Tag Archives: Patient Outcomes

New nurses work overtime, long shifts, and sometimes a second job, research shows

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Overtime in particular has been negatively associated with patient care, and a good proportion of nurses are required to work extra hours.

New nurses are predominantly working 12-hour shifts and nearly half work overtime, trends that have remained relatively stable over the past decade, finds a new study by researchers at NYU Rory Meyers College of Nursing. And 13 percent hold a second job.

Changes in health policy in recent years — from the passage of the Affordable Care Act and increased access to healthcare, to the recession — which delayed some nurses’ retirements — have had implications for nurses and the hours they work, while overtime has been linked to patient safety and nurse well-being.

IMPACT

The research team analyzed surveys from more than 4,500 newly licensed nurses in 13 states and Washington D.C., collecting information on nurse demographics, education, work attributes and attitudes. Specifically, nurses were asked about their work schedule, daily shift length, weekly work hours, overtime, and whether they worked a second job.

In addition to the 12-hour shifts and second jobs, it was found that new nurses prefer working the day shift and 12 hours is the preferred shift length.

Twelve percent of nurses report working mandatory overtime (an average of less than an hour in a typical week), and nearly half, 45.6 percent, work voluntary overtime (an average of three hours in a typical week).

There were nuanced changes in overtime hours during the decade studied: There was a decline in both mandatory and voluntary overtime during the economic recession by about an hour per week, but overtime hours rose in the most recent cohort.

There’s good news and bad news in the results. The good news is that new nurses seem to be working a similar proportion of 12-hour shifts as more experienced nurses, and most are working the shift and schedule they prefer. There also weren’t statistically significant increases in weekly work hours or overtime hours.

But the findings on overtime were troubling given that previous research has established associations between working overtime and patient outcomes (such as medication errors), occupational injury among nurses, and factors like burnout and job dissatisfaction.

While voluntarily working overtime can be a welcome source of income for some nurses, mandatory overtime — which is restricted by law in 18 states — was found to be a practice norm, occurring for 12 percent of new nurses.

THE TREND

Nurses operate within a highly competitive job market, and as is the case in other high-stress fields, there’s a fatigue starting to set in. Burnout is a very real danger, and much like physicians, nurses are prone to leaving when they’ve finally had enough — and that turnover can have detrimental effects on everything from a hospital’s financial strength to the quality of patient care.

The Burgeoning Role Of Venture Capital In Health Care

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The US health care system relies heavily on private markets. While private insurers, provider organizations, and drug and device companies are familiar to many, little is known about the increasing presence of venture capital in today’s delivery system. The growth of venture capital and venture capital -backed, early-stage companies (startups) deserves the attention of patients and policy makers because advancements in medicine are no longer exclusively born from providers within the delivery system and increasingly from innovators outside of it.

While venture capital -backed startups in digital health offer opportunities to affect the cost and quality of care, often by challenging prevailing modes of care delivery, they pose potential risks to patient care and raise important questions for policy makers. To date, however, an analytic framework for understanding the role of venture capital in medicine is lacking. 

A Brief History

Venture capital firms provide funding to startups judged to have potential to disrupt existing industries in exchange for ownership and some control over strategy and operations. Venture capital businesses have recently funded hundreds of startups developing technology-enabled digital health products, including wearable devices, mobile health applications, telemedicine, and personalized medicine tools. Between 2010 and 2017, the value of investments in digital health increased by 858 percent, and the number of financing deals in this sector increased by 412 percent; more than $41.5 billion has been invested in digital health this decade (see Exhibit 1). This growth far exceeds the growth of total venture capital funding (166 percent) and total number of venture capital deals (50 percent) (in all fields) in the overall economy, as well as growth in health care spending (34 percent). In 2017 alone, venture capital firms invested more than $11.5 billion in digital health, from patient-facing devices to provider-facing practice management software to payer-facing data analysis services.

