The unintended and unexpected impact of downsizing: costly hospitals become more costly

Effects of Hospital Restructuring and Downsizing on Nursing Staff

The healthcare system underwent considerable restructuring and downsizing in the early to mid-1990s as governments cut costs to reduce their budget deficits. Studies of the effects of these efforts on nursing staff and hospital functioning generally reported negative impacts. Healthcare restructuring and hospital downsizing was again being implemented as governments struggled to once again reduce deficits. The present study examines the relationship of union support during hospital restructuring initiatives with a range of individual and unit/hospital outcomes in a sample of nursing staff working in healthcare settings (hospitals) undergoing significant restructuring and downsizing. Data were collected from 289 nursing staff in California hospitals. Nurses reported a relatively large number of restructuring and downsizing initiatives during the preceding year. Levels of union support had a significant relationship with hospital functioning, but not with nursing staff work and well-being outcomes. Although union support has not shown many benefits for nursing staff during hospital restructuring and downsizing given their focus on adherence to collective agreements, nursing unions can play a larger role here. The present study adds to our understanding of the potential benefits of union support during the current hospital restructuring and downsizing, and highlights the role of union leadership and management.

Elevated risk of early reoperation in total hip replacement during the stage of unit closure: A population-based registry study of total hip and knee replacements in Finland, 1998-2011

BACKGROUND AND PURPOSE

The effects of launch or closure of an entire arthroplasty unit on the first or last patients treated in these units have not been studied. Using a 3-year follow-up, we investigated whether patients who were treated at the launch or closure stage of an arthroplasty unit of a hospital would have a higher risk of reoperation than patients treated in-between at the same units.

PATIENTS AND METHODS

From the Finnish Arthroplasty Register, we identified all the units that had performed total joint arthroplasty and the units that were launched or closed in Finland between 1998 and 2011. The risks of reoperation within 3 years for the 41,748 total hip and knee replacements performed due to osteoarthritis in these units were modeled with Cox proportional-hazards regression, separately for hip and knee and for the launch and the closure stage.

RESULTS

The unadjusted and adjusted hazard ratios (HRs) for total hip and knee replacements performed in the initial stage of activity of the units that were launched were similar to the reoperation risks in patients who were operated in these units after the early stage of activity. The unadjusted and risk-adjusted HRs for early reoperation after total hip replacement (THR) were increased at the closure stage (adjusted HR = 1.8, 95% CI: 1.2-2.8). The reoperation risk at the closure stage after total knee replacement (TKR) was not increased.

INTERPRETATION

The results indicate that closure of units performing total hip replacements poses an increased risk of reoperation. Closures need to be managed carefully to prevent the quality from deteriorating when performing the final arthroplasties.

Monitoring the impact of hospital downsizing on access to care and quality of care

The most recent data used for monitoring the potential effects of bed closures in Winnipeg hospitals since 1992/93 found that despite downsizing, access to care was by no means compromised. Just as many patients were cared for in 1995/96 as in 1991/92. Changes in patterns of care included more outpatient and fewer inpatient surgeries, and a decrease in the number of hospital days. The number of high-profile surgical procedures, such as angioplasty, bypass, and cataract surgery, performed increased dramatically during downsizing. Quality of care delivered to patients, measured by mortality and readmission rates, was unaffected by bed closures. Of particular concern was the impact of downsizing on the two most vulnerable health groups--the elderly and Manitobans in the lowest income group. Access and quality of care for these groups also remained unchanged. However, those in the lowest income group spent almost 43% more days in hospital than those in the middle income group, and research demonstrates that these variations in hospital use across socioeconomic groups reflect real and important health differences and are not driven by social reasons for admissions. Finally, a large decrease in waiting time for nursing home placement underlines the relationship between downsizing and availability of alternatives to hospitalization.

Adding up provincial expenditures on health care for Manitobans: a POPULIS project. Population Health Information System

OBJECTIVES

Using the POPULIS framework, this project estimated health care expenditures across the entire population of Manitoba for inpatient and outpatient hospital utilization, physician visits, mental health inpatient, and nursing home utilization.

RESEARCH DESIGN

This estimated expenditure information was then used to compare per capita expenditures relative to premature mortality rates across the various areas of Manitoba.

RESULTS

Considerable variation in health care expenditures was found, with those areas having high premature mortality rates also having higher health care expenditures.