Impact of the Centers for Medicare and Medicaid Services Sepsis Core Measure on Antibiotic Use.

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) implemented a core measure sepsis (SEP-1) bundle in 2015. One element was initiation of broad-spectrum antibiotics within 3 hours of diagnosis. The policy has the potential to increase antibiotic use and Clostridioides difficile infection (CDI). We evaluated the impact of SEP-1 implementation on broad-spectrum antibiotic use and CDI occurrence rates. METHODS: Monthly adult antibiotic data for 4 antibiotic categories (surgical prophylaxis, broad-spectrum for community-acquired infections, broad-spectrum for hospital-onset/multidrug-resistant [MDR] organisms, and anti-methicillin-resistant Staphylococcus aureus [MRSA]) from 111 hospitals participating in the Clinical Data Base Resource Manager were evaluated in periods before (October 2014-September 2015) and after (October 2015-June 2017) policy implementation. Interrupted time series analyses, using negative binomial regression, evaluated changes in antibiotic category use and CDI rates. RESULTS: At the hospital level, there was an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+2.3%, P = .0375) as well as a long-term increase in trend (+0.4% per month, P = .0273). There was also an immediate increase in level of overall antibiotic use (+1.4%, P = .0293). CDI rates unexpectedly decreased at the time of SEP-1 implementation. When analyses were limited to patients with sepsis, there was a significant level increase in use of all antibiotic categories at the time of SEP-1 implementation. CONCLUSIONS: SEP-1 implementation was associated with immediate and long-term increases in broad-spectrum hospital-onset/MDR organism antibiotics. Antimicrobial stewardship programs should evaluate sepsis treatment for opportunities to de-escalate broad therapy as indicated.

Reassessing the labor market effects of California's minimum nurse staffing regulations.

California implemented hospital-unit level licensed nurse minimum staffing regulations in 2004, with more stringent regulations applying for certain units in 2005 and 2008. All analyses agree that there were significant increases in Registered Nurse (RN) staffing levels, especially in hospitals with lower preregulation staffing. Analyses of the labor market effects of the regulations, however, come to mixed conclusions. I revisit the labor market effects of the regulations using different data and a different analytical model for RN wages. For the analysis of growth of RN employment, I use information from the National Sample Survey of Registered Nurses, the largest and most complete source of information on nurse employment, and find that RN employment grew significantly faster in California than in other states after the regulations were implemented. For the analysis of changes in RN wages, I apply a panel difference-in-difference-in-difference model to wage averages in Metropolitan Statistical Areas, controlling for MSA-, occupation-, and time-fixed effects, and all their two-way interactions. Analysis of changes in the differential between RN wages and wages in four other selected occupations indicates significant growth in RN wages after the regulations were implemented.

Factors associated with hospital participation in Centers for Medicare and Medicaid Services' Accountable Care Organization programs.

BACKGROUND: In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) programs. Organizations in the MSSP model shared cost savings they generated with CMS, and those in the Pioneer program shared both savings and losses. It is largely unknown what hospital and environmental characteristics are associated with the development of CMS ACOs with one- or two-sided risk models. PURPOSE: The aim of this study was to assess the organizational and environmental characteristics associated with hospital participation in the MSSP and Pioneer ACOs. METHODOLOGY: Hospitals participating in CMS ACO programs were identified using primary and secondary data. The ACO hospital sample was linked with the American Hospital Association, Health Information and Management System Society, and other data sets. Multinomial probit models were estimated that distinguished organizational and environmental factors associated with hospital participation in the MSSP and Pioneer ACOs. RESULTS: Hospital participation in both CMS ACO programs was associated with prior experience with risk-based payments and care management programs, advanced health information technology, and location in higher-income and more competitive areas. Whereas various health system types were associated with hospital participation in the MSSP, centralized health systems, higher numbers of physicians in tightly integrated physician-organizational arrangements, and location in areas with greater supply of primary care physicians were associated with Pioneer ACOs. Favorable hospital characteristics were, in the aggregate, more important than favorable environmental factors for MSSP participation. CONCLUSION: MSSP ACOs may look for broader organizational capabilities from participating hospitals that may be reflective of a wide range of providers participating in diverse markets. Pioneer ACOs may rely on specific hospital and environmental characteristics to achieve quality and spending targets set for two-sided contracts. PRACTICE IMPLICATIONS: Hospital and ACO leaders can use our results to identify hospitals with certain characteristics favorable to their participation in either one- or two-sided ACOs.

A taxonomy of hospitals participating in Medicare accountable care organizations.

BACKGROUND: Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012-2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants. PURPOSE: Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time. METHODOLOGY/APPROACH: Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012-2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society. RESULTS: Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology. CONCLUSION: Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals. PRACTICE IMPLICATIONS: ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.

Impact of Medicaid disenrollment in Tennessee on breast cancer stage at diagnosis and treatment.