Exhibit 1: Venture Capital Funding For Digital Health Versus US Health Care Spending

Sources: Data are from StartUp Health Insights 2017 Year End Report and the National Health Expenditure (NHE) Accounts Team. Notes: Dollars invested (blue bars) have units of billions. The NHE plot is expressed in trillions (T) of dollars. A deal is a distinct agreement reached between venture capital investors and a startup company, typically including parameters such as the amount of money invested and equity involved in a given startup company. 

Three key elements have likely driven this growth. First, the inability of physicians to consistently monitor patients and persistent challenges with patient adherence have created a need for digital technologies to serve as a mechanism for care delivery. Second, the increasing migration of medical care out of the hospital and fragmentation of care among specialties has increased demand for new forms of patient-to-provider and provider-to-provider communication. Third, expansions in insurance coverage and new payment models that encourage cost control have aligned incentives for technologies that aim to substitute higher-cost services with lower-cost, higher-value services.

Strategies For Disruption

The venture capital movement will likely be judged on two factors: whether it improves patient outcomes and experience, and whether it saves money for society. To date, rigorous evidence on the impact of venture capital -backed innovations is scarce. Most deals have occurred in the past few years, and most startup technologies take time to scale and are not implemented with a control group or a design that facilitates easy evaluation. Traditional provider groups may often be too small, hospital operations too rigid, and delivery systems too skeptical for a given digital health innovation to be implemented widely and tested rigorously. Moreover, data on the impact of such technologies on patients and costs may often be held privately akin to trade secrets.

However, some early small-scale randomized controlled studies have suggested potential health benefits (for example, improved glycemic and blood pressure control) of mobile health applications and wearable biosensors. Evidence may grow as startup products are brought closer to market.

Despite the shortage of rigorous public evidence, the strategies of startups to influence use and spending are apparent. Many startups target wellness and prevention among self-insured employers, using smartphones and wearable devices to engage and track patients with the hope of lowering costs through decreasing use. Although this strategy of saving money through helping people become healthier in their daily lives remains largely unproven, hundreds of companies in this space have received substantial amounts of funding. Among the most well-known is Omada Health, which provides proprietary online coaching programs and other digital tools to help prevent diabetes and other chronic diseases. It is considered the nation’s largest federally recognized provider of the Centers for Medicare and Medicaid Services (CMS) Diabetes Prevention Program, having received more than $125 million in venture funding since it was founded in 2011. 

Another segment of startups focus on a separate driver of health care costs—the prices of medical services. These firms are increasingly partnering with employers to steer patients toward lower-cost providers for expensive treatments such as joint replacements. Their path to success—creating savings through price transparency—is also largely unproven, although lowering prices through enhancing competition is a reasonable approach. 

Still other digital health startups focus on improving access to primary care via telehealth, virtual visits, and related mechanisms of accessing care. Some use biometric data (genetics or biosensor data) to facilitate early detection of medical problems. While evidence is sparse, these efforts may lead to increased use and spending. Moreover, there is no guarantee that the startup technologies will be priced below existing substitutes. To the extent that these technologies improve outcomes but at a greater total cost, policy makers and adopters of such innovations may face difficult decisions over access and tradeoffs. 

Points Of Caution 

Given differences among health care and other industries, the success of the digital health boom is far from promised. Medical evidence suggests that changes in practice typically lag behind technological advancements. For evidence-based guidelines, randomized controlled trials remain the gold standard despite their considerable expense and length, which place them out of reach for many startup technologies. In addition to showing efficacy, interventions must convincingly demonstrate that they “do no harm.” 

This culture directly conflicts with the “fail fast, fail hard” reality of venture capital, in which a return on investment is typically sought within several years. Furthermore, the complex clinical workflows of traditional medical practices offer little room for disruption without potentially putting provider satisfaction or patient safety at risk (at least in the short term). In a profession in which institutions move slowly and health is at stake, technological innovations face a higher threshold for acceptance relative to other industries.

