regulatory oversight, the quality of care provided to residents in the nation's nursing facilities is inadequate, and strategies to address this problem are needed. Staffing characteristics are important predictors of quality in nursing facilities, and the relationship between staffing and various quality measures fluctuates across studies and in analyses that account for the effects of market, resident, and organizational characteristics. However and even with such variations, it is has generally been concluded that higher staffing levels, less turnover, and higher retention rates are associated with an array of improved resident and facility outcomes. This article synthesizes literature, including published reports, expert opinion, and peer reviewed studies, on staffing levels, turnover, and quality of care in nursing homes. The findings were used to develop three staffing interventions that need to be further evaluated in an effort to improve the quality of care in nursing facilities.

The work of the RN Minimum Data Set coordinator in its organizational context

The Resident Assessment Instrument/Minimum Data Set (RAI/MDS) is the foundational clinical framework for nursing home care, functioning as both a clinical assessment instrument and an assessment process. An RN is mandated by statute to complete or coordinate the work associated with this framework. Using both focus groups and questionnaires, 24 RN MDS coordinators attending a national conference for MDS coordinators described their work in its organizational context. Shortell et al.'s continuous quality framework of structural, technical, cultural, and strategic organizational dimensions was used to categorize descriptive themes. Clinical implications of the study findings are summarized.

The volume-outcome relationship in nursing home care: an examination of functional decline among long-term care residents

BACKGROUND

Extensive evidence has demonstrated a relationship between patient volume and improved clinical outcomes in hospital care. This study sought to determine whether a similar association exists between nursing home volume of long-term care residents and rates of decline in physical function.

METHODS

We conducted retrospective analyses on the 2004 and 2005 Minimum Data Set files that contain 605,433 eligible long-term residents in 9336 nursing homes. The outcome was defined following the federal "Nursing Home Compare" measure that captures changes in 4 basic activities of daily living status between 2 consecutive quarters. Both the outcome measure and nursing home volume were defined on the basis of long-term care residents. We estimated random-effects logistic regression models to quantify the independent impact of volume on functional decline.

RESULTS

As volume increased, nursing home's unadjusted rate of functional decline tended to be lower. After multivariate adjustment for baseline resident characteristics and the nesting of residents within facilities, the odds ratio of activities of daily living decline was 0.82 (95% confidence interval: 0.79-0.86, P < 0.000) for residents in high-volume nursing homes (>101 residents/facility), compared with residents in low-volume facilities (30-51 residents/facility).

CONCLUSIONS

High volume of long-term care residents in a nursing home is associated with overall less functional decline. Further studies are needed to test other important nursing home outcomes, and explore various institutional, staffing, and resource attributes that underlie this volume-outcome association for long-term care. Understanding how greater experience of high-volume facilities leads to better resident outcome may help guide quality improvement efforts in nursing homes.

Health status utilities and the impact of pressure ulcers in long-term care residents in Ontario

Purpose

To estimate health status utilities in long-term care (LTC) residents in Ontario, both with and without pressure ulcers (PUs), and to determine the impact of PU on health-related quality of life (HRQOL).

Methods

A retrospective population-based study was carried out using Minimum Data Set (MDS) health assessment data among all residents in 89 LTC homes in Ontario who had a full MDS assessment between May 2004 and November 2007. The Minimum Data Set-Health Status Index (MDS-HSI) was used to measure HRQOL. A stepwise regression was used to determine the impact of PU on MDS-HSI scores.

Results

A total of 1,498 (9%) of 16,531 LTC residents had at least one stage II PU or higher. The mean ± SD MDS-HSI scores of LTC residents without PU and those with PU were 0.36 ± 0.17 and 0.26 ± 0.13, respectively (p < 0.001). Factors associated with lower MDS-HSI scores included: older age; being female; having a PU; recent hip fracture; multiple comorbid conditions; bedfast; incontinence; Changes in Health, End-stage disease and Symptoms and Signs; clinically important depression; treated with a turning/repositioning program; taking antipsychotic medications; and use of restraints.

Conclusions

LTC residents with PU had slightly though statistically significantly lower HRQOL than those without PU. Comorbidity contributed substantially to the low HRQOL in these populations. Community-weighted MDS-HSI utilities for LTC residents are useful for cost-effectiveness analyses and help guide health policy development.

The costs of turnover in nursing homes

BACKGROUND

Turnover rates in nursing homes have been persistently high for decades, ranging upwards of 100%.

OBJECTIVES

To estimate the net costs associated with turnover of direct care staff in nursing homes. DATA AND SAMPLE: Nine hundred two nursing homes in California in 2005. Data included Medicaid cost reports, the Minimum Data Set, Medicare enrollment files, Census, and Area Resource File.

RESEARCH DESIGN

We estimated total cost functions, which included in addition to exogenous outputs and wages, the facility turnover rate. Instrumental variable limited information maximum likelihood techniques were used for estimation to deal with the endogeneity of turnover and costs.

RESULTS

The cost functions exhibited the expected behavior, with initially increasing and then decreasing returns to scale. The ordinary least square estimate did not show a significant association between costs and turnover. The instrumental variable estimate of turnover costs was negative and significant (P = 0.039). The marginal cost savings associated with a 10% point increase in turnover for an average facility was $167,063 or 2.9% of annual total costs.

CONCLUSION

The net savings associated with turnover offer an explanation for the persistence of this phenomenon over the last decades, despite the many policy initiatives to reduce it. Future policy efforts need to recognize the complex relationship between turnover and costs.