Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals

The association between nurse staffing level and length of stay in general ward and intensive care unit in Korea

BACKGROUND

Although many studies investigating the relationship between nurse staffing and quality of care have been published, the appropriate nurse-to-patient ratio with patient severity considered remains poorly understood. The aim of this study was to evaluate the impact of nurse staffing levels on length of stay (LOS) in the intensive care unit (ICU) and general ward.

METHODS

This study used a retrospective cohort study. The nurse staffing level was classified into nine grades for ICU based on a nurse-to-bed ratio, and eight grades for general wards based on a nurse-to-patient ratio. A generalized estimating equation model was used to evaluate the associations between the nurse staffing level and LOS. Subgroup analysis was conducted to assess these associations according to patient nursing needs at each hospital type.

RESULTS

This study included 13,135 ICU patients and 263,818 patients admitted to the general ward. In the ICU, the level of nurse staffing (based on the nurse-to-bed ratio) in grade 4 and above (grade 2: <0.63, grade 3: <0.77, grade 4: <0.88) was significantly associated with reduced LOS compared to grade 7 (<1.25). In the general ward, the level of nurse staffing in grade 4 and above was linked to reduced LOS compared to grade 7.

CONCLUSION

The results of this study show that an appropriate nurse-to-patient ratio is associated with a shorter LOS. In particular, hospitals with a higher proportion of severely ill patients require a larger staff of nurses, making it necessary to develop standards for determining nurse staffing level with patient severity taken into account.

Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations

OBJECTIVES

To assess whether Massachusetts legislation directed at ICU nurse staffing was associated with improvements in patient outcomes.

DESIGN

Retrospective cohort study; difference-in-difference design to compare outcomes in Massachusetts with outcomes of other states (before and after the March 31, 2016, compliance deadline).

SETTING

Administrative claims data collected from medical centers across the United States (Vizient).

PATIENTS

Adults between 18 and 99 years old who were admitted to ICUs for greater than or equal to 1 day.

INTERVENTIONS

Massachusetts General Law c. 111, § 231, which established 1) maximum patient-to-nurse assignments of 2:1 in the ICU and 2) that this determination should be based on a patient acuity tool and by the staff nurses in the unit.

MEASUREMENTS AND MAIN RESULTS

Nurse staffing increased similarly in Massachusetts (n = 11 ICUs, Baseline patient-to-nurse ratio 1.38 ± 0.16 to Post-mandate 1.28 ± 0.15; p = 0.006) and other states (n = 88 ICUs, Baseline 1.35 ± 0.19 to Post-mandate 1.31 ± 0.17; p = 0.002; difference-in-difference p = 0.20). Massachusetts ICU nurse staffing regulations were not associated with changes in hospital mortality within Massachusetts (Baseline n = 29,754, standardized mortality ratio 1.20 ± 0.04 to Post-mandate n = 30,058, 1.15 ± 0.04; p = 0.11) or when compared with changes in hospital mortality in other states (Baseline n = 572,952, 1.15 ± 0.01 to Post-mandate n = 567,608, 1.09 ± 0.01; difference-in-difference p = 0.69). Complications (Massachusetts: Baseline 0.68% to Post-mandate 0.67%; other states: Baseline 0.72% to Post-mandate 0.72%; difference-in-difference p = 0.92) and do-not-resuscitate orders (Massachusetts: Baseline 13.5% to Post-mandate 15.4%; other states: Baseline 12.3% to Post-mandate 14.5%; difference-in-difference p = 0.07) also remained unchanged relative to secular trends. Results were similar in interrupted time series analysis, as well as in subgroups of community hospitals and workload intensive patients receiving mechanical ventilation.

CONCLUSIONS

State regulation of patient-to-nurse staffing with the aid of patient complexity scores in intensive care was not associated with either increased nurse staffing or changes in patient outcomes.

Rural Hospital Nursing Skill Mix and Work Environment Associated With Frequency of Adverse Events

Introduction:

Although rural hospitals serve about one fifth of the United States, few studies have investigated relationships among nursing resources and rural hospital adverse events.

