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OBJECTIVE: To examine how estimates of the association between nurse staffing and patient length of stay (LOS) change with data aggregation over varying time periods and settings, and statistical controls for unobserved heterogeneity. DATA SOURCES/STUDY SETTING: Longitudinal secondary data from October 2002 to September 2006 for 215 intensive care units and 438 general acute care units at 143 facilities in the Veterans Affairs (VA) health care system. RESEARCH DESIGN: This retrospective observational study used unit‐level panel data to analyze the association between nurse staffing and LOS. This association was measured over both a month‐long and a year‐long period, with and without fixed effects. DATA COLLECTION: We used VA administrative data to obtain patient data on the severity of illness and LOS, as well as labor hours and wages for each unit by month. PRINCIPAL FINDINGS: Overall, shorter LOS was associated with higher nurse staffing hours and lower proportions of hours provided by licensed professional nurses (LPNs), unlicensed personnel, and contract staff. Estimates of the association between nurse staffing and LOS changed in magnitude when aggregating data over years instead of months, in different settings, and when controlling for unobserved heterogeneity. CONCLUSIONS: Estimating the association between nurse staffing and LOS is contingent on the time period of analysis and specific methodology. In future studies, researchers should be aware of these differences when exploring nurse staffing and patient outcomes.

BACKGROUND: Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis. OBJECTIVE: To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis. DESIGN: Retrospective cohort study using multivariable analysis of clinical data. PARTICIPANTS: A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection. SETTING: Four university hospitals in California between 2014 and 2016. MAIN OUTCOMES AND MEASURES: The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen. KEY RESULTS: Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29–0.38, p

Background There has been little research on the relationship between education and healthcare utilization, especially for racial/ethnic minorities. This study aimed to examine the association between education and hospitalizations, investigate the mechanisms, and disaggregate the relationship by gender, race/ethnicity, and age groups. Methods A retrospective cohort analysis was conducted using data from the 1992-2016 US Health and Retirement Study. The analytic sample consists of 35,451 respondents with 215,724 person-year observations. We employed a linear probability model with standard errors clustered at the respondent level and accounted for attrition bias using an inverse probability weighting approach. Results On average, compared to having an education less than high school, having a college degree or above was significantly associated with an 8.37 pp (95% CI, -9.79 pp to -7.95 pp) lower probability of being hospitalized, and having education of high school or some college was related to 3.35 pp (95% CI, -4.57 pp to -2.14 pp) lower probability. The association slightly attenuated after controlling for income but dramatically reduced once holding health conditions constant. Specifically, given the same health status and childhood environment conditions, compared to those with less than high school degree, college graduates saw a 1.79 pp (95% CI, -3.16 pp to -0.42 pp) lower chance of being hospitalized, but the association for high school graduates became indistinguishable from zero. Additionally, the association was larger for females, whites, and those younger than 78. The association was statistically significantly smaller for black college graduates than their white counterparts, even when health status is held constant. Conclusions Educational attainment is a strong predictor of hospitalizations for middle-aged and older US adults. Health mediates most of the education-hospitalization gradients. The heterogeneous results across age, gender, race, and ethnicity groups should inform further research on health disparities.

BackgroundThe association of nursing staffing with patient outcomes has primarily been studied by comparing high to low staffed hospitals, raising concern other factors may account for observed differences. We examine the association of inpatient mortality with patients’ cumulative exposure to shifts with low registered nurse (RN) staffing, low nursing support staffing and high patient turnover.MethodsCumulative counts of exposure to shifts with low staffing and high patient turnover were used as time-varying covariates in survival analysis of data from a three-campus US academic medical centre for 2007–2012. Staffing below 75% of annual median unit staffing for each staff category and shift type was characterised as low. High patient turnover per day was defined as admissions, discharges and transfers 1 SD above unit annual daily averages.ResultsModels included cumulative counts of patient exposure to shifts with low RN staffing, low nursing support staffing, both concurrently and high patient turnover. The HR for exposure to shifts with low RN staffing only was 1.027 (95% CI 1.002 to 1.053, pConclusionLow RN and nursing support staffing were associated with increased mortality. The results should encourage hospital leadership to assure both adequate RN and nursing support staffing.

Background The Veterans Health Administration (VA) primary care is organized as a Patient Centered Medical Home (PCMH) that is based on continuity management of patient panels by interdisciplinary “teamlets” consisting of primary care providers, nurses, and clerical associates. While the teamlets are envisioned as interdisciplinary in this model, teamlet members may continue to report separately to middle management supervisors within their respective disciplines. Little is known about the role of middle managers in medical home implementation; therefore, the study purpose is to examine and characterize teamlet members’ perceptions of middle managers’ role in primary care operations and teamlet functioning in an outpatient setting. Methods This study applied a formal qualitative data collection method and analysis based on semi-structured interviews of 79 frontline interdisciplinary staff (primary care providers, nurses, and clerical associates) in VA Patient Aligned Care Teams (PACT) teamlets. Interviews were analyzed using a method of constant comparison. Results Teamlet members recognize that their supervising middle managers are essential to daily functioning of PACT teamlets in terms of clarifying roles and responsibilities, setting expectations, providing coverage strategies, supporting conflict resolution, and facilitating teamlet-initiated innovation. Teamlet members identified challenges when middle manager involvement was lacking. Conclusion Within a multilevel system, frontline interdisciplinary staff continue to perceive the need for leadership by middle managers from their own professional disciplines for solving interdisciplinary problems, setting role-specific schedules and expectations, and fostering innovation. As such, greater focus on the structure and training of middle managers for participation in PCMH models is needed.