Other barriers to adoption include: the difficulty of building successful business models centered on lowering spending in a largely revenue-maximizing system in which providers often lack the incentives to eliminate waste; HIPAA-related privacy rules and restrictions that hinder data sharing across digital platforms; incompatibility between newer cloud-based technologies that startups build and old legacy technologies used by traditional providers; and the lack of billing codes and ways of recognizing provider effort in digital health, which complicates budget or price negotiations. It is perhaps no surprise that 98 percent of digital health startups ultimately fail. 

Outlook For The Future 

In the first three quarters of 2018, venture capital involvement in health care has further accelerated. The third quarter saw an estimated $4.5 billion in digital health funding—the most of any quarter on record. As this industry grows, policy makers have an important role to play. 

Regulatory guidance is needed to shape the scope and direction of new technologies, with patient safety and societal costs in mind. Venture capital firms and startups often point to a lack of regulatory guidance on what must undergo formal approval. The current Food and Drug Administration (FDA) Digital Health Innovation Plan is a positive step toward defining the path to market for low-risk digital devices and specifying what digital health tools fall outside the FDA’s scope.

Second, a reimbursement framework for digital technologies is needed. Thoughtful debate about their prices and new billing codes should be had in an open forum. Outcomes-based pricing and other value-based approaches that go beyond the fee-for-service standard should be considered.

Most importantly, policy makers and government agencies such as the FDA, CMS, and the National Institutes of Health should study the effects of startups in health care and facilitate research on these products to inform payers and the public of their benefits and drawbacks. In the current climate, little funding has been allocated toward such research. This leaves providers and patients relying almost exclusively on industry-funded studies, at times conducted by the same startup that is selling the product or service. Publicly funded, independent studies of the impact of venture capital-backed products and services on clinical and economic outcomes are needed to establish an evidence base that patients and providers can broadly trust.

 

 

 

WILL THEY OR WON’T THEY? MASSACHUSETTS VOTERS TO DECIDE ON NURSE STAFFING RATIOS.

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On Tuesday, Massachusetts voters will face a ballot question on mandating nurse-to-patient ratios.

Nurse staffing ratios are one of the most hotly debated issues within the nursing profession. Those in favor say the limits improve patient safety and care. Those against them say ratios don’t account for patient acuity and would create a financial burden on hospitals and healthcare systems.

Now the public gets to weigh in on the issue. On Nov. 6, Massachusetts voters will face ballot Question 1, which would implement nurse to patient ratios in hospitals and other healthcare settings. The ratios vary according to the type of unit and level of care provided.

The Massachusetts Nurses Association supports the law, while hospitals, health systems and some other nursing professional organizations oppose it.

Both sides have pumped millions of dollars into the debate.

Voters seem to be split on the issue as well.

According to an October 25 to 28  WBUR poll,  58% of voters say they are against Question 1. This is a change from September when respondents to a previous WBUR poll were more evenly split with 44% in favor, 44% against, and 12% undecided.

Massachusetts is not completely unfamiliar with nurse-patient staffing ratios. In 2014, Massachusetts passed a law requiring 1-to-1 or 2-to-1 patient-to-nurse staffing ratios in intensive care units, as guided by a tool that accounts for patient acuity and anticipated care intensity.

However, an analysis by physician-researchers at Beth Israel Deaconess Medical Center found those regulations were not associated with improvements in patient outcomes.

Should the law pass, Massachusetts will join California as the only other state to require this level of mandatory ratios. In California, the law supporting ratios was passed in 1999 and was then rolled out in a staggered fashion until it was in full-effect in 2004.

Will mandatory ratios become a reality for those in the Baystate? That will be known, most-likely, in just a few short days.

 

 

Teaching Hospitals Cost More, but Could Save Your Life

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Teaching Hospitals Cost More, but Could Save Your Life

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Perhaps not evident to many patients, there are two kinds of hospitals — teaching and nonteaching — and a raging debate about which is better. Teaching hospitals, affiliated with medical schools, are the training grounds for the next generation of physicians. They cost more. The debate is over whether their increased cost is accompanied by better patient outcomes.