Objectives:

The purpose was to determine relationships among nursing skill mix (proportion of registered nurses [RNs] to all nursing staff), the work environment, and adverse events (medication errors, patient falls with injury, pressure ulcers, and urinary tract infections) in rural hospitals.

Methods:

Using a cross-sectional design, nurse survey data from a large study examining nurse organizational factors, patient safety, and quality from four U.S. states were linked to the 2006 American Hospital Association data. The work environment was measured using the Practice Environment Scale of the Nursing Work Index (PES-NWI). Nurses reported adverse event frequency. Data analyses were descriptive and inferential.

Results:

On average, 72% of nursing staff were RNs (range = 45%–100%). Adverse event frequency ranged from 0% to 67%, across 76 hospitals. In regression models, a 10-point increase in the proportion of RNs among all nursing staff and a one standard deviation increase in the PES-NWI score were significantly associated with decreased odds of frequent adverse events.

Conclusion

Rural hospitals that increase the nursing skill mix and improve the work environment may achieve reduced adverse event frequency.

Beyond Pain: Nurses' Assessment of Patient Suffering, Dignity, and Dying in the Intensive Care Unit

CONTEXT

Deaths in the intensive care unit (ICU) are increasingly common in the U.S., yet little is known about patients' experiences at the end of life in the ICU.

OBJECTIVES

The objective of this study was to determine nurse assessment of symptoms experienced, and care received by ICU patients in their final week, and their associations with nurse-perceived suffering and dignity.

METHODS

From September 2015 to March 2017, nurses who cared for 200 ICU patients who died were interviewed about physical and psychosocial dimensions of patients' experiences. Medical chart abstraction was used to document baseline patient characteristics and care.

RESULTS

The patient sample was 61% males, 70.2% whites, and on average 66.9 (SD 15.1) years old. Nurses reported that 40.9% of patients suffered severely and 33.1% experienced severe loss of dignity. The most common symptoms perceived to contribute to suffering and loss of dignity included trouble breathing (44.0%), edema (41.9%), and loss of control of limbs (36.1%). Most (n = 9) remained significantly (P < 0.05) associated with suffering, after adjusting for physical pain, including fever/chills, fatigue, and edema. Most patients received vasopressors and mechanical ventilation. Renal replacement therapy was significantly (<0.05) associated with severe suffering (adjusted odds ratio [AOR] 2.53) and loss of dignity (AOR 3.15). Use of feeding tube was associated with severe loss of dignity (AOR 3.12).

CONCLUSION

Dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. Attention to symptoms such as dyspnea and edema may improve the quality of death in the ICU.

Hospital mortality and optimality of nursing workload: A study on the predictive validity of the RAFAELA Nursing Intensity and Staffing system

BACKGROUND

Patient classification systems have been developed to manage workloads by estimating the need for nursing resources through the identification and quantification of individual patients' care needs. There is in use a diverse variety of patient classification systems. Most of them lack validity and reliability testing and evidence of the relationship to nursing outcomes.

OBJECTIVE

Predictive validity of the RAFAELA system was tested by examining whether hospital mortality can be predicted by the optimality of nursing workload.

METHODS

In this cross-sectional retrospective observational study, monthly mortality statistics and reports of daily registrations from the RAFAELA system were gathered from 34 inpatient units of two acute care hospitals in 2012 and 2013 (n=732). The association of hospital mortality with the chosen predictors (hospital, average daily patient to nurse ratio, average daily nursing workload and average daily workload optimality) was examined by negative binomial regression analyses.

RESULTS

Compared to the incidence rate of death in the months of overstaffing when average daily nursing workload was below the optimal level, the incidence rate was nearly fivefold when average daily nursing workload was at the optimal level (IRR 4.79, 95% CI 1.57-14.67, p=0.006) and 13-fold in the months of understaffing when average daily nursing workload was above the optimal level (IRR 12.97, 95% CI 2.86-58.88, p=0.001).