BackgroundAsthma disproportionately affects individuals with lower income. High uninsured rates are a potential driver for this disparity. Previous studies have not examined the effect of the Affordable Care Act (ACA) on asthma-related outcomes for individuals with low income.Research questionWhat is the impact of insurance status and the ACA on asthma outcomes for adults 18 to 64 years of age in households with low-income status?Study design and methodsThis study was a pooled cross-sectional observational study using National Health Interview Survey data from 2011 through 2013 and 2016 through 2018. Individuals 18 to 64 years of age with a history of asthma and low income were included. Survey-weighted regression modeling and mediation analysis was used to explore the relationship of insurance status and asthma control. Univariate and multivariate survey-weighted regression modeling then was used to evaluate the correlation of the ACA and asthma outcomes.ResultsWe identified 4,043 individual observations. Having health insurance was correlated with improved asthma outcomes (OR, 1.25). This relationship was completely mediated by cost barriers to medications and physician visits. Although the ACA resulted in significant changes in insurance status (OR, 2.4), no statistically significant change was found in asthma outcomes. Furthermore, cost barriers to both medications and physician visits persisted in the insured population, 20.7%and 30.0%, respectively.InterpretationInsurance coverage is associated with improved asthma control for adults 18 to 64 years from households with low socioeconomic status. The ACA reduced the rates of uninsured, but did not have the same magnitude of effect on reducing cost barriers. The persistence of cost barriers may explain in part the lack of population-level improvement in asthma control.

Author(s): Keller, Michelle S; Chen, Xiao; Godwin, Jamie; Needleman, Jack; Pourat, Nadereh | Abstract: ObjectiveThe California Delivery System Reform Incentive Payment Program (DSRIP) provided incentive payments to Designated Public Hospitals (DPHs) to improve quality of care. We assessed the program's impact on reductions in sepsis mortality, central line-associated bloodstream infections (CLABSIs), venous thromboembolisms (VTEs), and hospital-acquired pressure ulcers (HAPUs).Data sourcesWe used 2009-2014 discharge data from California hospitals.Study designWe used a pre-post study design with a comparison group. We constructed propensity scores and used them to assign inverse probability weights according to their similarity to DPH discharges. Interaction term coefficients of time trends and treatment group provided significance testing.Data extractionWe used Patient Safety Indicators for CLABSI, HAPU, and VTE, and constructed a sepsis mortality measure.Principal findingsDischarges from DPHs and non-DPHs both saw decreases in the four outcomes over the DSRIP period (2010-2014). The difference-in-difference estimator (DD) for sepsis was only significant during two time periods, comparing 2010 with 2012 (DD: -2.90 percent, 95% CI: -5.08, -0.72 percent) and 2010 with 2014 (DD: -5.74, 95% CI: -8.76 percent, -2.72 percent); the DD estimator was not significant comparing 2010 with 2012 (DD: -1.30, 95% CI: -3.18 percent, 0.58 percent) or comparing 2010 with 2013 (DD: -3.05 percent, 95% CI: -6.50 percent, 0.40 percent). For CLABSI, we did not find any meaningful differences between DPHs and non-DPHs across the four time periods. For HAPU and VTE, the only significant DD estimator compared 2014 with 2010.ConclusionsWe did not find that DPHs participating in DSRIP outperformed non-DPHs during the DSRIP program. Our results were robust to multiple sensitivity analyses. Given multiple concurrent inpatient safety initiatives, it was challenging to assign improvements over time periods to DSRIP.

Prior research has found that 25% of women veterans who are new to the Department of Veterans Affairs (VA) health care system discontinue services within 3 years of initial use. Although it has been suggested that providing more gender-sensitive care might improve women veterans' health care experiences, no study has yet documented an empirical relationship between clinic and provider factors associated with the provision of gender-sensitive care and women veterans' care discontinuity.Surveys of primary care providers (n = 82) and staff members (n = 108) from 12 VA medical centers were linked to administrative data for women veteran patients with at least one primary care visit in 2014 and 2015 (n = 9,958). Patient care discontinuity was operationalized as having no additional primary care visit within 3 years after the patient's baseline visit. Key indicators of gender-sensitive comprehensive primary care included type of medical home (women's health-focused vs. general primary care), workforce gender sensitivity, team functioning, perceived quality of provider/staff communication, leadership support for medical home implementation, and other structural components of care delivery (e.g., chaperone availability). We used logistic regression to assess the association between these indicators and women's care discontinuity, measuring discontinuity for both new and continuing VA users and controlling for patient characteristics.Eleven percent of women patients discontinued primary care within 3 years. Poor workforce gender sensitivity (lowest quartile vs. top three quartiles) was significantly associated with higher odds of discontinuity (odds ratio, 1.26; 95% confidence interval, 1.01-1.57); other indicators were not associated with discontinuity.This study is the first to document a relationship between workforce gender sensitivity and women veterans' care continuity. This finding underscores the need for additional attention to enhancing workforce gender sensitivity in VA.

Background: While administrators of pay-for-performance may have good intentions, physicians may be reluctant to participate for various reasons, including poor program alignment with realities of clinical practice. In this study, we sought to characterize how primary care physicians (PCPs) participating in Medicare9s Merit-Based Incentive Payment System (MIPS) conceptualize the quality of health care to help inform future measurement strategies that physicians would understand and appreciate. Methods: We performed semi-structured qualitative interviews with a nationwide sample of 20 PCPs in MIPS. We asked PCPs how they would characterize quality and what distinguished exceptional, good, and poor quality. Interviews were transcribed and 2 coders independently read transcripts, allowing data to emerge from the interviews and developing theories about the data. The coders met intermittently to discuss findings, harmonize the coding scheme, develop a final list of themes and subthemes, and aggregate a list of representative quotations. Results: Participants described quality as consisting of 2 components: (1) evidence-based care that is safe, which included health maintenance and chronic disease control, accurate diagnoses, and guideline adherence, and (2) patient-centered care, which included spending enough time with patients, responding to patient concerns, and establishing long-term relationships founded on trust. Conclusions: PCPs consider patient-centered care necessary for the provision of exceptional quality. Program administrators for quality measurement and pay-for-performance programs should explore new ways to reward PCPs for providing outstanding patient-centered care. Future research should be undertaken to determine whether patient-centered activities such as forging long-term, favorable patient-physician relationships, are associated with improved health outcomes.