Teaching hospitals cost taxpayers more in part because Medicare pays them more, to compensate them for their educational mission. They also tend to command higher prices in the commercial market because the medical-school affiliation enhances their brand. Their higher prices could even cost patients more, if they are paying out of pocket.

To save money, insurers have started establishing hospital networks, and policy makers are considering ways to steer patients away from teaching hospitals. Those efforts may well save patients and taxpayers money. But how will that affect the quality of care?

One answer is provided in a new study of over 21 million hospital visits paid for by Medicare in 2012 and 2013. Teaching hospitals save lives. For every 83 elderly patients seen by a major teaching hospital, one more is alive 30 days after discharge than if those patients had been admitted to a nonteaching hospital. This is a large mortality effect.

“It’s about half the size of a breakthrough medical therapy like stenting for heart-attack patients,” said Amitabh Chandra, an economist with the Harvard Kennedy School and a longtime skeptic of the value of teaching hospitals, who wasn’t involved in this study.

“Minor” teaching hospitals — which also have educational missions but are not members of the Council of Teaching Hospitals and Health Systems — also outperformed nonteaching hospitals, but by a smaller margin.

The study, published in the Journal of the American Medical Association, adjusted for other factors that could have skewed the results, like demographics, patients’ diagnoses, hospital size and profit status. Because mortality rates differ geographically, it compared teaching with nonteaching hospitals within the same state. Even after such adjustments, it found mortality rates are lower at teaching hospitals for 11 of 15 common medical conditions and five of six major surgical conditions. The more doctors in training per bed a hospital had, the lower its mortality rate.

Given the importance of this issue, you’d think we would already know the mortality differences between teaching and nonteaching hospitals. But the seminal studies on the subject are based on data at least two decades old. Other, more recent studies focus on only a few types of patients or offer conflicting results.

“We thought the comparative performance of teaching and nonteaching hospitals was worth a fresh look because medicine has changed considerably since those older studies,” said Laura Burke, the lead author on the study and an emergency physician with the Harvard T.H. Chan School of Public Health. “And the more recent studies don’t settle the question.” (I am a co-author on the study, along with Dr. Burke and other Harvard colleagues Dhruv Khullar, E. John Orav and Ashish Jha. Dr. Khullar is also an Upshot contributor.) The study was funded by the American Association of Medical Colleges, which had no editorial control over analysis or publication.

Though the study revealed mortality differences by teaching status, it could not illuminate the cause of those differences. Perhaps teaching hospitals attract higher-quality practitioners, more closely follow best practices, or use medical technology more effectively.

Other studies suggest teaching hospitals do not offer higher quality more broadly. For example, an analysis led by Jose Figueroa, a physician with the Harvard T.H. Chan School of Public Health, found that teaching hospitals were more likely to be penalized by Medicare for low quality compared with nonteaching hospitals. Another study found teaching hospitals were more likely to be penalized for higher hospital readmission rates.

An examination of Massachusetts hospitals found comparable quality performance at teaching and nonteaching hospitals. The state has a goal — codified in a 2012 state law — of bringing health care spending growth in line with overall economic growth. The Massachusetts Health Policy Commission has highlighted the high costs of teaching hospitals as part of this effort.

The new study did not assess the cost of the benefits in mortality that teaching hospitals deliver.

“The typical teaching hospital is at least 30 percent more expensive,” Mr. Chandra said. “Is 1 percent fewer deaths worth that price?” It’s a question few like to ask, but spending more on hospital care means less for other things we value — and that are known to improve health and welfare, too — like education and nutrition programs.

About 26 percent of hospitals are teaching hospitals, accounting for just over half of all admissions. Unsure which hospitals in your area are teaching hospitals? It’s something most of them make a point of mentioning, so you can often find a hospital’s teaching status on its website. If not, an inquiry to the hospital should settle the matter. If you use one, the cost of your care will be higher, but it might save your life.