CONCLUSIONS

Hospital mortality can be predicted by the RAFAELA system. This study rendered additional confirmation for the predictive validity of this patient classification system. In future, larger studies with a wider variety of nurse sensitive outcomes and multiple risk adjustments are needed. Future research should also focus on other important criteria for an adequate nursing workforce management tool such as simplicity, efficiency and acceptability.

The Concept of Care Complexity: A Qualitative Study

Background:

Hospital organisations based on the level of care intensity have clearly revealed a concept, that of care complexity, which has been widely used for decades in the healthcare field. Despite its wide use, this concept is still poorly defined and it is often confused with and replaced by similar concepts such as care intensity or workload. This study aims to describe the meaning of care complexity as perceived by nurses in their day-to-day experience of hospital clinical care, rehabilitation, home care, and organisation.

Design and methods

Fifteen interviews were conducted with nurses belonging to clinical-care areas and to heterogeneous organisational areas. The interview was of an unstructured type. The participants were selected using a propositional methodology. Colaizzi’s descriptive phenomenological method was chosen for the analysis of the interviews.

Results:

The nurses who were interviewed predominantly perceive the definition of care complexity as coinciding with that of workload. Nevertheless, the managerial perspective does not appear to be exclusive, as from the in-depth interviews three fundamental themes emerge that are associated with the concept of care complexity: the patient, the nurse and the organisation.

Conclusions:

The study highlights that care complexity consists of both quantitative and qualitative aspects that do not refer only to the organisational dimension. The use of the terminology employed today should be reconsidered: it appears to be inappropriate to talk of measurement of care complexity, as this concept also consists of qualitative – thus not entirely quantifiable – aspects referring to the person being cared for. In this sense, reference should instead be made to the evaluation of care complexity, which would also constitute a better and more complete basis for defining the nursing skills required in professional nursing practice.

Pre-implementation studies of a workforce planning tool for nurse staffing and human resource management in university hospitals

AIM

To investigate the reliability, validity and feasibility of the RAFAELA workforce planning system (including the Oulu patient classification system - OPCq), before deciding on implementation in Dutch hospitals.

BACKGROUND

The complexity of care, budgetary restraints and demand for high-quality patient care have ignited the need for transparent hospital workforce planning.

METHODS

Nurses from 12 wards of two university hospitals were trained to test the reliability of the OPCq by investigating the absolute agreement of nursing care intensity (NCI) measurements among nurses. Validity was tested by assessing whether optimal NCI/nurse ratio, as calculated by a regression analysis in RAFAELA, was realistic. System feasibility was investigated through a questionnaire among all nurses involved.

RESULTS

Almost 67 000 NCI measurements were performed between December 2013 and June 2014. Agreement using the OPCq varied between 38% and 91%. For only 1 in 12 wards was the optimal NCI area calculated judged as valid. Although the majority of respondents was positive about the applicability and user-friendliness, RAFAELA was not accepted as useful workforce planning system.

CONCLUSION AND IMPLICATIONS FOR NURSING MANAGEMENT

Nurses' performance using the RAFAELA system did not warrant its implementation. Hospital managers should first focus on enlarging the readiness of nurses regarding the implementation of a workforce planning system.

Weighted staffing plans for better prediction of staffing needs

OBJECTIVE

The aim of this study was to examine the effect of patient turnover and acuity on worked hours per patient day (WHPPD).

BACKGROUND

An examination of staffing plans publically posted by Massachusetts hospitals with more than 300 beds revealed that less than 40% were within 5% of their planned versus actual WHPPD.

METHODS

Three years of WHPPD data collected from 14 adult acute care units were correlated with patient turnover and acuity data. A weight factor was retrospectively added to 8 paired units' planned WHPPD where correlations were identified.

RESULTS

Twelve units (86%) showed significant correlations between WHPPD and patient turnover. Correlations between patient acuity and WHPPD were significant only at the aggregate level. After weighting WHPPD, the 8 paired units demonstrated a decreased variance between planned and actual WHPPD.

CONCLUSION

Using a weight factor added to WHPPD to right size acute care medical-surgical units may be useful for accurate staff planning and budgeting.