Background/objectives To evaluate differences in end-of-life cost trajectories for cancer patients treated through Medicare versus by the Veterans Health Administration (VA). Design A retrospective analysis of VA and Medicare administrative data from FY 2010 to 2014. We employed three-level generalized estimating equations to evaluate monthly cost trajectories experienced by patients in their last year of life, with patients nested within hospital referral region. Setting Care received at VA facilities or by Medicare-reimbursed providers nationwide. Participants A total of 36,401 patients dying from cancer and dually enrolled in VA and Medicare. Measurements We evaluated trajectories for total, inpatient, outpatient, and drug costs, using the last 12 months of life. Cost trajectories were prioritized as costs are not directly comparable across Medicare and VA. Patients were assigned to be VA-reliant, Medicare-reliant or Mixed-reliant based on their healthcare utilization in the last year of life. Results All three groups experienced significantly different cost trajectories for total costs in the last year of life. Inpatient cost trajectories were significantly different between Medicare-reliant and VA-reliant patients, but did not differ between VA-reliant and Mixed-reliant patients. Outpatient and drug cost trajectories exhibited the inverse pattern: they were significantly different between VA-reliant and Mixed-reliant patients, but not between VA-reliant and Medicare-reliant patients. However, visual examination of cost trajectories revealed similar cost patterns in the last year of life among all three groups; there was a sharp rise in costs as patients approach death, largely due to inpatient care. Conclusion Despite substantially different financial incentives and organization, VA- and Medicare-treated patients exhibit similar patterns of increasing end-of-life costs, largely driven by inpatient costs. Both systems require improvement to ensure quality of end-of-life care is aligned with recommended practice.

Objective Compare comorbidity identification in Medicare and Veterans Health Administration (VA) data for the purposes of risk adjustment. Data sources Analysis of Medicare and VA datasets for dually-enrolled Veterans receiving care in both settings, fiscal years 2010-2014. Study design A retrospective analysis of administrative data for a national sample of cancer decedents. Data extraction methods Comorbidities were evaluated using Elixhauser and Charlson coding algorithms. Principal findings Clinical comorbidities were more likely to be recorded in Medicare than in VA datasets. Of 42 comorbidities, 36 (86%) were recorded at a different frequency. For example, congestive heart failure was recorded for 22.0% of patients in Medicare data and for 11.3% of patients in VA data (P Conclusion There are large differences in comorbidity assessment across VA and Medicare administrative data for the same patient, posing challenges for risk adjustment.

Background Gender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- and individual-level characteristics associated with gender sensitivity of primary care providers (PCPs) and staff. Methods We surveyed PCPs and staff (nurses, medical assistants, and clerks) at 12 VA medical centers (VAMCs) (n = 256 of 649; response rate, 39%). Gender sensitivity was measured using a 10-item scale adapted from the Gender Awareness Inventory-VA. We used weighted multivariate regression with maximum likelihood estimation to identify individual- and practice-level characteristics associated with gender sensitivity of PCPs and staff. Results PCPs and staff had similar gender sensitivity but differed in most characteristics associated with that gender sensitivity. Among PCPs, women's health training and positive communication with others in the clinic were associated with greater gender sensitivity. For staff, prior work experience caring for women, working in Women's Health Patient-Aligned Care Teams, and rural location were associated with greater gender sensitivity, whereas more years of VA service was associated with lower gender sensitivity. Working at VA medical centers with a higher volume of women veteran patients was associated with greater gender sensitivity for both PCPs and staff. Conclusions Women's health training and experience in working with other women's health professionals are strongly correlated with greater gender sensitivity in the clinical workforce.

Author(s): Squitieri, Lee; Waxman, Daniel A; Mangione, Carol M; Saliba, Debra; Ko, Clifford Y; Needleman, Jack; Ganz, David A | Abstract: OBJECTIVES:To evaluate national present-on-admission (POA) reporting for hospital-acquired pressure ulcers (HAPUs) and examine the impact of quality measure exclusion criteria on HAPU rates. DATA SOURCES/STUDY SETTING:Medicare inpatient, outpatient, and nursing facility data as well as independent provider claims (2010-2011). STUDY DESIGN:Retrospective cross-sectional study. DATA COLLECTION/EXTRACTION METHODS:We evaluated acute inpatient hospital admissions among Medicare fee-for-service (FFS) beneficiaries in 2011. Admissions were categorized as follows: (1) no pressure ulcer diagnosis, (2) new pressure ulcer diagnosis, and (3) previously documented pressure ulcer diagnosis. HAPU rates were calculated by varying patient exclusion criteria. PRINCIPAL FINDINGS:Among admissions with a pressure ulcer diagnosis, we observed a large discrepancy in the proportion of admissions with a HAPU based on hospital-reported POA data (5.2 percent) and the proportion with a new pressure ulcer diagnosis based on patient history in billing claims (49.7 percent). Applying quality measure exclusion criteria resulted in removal of 91.2 percent of admissions with a pressure injury diagnosis from HAPU rate calculations. CONCLUSIONS:As payers and health care organizations expand the use of quality measures, it is important to consider how the measures are implemented, coding revisions to improve measure validity, and the impact of patient exclusion criteria on provider performance evaluation.

BackgroundHospital-acquired pressure injuries (HAPIs) are publicly reported in the USA and used to adjust Medicare payment to acute inpatient facilities. Current methods used to identify HAPIs in administrative claims rely on hospital-reported present-on-admission (POA) data instead of prior patient health information.ObjectiveTo study the reliability of claims data for HAPIs and pressure injury (PI) stage by evaluating diagnostic coding agreement across interfacility transfers.MethodsUsing the 2012 100% Medicare Provider and Analysis Review file, we identified all fee-for-service acute inpatient discharge records with a PI diagnosis among Medicare patients 65 years and older. We then identified additional facility claims (eg, acute inpatient, long-stay inpatient or skilled nursing facility) belonging to the same patient who had either (1) admission within 1day of hospital discharge or (2) discharge within 1day of hospital admission. Multivariable logistic regression and stratified kappa statistics were used to measure coding agreement between transferring and receiving facilities in the presence or absence of a PI diagnosis at the time of patient transfer and PI stage category (early vs advanced).ResultsIn our comparison of claims data between transferring and receiving facilities, we observed poor agreement in the presence or absence of a PI diagnosis at the time of transfer (36.3%, kappa=0.03) and poor agreement in PI stage category (74.3%, kappa=0.17). Among transfers with a POA PI reported by the receiving hospital, only 34.0% had a PI documented at the prior transferring facility.ConclusionsThe observed discordance in PI documentation and staging between transferring and receiving facilities may indicate inaccuracy of HAPI identification in claims data. Future research should evaluate the accuracy of hospital-reported POA data and its impact on PI quality measurement.

Objective The aim of this study is to examine the relationship between nursing time use and perceptions of missed care. Background Recent literature has highlighted the problem of missed nursing care, but little is known about how nurses' time use patterns are associated with reports of missed care. Methods In 15 nursing units at 2 hospitals, we assessed registered nurse (RN) perceptions of missed care, observed time use by RNs, and examined the relationship between time spent and degree of missed care at the nursing unit level. Results Patterns of time use were similar across hospitals, with 25% of time spent on documentation. For 6 different categories of nursing tasks, no association was detected between time use, including time spent on documentation, and the degree of missed care at the nursing unit level. Conclusions Nursing time use cannot fully explain variation in missed care across nursing units. Further work is needed to account for patterns of missed care.

Primary care is evolving in response to payment reform, changes in the primary care workforce, and development of new models of work emphasizing team care. The role of registered nurses in these new models is being reexamined and reimagined, with increased registered nurse engagement in chart review prior to visits, histories and physicals, preliminary patient assessment, patient education and coaching in ordered care, delivery of care under standardized orders and protocols, transition planning, and care coordination. The business case for employing registered nurses in these new roles has not been fully addressed. This article examines the business case and financial issues in this expansion of practice. Under both fee-for-service and value-based, capitated, or shared saving models of reimbursement, there are strategies for increasing the number of registered nurses in primary care practices, and expanding the engagement of registered nurses that can increase net revenues for primary care practices, even when the costs of the additional staffing are taken into account.

The Emergency Medical Treatment and Labor Act (EMTALA), which requires Medicare-participating hospitals to provide emergency care to patients regardless of their ability to pay, plays an important role in protecting the uninsured. Yet many hospitals do not comply. This study examines the reasons for noncompliance and proposes solutions. We conducted eleven semi-structured key informant interviews with hospitals, hospital associations, and patient safety organizations in the Centers for Medicare & Medicaid Services region with the highest number of EMTALA complaints filed. Respondents identified five main causes of noncompliance: financial incentives to avoid unprofitable patients, ignorance of EMTALA’s requirements, high referral burden at hospitals receiving EMTALA transfer patients, reluctance to jeopardize relationships with transfer partners by reporting borderline EMTALA violations, and opposing priorities of hospitals and physicians. Respondents suggested five methods to improve compliance, including educating subspecialists about EMTALA, informally educating hospitals about borderline violations, and incorporating EMTALA-compliant processes into hospital operations such as by routing transfer requests through the emergency department. To improve compliance we suggest: 1) more closely aligning Medicaid/Medicare payment policies with EMTALA, 2) amending the Act to permit informal mediation between hospitals about borderline violations, 3) increasing the hospital’s role in ensuring EMTALA compliance, and 4) expanding the role of hospital associations.

© 2014 Society for Adolescent Health and Medicine. Conclusions Nationwide, states responded to the new HPV vaccine by introducing policies designed to increase the availability of information about the vaccine, provide funding, and regulate private insurance coverage rather than require vaccination for school entry.Purpose To examine the policies state governments pursued and enacted across the United States in the 5-year period after the U.S. Food and Drug Administration licensed the human papillomavirus (HPV) vaccine in 2006, including the timing and number of bills introduced, the policies proposed, and the legislative success of HPV vaccine policy proposals.Methods Content abstraction and analysis of state-level HPV vaccine-related bills across the 50 states and the District of Columbia introduced between 2006 and 2010.Results All but five states (Alaska, Delaware, Idaho, New Hampshire, and Wyoming) introduced HPV vaccine bills between 2006 and 2010. Two-thirds of all bills were introduced in 2007. In all, 141 bills were introduced and 23% or 32 bills were enacted. Of the bills that were enacted, 43.8% provided information for parents and schools about the vaccine; 37.5% provided public financing for HPV vaccines; 34.4% were classified as other policies; 25% created awareness campaigns; 25% required private insurance coverage of the HPV vaccination; 12.5% included voluntary vaccination, and 9.4% mandated vaccination for school entry. One bill reversed prior mandatory vaccination policies. Overall, 91% of enacted HPV vaccine bills did not refer to mandated vaccinations but adopted alternate policy strategies in response to the availability of the new HPV vaccine.

Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid (known as Medicaid shortfalls). The Affordable Care Act (ACA) anticipates that insurance expansion will increase safety-net hospitals' revenues and will reduce DSH payments accordingly. We examined the impact of the ACA's Medicaid DSH reductions on California public hospitals' financial stability by estimating how total DSH costs (uncompensated care costs and Medicaid shortfalls) will change as a result of insurance expansion and the offsetting DSH reductions. Decreases in uncompensated care costs resulting from the ACA insurance expansion may not match the act's DSH reductions because of the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation. Taking these three factors into account, we estimate that California public hospitals' total DSH costs will increase from $2.044 billion in 2010 to $2.363-$2.503 billion in 2019, with unmet DSH costs of $1.381-$1.537 billion.