Nursing intellectual capital theory: testing selected propositions

AIMS

To test the selected propositions of the middle-range theory of nursing intellectual capital.

BACKGROUND

The nursing intellectual capital theory conceptualizes nursing knowledge's influence on patient and organizational outcomes. The theory proposes nursing human capital, nurses' knowledge, skills and experience, is related to the quality of patient care and nurse recruitment and retention of an inpatient care unit. Two factors in the work environment, nurse staffing and employer support for nurse continuing professional development, are proposed to influence nursing human capital's association with patient and organizational outcomes.

DESIGN

A cross-sectional survey design.

METHODS

The study took place in 2008 in six Canadian acute care hospitals. Financial, human resource and risk data were collected from hospital departments and unit managers. Clearly specified empirical indicators quantified the study variables. The propositions of the theory were tested with data from 91 inpatient care units using structural equation modelling.

RESULTS

The propositions associated with the nursing human capital concept were supported. The propositions associated with the employer support for nurse continuing professional development concept were not. The proposition that nurse staffing's influences on patient outcomes was mediated by the nursing human capital of an inpatient unit, was partially supported.

CONCLUSION

Some of the theory's propositions were empirically validated. Additional theoretical work is needed to refine the operationalization and measurement of some of the theory's concepts. Further research with larger samples of data from different geographical settings and types of hospitals is required to determine if the theory can withstand empirical scrutiny.

The professional nursing practice environment and nurse-reported job outcomes in two European countries: a survey of nurses in Finland and the Netherlands

The working environment of nurses is receiving international interest, because there is a growing consensus that identifying opportunities for improving working conditions in hospitals is essential to maintain adequate staffing, high-quality care, nurses' job satisfaction and hence their retention. Thus, the aim of this study was to investigate the relationship between nurse work environment characteristics and nurse-reported job outcomes in hospital settings in Finland and the Netherlands and to compare these results. A comparative cross-sectional nurse survey was conducted. Data were collected from the two countries randomly sampling the countries' National Nurses Association' membership databases. In this paper, the results from Registered Nurses working in hospital settings are used. In total, 869 hospital nurses participated: 535 from Finland and 334 from the Netherlands with the response rate of 44.9 and 33.4%, respectively. Fifty-five items from the Nursing Work Index-Revised were used as a main tool for the practice environment. Exploratory factor analysis was used to identify a set of internally consistent subscales. Further, logistic regression analysis and T-tests were used. Three practice environment characteristics were identified: adequacy of resources, supportiveness of management and assurance of care quality via collaborative relationships. Favourable evaluations of the adequacy of resources and supportiveness of management were positively correlated with nurse-assessed quality of care and job-related positive feelings and negatively correlated with intentions to leave a unit, organization or the entire profession. In neither of the participating countries were adverse incidents affecting nurses related to nurses' evaluations of their current professional practice environment. Compared with Finland, in the Netherlands, RN appears to evaluate the majority of work environment characteristics more positively; nevertheless, to some extent, the results were uniform as adequacy of resources and supportiveness of management were main predictors for nurse-reported job outcomes considered.

The Zebra index: one method for comparing units in terms of nursing care

AIM

To describe an approach for developing a nursing index that is based on the patients' needs of nursing care and enables nursing costs to be calculated.

BACKGROUND

Usually staffing resources are calculated as the ratio between the number of staff and the number of occupied beds per unit.

METHOD

The index was developed from two parts of the Zebra method. The index factor per patient category of care was calculated first. The patient days per category of care was multiplied next with the index factor for the category, which gives the same value in terms of nursing care given for all the patient days. The third step was the calculation of the Zebra index (ZI).

RESULTS

The ZI shows 'the intensity of nursing care' given. The index makes it possible to follow changes in the nursing care given over a period of time and it can also explain why two similar units with the same number of staff per patient can have a totally different workload situation.

CONCLUSION

The ZI obtains reliable information about the changing nursing situations over a period of time.

IMPLICATIONS FOR NURSING MANAGEMENT

The approach described can be used in different settings and is not bound to Sweden but can be looked upon as a general method. The index is useful for comparing different units and clinics in terms of nursing care and staffing.