Key Points Question What is the cost associated with National Quality Forum–identified intensive medical services in the last month of life to beneficiaries and to the health care system? Findings In this cohort study of 48 937 patients with cancer enrolled in Medicare and the Veterans Health Administration, those receiving no intensive service had a health system cost of $7660, whereas for the 59% of patients receiving 1 or more intensive services in the last month of life, the cost was $23 612. Expected beneficiary costs in the last month of life were $133 for patients with no intensive service and $1257 for patients with at least 1 intensive service. Meaning Despite recommendations, more than half of patients with cancer receive intensive services at the end of life at a substantial cost to beneficiaries and the heath system., Importance Despite recommendations to reduce intensive medical treatment at the end of life, many patients with cancer continue to receive such services. Objective To quantify expected beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life. Design, Setting, and Participants This retrospective cohort study used data collected nationally from Medicare and the Veterans Health Administration for care provided in fiscal years 2010 to 2014. Participants were 48 937 adults aged 66 years or older who died of solid tumor and were continuously enrolled in fee-for-service Medicare and the Veterans Health Administration in the 12 months prior to death. The data were analyzed from February to August 2019. Exposures American Society of Clinical Oncology metrics regarding medically intensive services provided in the last month of life, including hospital stay, intensive care unit stay, chemotherapy, 2 or more emergency department visits, or hospice for 3 or fewer days. Main Outcomes and Measures Costs in the last month of life associated with receipt of intensive medical services were evaluated for both beneficiaries and the health system. Costs were estimated from generalized linear models, adjusting for patient demographics and comorbidities and conditioning on geographic region. Results Of 48 937 veterans who received care through the Veterans Health Administration and Medicare, most were white (90.8%) and male (98.9%). More than half (58.9%) received at least 1 medically intensive service in the last month of life. Patients who received no medically intensive service generated a mean (SD) health system cost of $7660 ($1793), whereas patients who received 1 or more medically intensive services generated a mean (SD) health system cost of $23 612 ($5528); thus, the additional financial consequence to the health care system for medically intensive services was $15 952 (95% CI, $15 676-$16 206; P, To provide physicians with reference cost estimates, this cohort study quantifies beneficiary and health system costs incurred in association with receipt of intensive medical services in the last month of life among patients with advanced cancer.

Residential segregation is associated geographic disparities in access to care, but its impact on local health care policy, including public hospitals, is unknown. We examined the effects of racial residential segregation on U.S. urban public hospital closures from 1987 to 2007, controlling for hospital, market, and policy characteristics. We found that a high level of residential segregation moderated the protective effects of Black population composition, such that a high level of residential segregation, in combination with a high percentage of poor residents, conferred a higher likelihood of hospital closure. More segregated and poorer communities face disadvantages in access to care that may be compounded as a result of instability in the health care safety net. Policy makers should consider the influence of social factors such as residential segregation on the allocation of the safety net resources.

Article-at-a-Glance Background Process improvement stresses the importance of engaging frontline staff in implementing new processes and methods. Yet questions remain on how to incorporate these activities into the workday of hospital staff or how to create and maintain its commitment. In a 15-month American Organization of Nurse Executives collaborative involving frontline medical/surgical staff from 67 hospitals, Transforming Care at the Bedside (TCAB) was evaluated to assess whether participating units successfully implemented recommended change processes, engaged staff, implemented innovations, and generated support from hospital leadership and staff. Methods In a mixed-methods analysis, multiple data sources, including leader surveys, unit staff surveys, administrative data, time study data, and collaborative documents were used. Results All units reported establishing unit-based teams, of which > 90% succeeded in conducting tests of change, with unit staff selecting topics and making decisions on adoption. Fifty-five percent of unit staff reported participating in unit meetings, and 64%, in tests of change. Unit managers reported substantial increase in staff support for the initiative. An average 36 tests of change were conducted per unit, with 46% of tested innovations sustained, and 20% spread to other units. Some 95% of managers and 97% of chief nursing officers believed that the program had made unit staff more likely to initiate change. Among staff, 83% would encourage adoption of the initiative. Conclusions Given the strong positive assessment of TCAB, evidence of substantial engagement of staff in the work, and the high volume of innovations tested, implemented, and sustained, TCAB appears to be a productive model for organizing and implementing a program of frontline-led improvement.

In 2007, the Department of Veterans Affairs (VA) established the VA Nursing Academy (VANA), a 5-year, $60-million pilot program funding 15 partnerships between schools of nursing and local VA health care facilities nationwide, to expand nursing faculty, enhance clinical faculty development, increase nursing student enrollment, and promote educational innovations. VA is an ideal setting for educating nursing students owing to a well-educated registered nurse staff, an array of traditional and nontraditional settings, a state-of-the-art computerized electronic health record system, and a unique patient population. Challenges related to the complex nature of VANA partnerships, conceptualized as strategic alliances created between disparate subunits, each embedded in a larger organization, require careful governance to ensure smooth implementation. To ensure the program’s aims are met, a 6-year national evaluation has been funded to help identify which strategies best achieve VANA’s goals. The speed of economic recovery and the resulting changes in the nursing workforce are important determinants of VANA’s future.

OBJECTIVE Studies suggest that a business case for improving nurse staffing can be made to increase registered nurse (RN) skill mix without changing total licensed nursing hours. It is unclear whether a business case for increasing RN skill mix can be justified equally among patients of varying health needs. This study evaluated whether nursing hours per patient day (HPPD) and skill mix are associated with higher inpatient care costs within acute medical/surgical inpatient units using data from the Veterans Health Administration. METHODS Retrospective cross-sectional study, including 139,360 inpatient admissions to 292 acute medical/surgical units at 125 Veterans Health Administration medical centers between February and June 2003, was conducted. Dependent variables were inpatient costs per admission and costs per patient day. RESULTS The average costs per surgical and medical admission were $18,624 and $6,636, respectively. Costs per admission were positively associated with total nursing HPPD among medical admissions ($164.49 per additional HPPD, P

Cross-sectional studies of hospital-level administrative data have shown an association between lower levels of staffing of registered nurses (RNs) and increased patient mortality. However, such studies have been criticized because they have not shown a direct link between the level of staffing and individual patient experiences and have not included sufficient statistical controls.We used data from a large tertiary academic medical center involving 197,961 admissions and 176,696 nursing shifts of 8 hours each in 43 hospital units to examine the association between mortality and patient exposure to nursing shifts during which staffing by RNs was 8 hours or more below the staffing target. We also examined the association between mortality and high patient turnover owing to admissions, transfers, and discharges. We used Cox proportional-hazards models in the analyses with adjustment for characteristics of patients and hospital units.Staffing by RNs was within 8 hours of the target level for 84% of shifts, and patient turnover was within 1 SD of the day-shift mean for 93% of shifts. Overall mortality was 61% of the expected rate for similar patients on the basis of modified diagnosis-related groups. There was a significant association between increased mortality and increased exposure to unit shifts during which staffing by RNs was 8 hours or more below the target level (hazard ratio per shift 8 hours or more below target, 1.02; 95% confidence interval [CI], 1.01 to 1.03; P0.001). The association between increased mortality and high patient turnover was also significant (hazard ratio per high-turnover shift, 1.04; 95% CI, 1.02 to 1.06; P0.001).In this retrospective observational study, staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients' needs for nursing care. (Funded by the Agency for Healthcare Research and Quality.).

Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units.To evaluate the association of in-hospital patient mortality with registered nurse staffing and skill mix comparing hospital and unit level analysis using data from the Veterans Health Administration (VHA).A retrospective observational study using administrative data from 129,579 patients from 453 nursing units (171 ICU and 282 non-ICU) in 123 VHA hospitals.We used hierarchical multilevel regression models to adjust for patient, unit, and hospital characteristics, stratifying by whether or not patients had an ICU stay during admission.In-hospital mortality.: Of the 129,579 patients, mortality was 2.9% overall: 6.7% for patients with an ICU stay compared with 1.6% for those without. Whether the analysis was done at the hospital or unit level affected findings. RN staffing was not significantly associated with in-hospital mortality for patients with an ICU stay (OR, 1.02; 95% CI, 0.99-1.03). For non-ICU patients, increased RN staffing was significantly associated with decreased mortality risk (OR, 0.91; 95% CI, 0.86-0.96). RN education was not significantly associated with mortality.Our findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level. Variable staffing on non-ICU units may significantly contribute to in-hospital mortality risk.

Anesthesia provider models were characterized based on responsibilities and technique privileges and the distribution of clinical resource and process variables using a survey of 1,135 hospitals offering obstetric care in eight representative states. The resulting models were then analyzed by resource availability. In the 40% of hospitals where certified registered nurse anesthetists (CRNAs) and anesthesiologists both practiced obstetric anesthesia, three models emerged based on consistency of privileges within the institution and permission to initiate procedures. Hospitals in which only anesthesiologists practice and those in which CRNAs practice was most restricted had more resources than other hospitals surveyed. Traditional characterizations of provider fail to capture differences in technique privileges. Clinical resource variables and the scope of technique privileges should be included in the study of anesthesia provider credentials on outcomes.

This article examines the social and business case for quality related to nursing and the need to restructure incentives to align the interests of the hospital and payers with the interests of the patients. Increasing the proportion of nurses who are registered nurses is associated with net cost savings. Increasing both nursing hours and the proportion of nurses who are registered nurses would result in improved quality and fewer deaths (creating a social case for improved staffing) but would be associated with small cost increases. Cost offsets associated with reduced turnover because of higher staffing would reduce the net cost increase but not result in savings. Under current reimbursement systems, hospitals that increase nurse staffing to improve patient outcomes will likely lose money as a result. Current proposals for pay for performance would create limited incentives for improving hospital nursing care.

Healthcare administrators increasingly face the challenge of how to spread innovation throughout their organizations. The authors present the results of an evaluation of the efforts of 3 major hospital systems to internally disseminate nursing unit change among medical-surgical units. The findings show that all 3 organizations carefully planned, coordinated, and implemented a spread process; none left dissemination to chance. Although clear differences were evident in the way they engineered their spread, many similarities also were found.

Long-term care hospitals are postacute care facilities for patients requiring extended hospital-level care. These facilities are reimbursed by Medicare under a prospective payment system with a short-stay outlier policy, which results in substantially lower payments for patients discharged before a diagnosis-related group-specific short-stay threshold. Using Medicare data, we examined the impact of the short-stay policy on lengths-of-stay and Medicare reimbursement among patients in long-term care hospitals who require prolonged mechanical ventilation. After accounting for case-mix and facility-level differences, we found that discharges for reasons other than death in the period 2005-10 were most likely to occur on the day of or immediately after the short-stay threshold; this held true regardless of facility ownership. In contrast, live discharges in 2002—the year before the prospective payment system started phasing out cost-based payment—were evenly distributed around the day that later became the short-stay threshold. Our findings confirm that the short-stay outlier payment policy created a strong financial incentive for long-term care hospitals to time patient discharges to maximize Medicare reimbursement. The results suggest that the new very-short-stay policy implemented in December 2012 could have a similar effect.

We construct national estimates of the cost of increasing hospital nurse staffing and associated reductions in days, deaths, and adverse outcomes. Raising the proportion of nursing hours provided by registered nurses (RNs) without increasing total nursing hours is associated with a net reduction in costs. Increasing nursing hours, with or without increasing the proportion of hours provided by RNs, reduces days, adverse outcomes, and patient deaths, but with a net increase in hospital costs of 1.5 percent or less at the staffing levels modeled. Whether or not staffing should be increased depends on the value patients and payers assign to avoided deaths and complications.

Hospitals, nurses, the media, Congress, and the private sector are increasingly concerned about shortages of registered nurses (RNs) and the impact on safety and quality of patient care. Findings from a growing number of studies provide evidence of a relationship between hospital nurse staffing and adverse outcomes experienced by medical and surgical patients. These findings have policy implications for strengthening the nursing profession, monitoring the quality of hospital care associated with nursing, and improving the relationship between hospitals and the nursing profession.