Hospital churn and casemix instability: implications for planning and educating the nursing workforce

Health workforce planning is a priority for Australian governments at both state and federal levels. Nursing shortages are a significant problem and addressing these shortages is likely to be a component of any workforce plan. This paper looks at the case of hospital nursing and argues that casemix, workforce and management instability inhibit workforce planning for hospital nursing. These issues are related and any efforts to objectively plan the hospital nursing workforce must seek to address them in order to succeed.

Care needs and functional status of older acute care patients

A growing number of older adults are admitted to hospitals, and information is needed on how age-related functional decline affects nursing care needs of this population. This study compared the functional status at admission and total nursing care needs of three age groups of older inpatients. A 12-month retrospective audit was performed on the records of 225 patients in a private metropolitan hospital. The three groups of patients were matched on diagnosis. Findings revealed that older patients were significantly more dependent, had greater total nursing care needs, and were less likely to be discharged to home, indicating that in addition to medical diagnoses, age-related differences of older patients' functional status at admission and inpatient nursing care needs should be factored into staff workloads and funding of nursing care. The finding that significantly fewer of the older patients returned home must be considered when reviewing health care policy and services.

Nurses' perceptions of the organizational attributes of their practice environment in acute care hospitals

AIM

The aim of the present study was to examine Estonian nurses' thinking with regard to how they perceive their autonomy, control over practice, teamwork and organizational support in regional, central and general hospitals. BACKGROUND; Despite the well-documented fact that there is a need to improve nurses' working environments in hospitals to promote safe patient care, in Europe broader studies on this topic have not received priority thus far.

METHODS

A nationally representative stratified random sample of 478 acute care hospital nurses was surveyed using the Nursing Work Index-Revised (NWI-R) instrument in 2005/2006.

RESULTS

Nurses perceived their autonomy, control over practice and organizational support remarkably lower than nurse-physician relationships. Age and tenure were highly related to the nurses' perceptions.

CONCLUSIONS

The Estonian nurses' ambivalent perceptions of the organizational attributes reflected the effects ascribed to hospital reforms.

IMPLICATIONS FOR NURSING MANAGEMENT

There is an urgent need for nurse managers to be particularly alert and attentive with regard to nurses who have been practising the profession for more than a decade. Support for their practice should be provided with the long-term goal of assuring the retention of those experienced nurses. Continuous monitoring of nurses' perceptions should be used systematically as a tool for staffing decisions at the hospital level.

Care model transformation: a necessity, not an option

The authors describe the need for a new approach to the delivery of patient care in the acute care setting. The case for a different care model is proposed and provides information on how a new approach clarifies registered nurse (RN) responsibilities to maximize the valuable resource of professional practice, the nurse of the future. This model proposes the patient care work being allocated between 2 groups of point-of-care providers: the professional RN and the patient care technologist. The transformed care model requires a departure from the traditional task-focused nursing education and practice and moves professional RN education to one that requires knowledge access and critical synthesis.

Nurse working conditions and nursing unit costs

The authors examined the relationship between nurse working conditions and nursing unit costs in 210 general medical, general surgical, and general medical surgical units in 112 randomly selected U.S. hospitals. Data were collected from registered nurses (N = 3,747 and 2,878), patients (N = 2,100), study coordinators, and secondary data sources. After controlling for relevant hospital, nursing unit, and patient characteristics, the authors found that good working conditions did not increase nursing unit costs. Teaching status was associated with higher costs, whereas larger unit size was associated with lower costs. Higher proportions of registered nurses and licensed practical nurse staffing were also associated with higher costs. Patient variables were not significantly related to costs. We suggest a variety of strategies that managers may use to improve working conditions.