This study aims to describe the magnitude of hospital costs among patients undergoing elective colectomy, cholecystectomy, and pancreatectomy, determine whether these costs relate as expected to duration of care, patient case-mix severity and comorbidities, and whether risk-adjusted costs vary significantly by hospital. Correctly estimating the cost of production of surgical care may help decision makers design mechanisms to improve the efficiency of surgical care.Patient data from 202 hospitals in the ACS-NSQIP were linked to Medicare inpatient claims. Patient charges were mapped to cost center cost-to-charge ratios in the Medicare cost reports to estimate costs. The association of patient case-mix severity and comorbidities with cost was analyzed using mixed effects multivariate regression. Cost variation among hospitals was quantified by estimating risk-adjusted hospital cost ratios and 95% confidence intervals from the mixed effects multivariate regression.There were 21,923 patients from 202 hospitals who underwent an elective colectomy (n = 13,945), cholecystectomy (n = 5,569), or pancreatectomy (n = 2,409). Median cost was lowest for cholecystectomy ($15,651) and highest for pancreatectomy ($37,745). Room and board costs accounted for the largest proportion (49%) of costs and were correlated with length of stay, R = 0.89, p0.001. The patient case-mix severity and comorbidity variables most associated with cost were American Society of Anesthesiologists (ASA) class IV (estimate 1.72, 95% CI 1.57 to 1.87) and fully dependent functional status (estimate 1.63, 95% CI 1.53 to 1.74). After risk-adjustment, 66 hospitals had significantly lower costs than the average hospital and 57 hospitals had significantly higher costs.The hospital costs estimates appear to be consistent with clinical expectations of hospital resource use and differ significantly among 202 hospitals after risk-adjustment for preoperative patient characteristics and procedure type.

Prior literature on social capital and health has predominantly focused on health outcomes and individual access to healthcare services. It is not known to what degree, if any, community social capital influences the performance or behaviors of public hospitals, a key source of healthcare for disadvantaged communities in the United States. In this study we developed measures of community bridging social capital – horizontal social networks between heterogeneous groups of similar social position – and linking social capital – vertical networks across the status hierarchy – relevant to public hospitals. We examined associations between social capital, and U.S. urban public hospital closures and conversions to private ownership from 1987 to 2007. We found that higher voting participation was associated with a greater hazard of public hospital closure over time (p < 0.01), whereas the number of business, professional and political organizations per 10,000 residents was associated a greater hazard of conversion (p < 0.05). Additional measures of bridging and linking social capital were not associated with either outcome. Taken together, our findings suggest that, at least historically, horizontal forms of social capital among more privileged groups (e.g., business, professional, and political associations) bear influence on public hospital outcomes. Specific efforts to increase engagement of disadvantaged groups and connect them with decision-makers may be needed to fully realize the potential of linking social capital to influence local healthcare policy promoting social protection.

As the work environment for nurses continues to evolve, the demands on nurses increase along with the potential for nurses to become more distant from their patients. Among the key changes in the environment are the increasing acuity of patients in all settings, the introduction and evolution of the electronic health record, the expansion of telemetry and smart bed technology, increased use of video monitoring and telemedicine, and changes in payment that will focus attention on specific aspects of care. Nurses and nursing departments will need to aggressively manage the changing environment so that patient care is enhanced. How these demands and new technologies can be harnessed to enhance the patient experience and the quality of the nurse-patient interaction is a central question that will shape the future of nursing.

Background The Agency for Healthcare Research and Quality (AHRQ) patient safety indicator "death among surgical inpatients with serious treatable complications" (failure-to-rescue) uses rules to exclude complications presumed to be present-on-admission (POA). Like other administrative data-based quality measures, exclusion rules were developed with limited information on whether complications were POA. We examine whether the accuracy of failure-to-rescue exclusion rules can be improved with data with good POA indicators. Methods POA-coded data from 243,825 discharges from a large academic medical center were used to develop 3 failure-to-rescue exclusion rules. Data from 82,871 discharges from California hospitals screened for good POA coding practices was used as a validation sample. The AHRQ failure-to-rescue measure and 3 new measures based on alternative exclusion rules were compared on sensitivity, specificity, and C-statistics for prediction of POA status. Using data from the AHRQ HCUP National Inpatient Sample, the alternative specifications were tested for sensitivity to nurse staffing. Results The AHRQ exclusion rules had sensitivity of 18.5%, specificity 92.1%, and a C-statistic of 0.553. All POA-informed specifications of exclusion rules improved the C-statistic of the failure-to-rescue measure and its sensitivity, with modest losses of specificity. For all tested specifications, higher licensed hours and proportions of registered nurse were statistically significant and associated with lower risk of death. Conclusions Failure-to-rescue is a robust quality measure, sensitive to nursing across alternative exclusion rule specifications. Despite expanded POA coding, exclusion-based rules are needed to analyze datasets not coded for POA, legacy datasets, and datasets with poor POA coding. POA-informed construction of exclusions significantly improves rules identifying POA complications.

Key Findings. The Patient Protection and Affordable Care Act (ACA) is designed to offer premium subsidies to help eligible individuals and their families purchase insurance coverage when affordable job-based coverage is not available. However, the law is unclear on how this affordability protection is applied in those instances where self-only coverage offered by an employer is affordable but family coverage is not. Regulations recently proposed by the Department of the Treasury would make family members ineligible for subsidized coverage in the exchange if an employee is offered affordable self-only coverage by an employer, even if family coverage is unaffordable. This could have significant financial consequences for low- and moderate-income families that fall in this gap. Using an alternative interpretation of the law could allow the entire family to enter the exchange when family coverage is unaffordable, which would broaden access to coverage. However, this option has been cited as cost prohibitive. In this brief we consider a middle ground alternative that would base eligibility for the individual worker on the cost of self-only coverage, but would use the additional cost to the employee for family coverage as the basis for determining affordability and eligibility for subsidies for the remaining family members. We find that: Under the middle ground alternative scenario an additional 144,000 Californians would qualify for and use premium subsidies in the California Health Benefit Exchange, half of whom are children. Less than 1 percent of those with employer-based coverage would move to subsidized coverage in the California Health Benefit Exchange as a result of having unaffordable coverage on the job.

This systematic review provides a comprehensive assessment of models used to expand the ranks of clinical nursing faculty. Nursing faculty shortages constrict the pipeline for educating nurses and make addressing the projected nursing shortage more difficult. Schools of nursing have denied admission to qualified applicants, citing insufficient numbers of nursing faculty as one major reason. Using key search terms in PubMed ® and CINAHL ® , we identified 14 peer-reviewed articles published between 1980 and 2010 about models for expanding clinical faculty. Partnership models ( n = 11) and expanded use of faculty resources ( n = 9) were the most common strategies. Few ( n = 8) studies assessed program efficacy. A need was identified for studies to assess the effect of alternative models on educational capacity and student performance and to examine the subcomponents of academic–practice partnerships and other innovative approaches to understand the essential factors necessary to implement successful programs. [ J Nurs Educ. 2013;52(5):245–252.]

Background: Fall-related injuries (FRIs) result in morbidity and mortality for patients, as well as unnecessary expense to health care institutions. Objectives: (a) Estimate the incidence of falls and FRIs with a nursing home as the source of admission in Veterans Administration (VA) and non-VA facilities. (b) Estimate the cost of hospitalizations for each level of FRI severity. Research Design: Retrospective analysis of falls and FRI resulting in a hospitalization whose source of admission was a VA nursing home. Data: Falls and FRIs were obtained from Minimum Data Set (MDS) reports (January 2007-June 2009). Costs were obtained from the VA Decision Support System reports and Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) reports (2000-2006). Measures: Incidence of falls, fracture incidence, number of hospitalizations for FRIs, and costs associated with hospitalization for by level of FRI severity. Results: Fall incidence was 10.6% in VA and 13.1% in CMS facilities. Fracture incidence was 0.9% in VHA and 1.65% in CMS facilities. Over a 3-year period, there were 2,400 admissions to VHA hospitals for FRI, with 55.4% hip fractures and10.1% intracranial injuries, with an average cost of US$23,723 per admission. Over a 9-year period, there were 141,308 admissions from nursing homes to non-VA hospitals for FRIs, with 38.8% hip fractures, 35.7% other fractures, and 11.1% intracranial injuries, with an average cost of US$31,507 per admission. Conclusions: Prevention program emphasis should shift away from a focus on preventing falls as a measure of quality care to decreasing FRIs. These findings support implementation of injury prevention programs for the elderly that reduces risk for injury as the primary outcome.

Discussions of hospital quality, efficiency, and nursing care often taken place independent of one another. Activities to assure the adequacy and performance of hospital nursing, improve quality, and achieve effective control of hospital costs need to be harmonized. Nurses are critical to the delivery of high-quality, efficient care. Lessons from Magnet program hospitals and hospitals implementing front-line staff-driven performance improvement programs such as Transforming Care at the Bedside illustrate how nurses and staff, supported by leadership, can be actively involved in improving both the quality and the efficiency of hospital care.

Through an initiative called Transforming Care at the Bedside (TCAB), the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement have created an innovative bottom-up framework for redesigning the work environment on medical-surgical units. The specific purpose of this study, conducted by the University of California Los Angeles/RAND evaluation team, was to examine the number of innovations tested and the association of the volume of tests made and changes in a summary measurement of self-reported vitality at the 13 participating hospitals. The findings of this evaluation yielded several important implications for nurse leaders.

Concerns about nurse staffing in hospitals, nursing's influence on patient safety and health care outcomes, and nurses' work environment (e.g., equipment failures, documentation burden) have led to increased interest in measuring and reporting nursing's performance. This article reviews recent efforts and issues involved in identifying a set of nursing-sensitive performance measures. Sustaining and strengthening current efforts requires developing measures that address all the domains of nursing, addressing technical issues needed to analyze the impact of nursing on patient safety and health care outcomes, developing data systems that provide the information needed to implement the model system, regularly improving the set of endorsed standards to reflect the most current science and empirical evidence, and persuading all health care stakeholders that measurement and reporting nursing-sensitive standards make a difference in the care and quality that are delivered. Each of these tasks requires substantial development work and construction and maintenance of the infrastructure to sustain the performance measurement efforts.

Purpose Recent studies and anecdotal evidence suggest that patient safety may be compromised on weekends. Our objective was to determine whether rates of complications in hospitals are higher on weekends than on weekdays. Methods We examined records from 4,967,114 admissions to acute care hospitals in 3 states and analyzed complication rates using the Patient Safety Indicators. We selected 8 indicators that could be assigned to a single day: complications of anesthesia, retained foreign bodies, postoperative hemorrhage, accidental cuts and lacerations during procedures, birth trauma, obstetric trauma during vaginal deliveries with and without instrumentation, and obstetric trauma during cesarean delivery. Odds ratios (ORs) comparing weekends versus weekdays were adjusted for demographics, type of admission, and admission route. In a subgroup analysis of surgical complications, we restricted the population to patients who underwent cardiac or vascular procedures. Results Four of the 8 complications occurred more frequently on weekends: postoperative hemorrhage (OR 1.07, 95% confidence interval [CI], 1.01-1.14), newborn trauma (OR 1.06, 95% CI, 1.03-1.10), vaginal deliveries without instrumentation (OR 1.03, 95% CI, 1.02-1.04), and obstetric trauma during cesarean sections (OR 1.36, 95% CI, 1.29-1.44). Complications related to anesthesia occurred less frequently on weekends (OR 0.86). Among patients undergoing vascular procedures, surgical complications occurred more frequently on weekends (OR 1.46, 95% CI, 1.16-1.85). Conclusions Rates of complications are marginally higher on weekends than on weekdays for some surgical and newborn complications, but more significantly for obstetric trauma and for surgical complications involving patients undergoing vascular procedures. Hospitals should work toward increasing the robustness of safeguards on weekends.

A 4-state (Alabama, California, Georgia, Pennsylvania) retrospective analysis of claims data from 1.6 million Medicaid beneficiaries to assess the performance of community health centers compared with other Medicaid providers (office-based and hospital-based practices) served as a regular source of care to Medicaid beneficiaries, each with at least one diagnosed ambulatory care-sensitive condition (ACSC). The health centers compared with the other Medicaid providers experienced one third fewer sentinel ACS events: 5.7 and 8.2 ACS admissions and 26.1 and 37.7 ACS emergency visits, respectively, per 100 persons. Controlling for case mix and other factors, the logistic regression results for sentinel events indicated that Medicaid beneficiaries who relied on health centers for primary care were significantly less likely to experience an ACS admission (OR = 0.89, P < .0001) or an ACS emergency visit (OR = 0.81, P < .0001) than the Medicaid beneficiaries who relied on other Medicaid providers. Sentinel ACS events can serve as efficient measures for assessing provider performance and comparing effectiveness of regular sources for primary care.

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