Testing an inpatient nursing intensity billing model

There has been growing concern about the costs and intensity of inpatient nursing care, which consumes more than 40% of hospital direct costs and $165 billion each year. Allocating nursing labor as an average cost per patient and charged as room and board creates cost compression, distorts hospital payment, and hides the economic value of nurses. This article examines a method for adjusting daily room charges using nursing intensity weights assigned by the diagnosis related group. In a test using claims data from 286 hospitals in four states representing 1,856,256 patient discharges in 2002, the nursing intensity adjustment improved explained total cost variance by 8.5% for adult all payer patients (R2 = .4448 vs. .4825) and 9.4% for Medicare only patients (R2 = .4387 vs. .4798) compared to unadjusted days. This article discusses unbundling inpatient nursing care intensity and charges from room and board and recommends implementing this billing process at all U.S. hospitals.

The effect of high nursing surveillance on hospital cost

PURPOSE

The purpose of this study was to determine the cost of one nursing treatment, surveillance, for older, hospitalized adults at risk for falling.

DESIGN

An observational study using information from data repositories at one Midwestern tertiary hospital. The inclusion criteria included patients age>60 years, admitted to the hospital between July 1, 1998 and June 31, 2002, at risk for falls or received the nursing treatment of fall prevention.

METHODS

Data came from clinical and administrative data repositories that included Nursing Interventions Classification (NIC). The nursing treatment of interest was surveillance and total hospital cost associated with surveillance was the dependent variable. Propensity-score analysis and generalized estimating equations (GEE) were used as methods to analyze the data. Independent variables related to patient characteristics, clinical conditions, nurse staffing, medical treatments, pharmaceutical treatments, and other nursing treatments were controlled for statistically.

FINDINGS

The total median cost per hospitalization was $9,274 for this sample. The median cost was different (p=0.050) for patients who received high versus low surveillance. High surveillance delivery cost $191 more per hospitalization than did low surveillance delivery.

CONCLUSION

Propensity scores were applied to determine the cost of surveillance among hospitalized adults at risk for falls in this observational study. The findings show the effect of high surveillance delivery on total hospital cost compared to low surveillance delivery and provides an example of a useful method of determining cost of nursing care rather than including it in the room rate. More studies are needed to determine the effects of nursing treatments on cost and other patient outcomes in order for nurses to provide cost-effective care. Propensity scores were a useful method for determining the effect of nursing surveillance on hospital cost in this observational study.

CLINICAL RELEVANCE

The results of this study along with possible clinical benefits would indicate that frequent nursing surveillance is important and might support the need for additional nursing staff to deliver frequent surveillance.

Implications of Medicare reimbursement changes related to inpatient nursing care quality

Recent changes to the inpatient prospective payment system by the Centers for Medicare and Medicaid Services will negatively affect reimbursement to hospitals for patients who develop certain types of nursing-sensitive, hospital-acquired conditions such as pressure ulcers, falls with injuries, or nosocomial infections. The author examines the effects of the new payment policy on inpatient nursing care and addresses ways to improve quality and minimize financial impacts to hospitals.

Establishing an Acute Care Nursing Bed Unit Size: Employing a Decision Matrix Framework

Determining the number of patient rooms for an acute care (medical-surgical) patient unit is a challenge for both healthcare architects and hospital administrators when renovating or designing a new patient tower or wing. Discussions on unit bed size and its impact on hospital operations in healthcare design literature are isolated, and clearly there is opportunity for more extensive research. Finding the optimal solution for unit bed size involves many factors, including the dynamics of the site and existing structures. This opinion paper was developed using a “balanced scorecard” concept to provide decision makers a framework for assessing and choosing a customized solution during the early planning and conceptual design phases. The context of a healthcare balanced scorecard with the quadrants of quality, finance, provider outcomes, and patient outcomes is used to compare the impact of these variables on unit bed size.

Nurse staffing and cost of care in adult intensive care units in a university hospital in Thailand

Decisions about nurse staffing levels in intensive care units (ICUs) should be guided by research to ensure optimal outcomes. This descriptive correlational study in a large Thai hospital was designed to evaluate the effect of nurse staffing levels on the costs of care, in terms of medical care cost per patient day and health personnel cost per patient day, in ICUs. The costing data were collected prospectively from the records of 242 critically ill patients while the nurse staffing levels were extracted from hospital management reports. The findings showed that a nurse staffing model with a higher number of registered nurses (RNs) led to an increase in the health personnel cost per patient day. However, a greater number of RNs was associated with improved patient safety and efficiency, thereby reducing the length of stay and the costs of care in the long term. This study provides evidence to support decisions by hospital administrators concerning RN staffing levels.

Hospital characteristics and patient populations served by physician owned and non physician owned orthopedic specialty hospitals

BACKGROUND

The emergence of physician owned specialty hospitals focusing on high margin procedures has generated significant controversy. Yet, it is unclear whether physician owned specialty hospitals differ significantly from non physician owned specialty hospitals and thus merit the additional scrutiny that has been proposed. Our objective was to assess whether physician owned specialty orthopedic hospitals and non physician owned specialty orthopedic hospitals differ with respect to hospital characteristics and patient populations served.

METHODS

We conducted a descriptive study using Medicare data of beneficiaries who underwent total hip replacement (THR) (N = 10,478) and total knee replacement (TKR) (N = 15,312) in 29 physician owned and 8 non physician owned specialty orthopedic hospitals during 1999-2003. We compared hospital characteristics of physician owned and non physician owned specialty hospitals including procedural volumes of major joint replacements (THR and TKR), hospital teaching status, and for profit status. We then compared demographics and prevalence of common comorbid conditions for patients treated in physician owned and non physician owned specialty hospitals. Finally, we examined whether the socio-demographic characteristics of the neighborhoods where physician owned and non physician owned specialty hospitals differed, as measured by zip code level data.

RESULTS

Physician owned specialty hospitals performed fewer major joint replacements on Medicare beneficiaries in 2003 than non physician owed specialty hospitals (64 vs. 678, P < .001), were less likely to be affiliated with a medical school (6% vs. 43%, P = .05), and were more likely to be for profit (94% vs. 28%, P = .001). Patients who underwent major joint replacement in physician owned specialty hospitals were less likely to be black than patients in non physician owned specialty hospitals (2.5% vs. 3.1% for THR, P = .15; 1.8% vs. 6.3% for TKR, P < .001), yet physician owned specialty hospitals were located in neighborhoods with a higher proportion of black residents (8.2% vs. 6.7%, P = .76). Patients in physician owned hospitals had lower rates of most common comorbid conditions including heart failure and obesity (P < .05 for both).

CONCLUSION

Physician owned specialty orthopedic hospitals differ significantly from non physician owned specialty orthopedic hospitals and may warrant the additional scrutiny policy makers have proposed.

A Dialogue on the Future of Nursing Practice

PURPOSE

The challenges of health care; its safety, effectiveness, and efficiency; the quality of care; and the outcomes patients experience are issues central to nursing practice. This centrality needs to be affirmed as the profession shapes its practice over the next 50 years. The purpose of this article is to initiate a dialogue on the future of nursing practice.

METHODS

The methods used are observation, reflection, dialogue, and proposed actions.

FINDINGS

The results of this process are preliminary. They suggest that the establishment of nursing hospitals is a distinct possibility.

CONCLUSIONS

This article concludes with a series of arguments for and against this position along with an invitation for your participation in this dialogue.

NURSING IMPLICATIONS

The major implications of this article are not "nursing" implications per se but client and patient implications and the future contribution of nursing to improved health and patient care.

Adjustment of inpatient care reimbursement for nursing intensity

The Centers for Medicare and Medicaid Services has begun an ambitious recalibration of the inpatient prospective payment system, the first since its introduction in 1983. Unfortunately, inpatient nursing care has been overlooked in the new payment system and continues to be treated as a fixed cost and billed at a set per-diem "room and board" fee despite the known variability of nursing intensity across different care settings and diagnoses. This article outlines the historical influences regarding costing, billing, and reimbursement of inpatient nursing care and provides contemporary evidence about the variability of nursing intensity and costs at acute care hospitals in the United States. A remedy is proposed to overcome the existing limitations of the Inpatient Prospective Payment System by creating a new nursing cost center and nursing intensity adjustment by DRG for each routine-and intensive-care day of stay to allow independent costing, billing, and reimbursement of inpatient nursing care.