BACKGROUND: States routinely may consider rollbacks of Medicaid expansions to address statewide economic conditions. To the authors' knowledge, little is known regarding the effects of public insurance contractions on health outcomes. The current study examined the effects of the 2005 Medicaid disenrollment in Tennessee on breast cancer stage at the time of diagnosis and delays in treatment among nonelderly women. METHODS: The authors used Tennessee Cancer Registry data from 2002 through 2008 and estimated a difference-in-difference model comparing women diagnosed with breast cancer who lived in low-income zip codes (and therefore were more likely to be subject to disenrollment) with a similar group of women who lived in high-income zip codes before and after the 2005 Medicaid disenrollment. The study outcomes were changes in stage of disease at the time of diagnosis and delays in treatment of >60 days and >90 days. RESULTS: Overall, nonelderly women in Tennessee were diagnosed at later stages of disease and experienced more delays in treatment in the period after disenrollment. Disenrollment was found to be associated with a 3.3-percentage point increase in late stage of disease at the time of diagnosis (P = .024), a 1.9-percentage point decrease in having a delay of >60 days in surgery (P = .024), and a 1.4-percentage point decrease in having a delay of >90 days in treatment (P = .054) for women living in low-income zip codes compared with women residing in high-income zip codes. CONCLUSIONS: The results of the current study indicate that Medicaid disenrollment is associated with a later stage of disease at the time of breast cancer diagnosis, thereby providing evidence of the potential negative health impacts of Medicaid contractions. Cancer 2017;123:3312-9. © 2017 American Cancer Society.

Delivery system characteristics and their association with quality and costs of care: implications for accountable care organizations.

BACKGROUND: Implementation of accountable care organizations (ACOs) is currently underway, but there is limited empirical evidence on the merits of the ACO model. PURPOSE: The aim was to study the associations between delivery system characteristics and ACO competencies, including centralization strategies to manage organizations, hospital integration with physicians and outpatient facilities, health information technology, infrastructure to monitor community health and report quality, and risk-adjusted 30-day all-cause mortality and case-mixed-adjusted inpatient costs for the Medicare population. METHODOLOGY: Panel data (2006-2009) were assembled from Florida and multiple sources: inpatient hospital discharge, vital statistics, the American Hospital Association, the Healthcare Information and Management Systems Society, and other databases. We applied a panel study design, controlling for hospital and market characteristics. PRINCIPAL FINDINGS: Hospitals that were in centralized health systems or became more centralized over the study period had significantly larger reductions in mortality compared with hospitals that remained freestanding. Surprisingly, tightly integrated hospital-physician arrangements were associated with increased mortality; as such, hospitals may wish to proceed cautiously when developing specific types of alignment with local physician organizations. We observed no statistically significant differences in the growth rate of costs across hospitals in any of the health systems studied relative to freestanding hospitals. Although we observed quality improvement in some organizational types, these outcome improvements were not coupled with the additional desired objective of lower cost growth. This implies that additional changes not present during our study period, potentially changes in provider payment approaches, are essential for achieving the ACO objectives of higher quality of care at lower costs. PRACTICE IMPLICATIONS: Provider organizations implementing ACOs should consider centralizing service delivery as a viable strategy to improve quality of care, although the strategy did not result in lower cost growth.

Comprehensive pregnancy dental benefits improved dental coverage and increased dental care utilization among Medicaid-enrolled pregnant women in Virginia.

Objectives: To evaluate the changes in dental insurance and utilization among pregnant women before and after the pregnancy Medicaid dental benefit policy implementation in 2015 in Virginia. Methods: We used pooled cross-sectional data from six cycles of the Virginia Pregnancy Risk Assessment Monitoring System on women aged ≥21 years. Using logistic regression models and a difference-in-difference design, we compared the effects of policy implementation on dental insurance and utilization between pre-policy (2013-2014) and post-policy period (2016-2019) among women enrolled in Medicaid (treatment, N = 1,105) vs. those with private insurance (control, N = 2,575). A p-value of 0.05 was considered significant. Results: Among Medicaid-enrolled women, the report of dental insurance (71.6%) and utilization (37.7%) was higher in the post-period compared to their pre-period (44.4% and 30.3%, respectively) estimates but still remained lower than the post-period estimates among women with private insurance (88.0% and 59.9%, respectively). Adjusted analyses found that Medicaid-enrolled women had a significantly greater change in the probability of reporting dental insurance in all post-period years than women with private insurance, while the change in the probability of utilization only became statistically significant in 2019. In 2019, there was a 16 percentage point increase (95% CI = 0.05, 0.28) in the report of dental insurance and a 17 percentage point increase (95% CI = 0.01-0.33) in utilization in treatment group compared to controls. Conclusions: The 2015 pregnancy Medicaid dental benefit increased dental insurance and dental care utilization among Medicaid-enrolled women and reduced associated disparities between Medicaid and privately insured groups.

Adjusting for patient acuity in measurement of nurse staffing: two approaches.

BACKGROUND: Researchers who examine the relationship between nurse staffing and quality of care frequently rely on the Medicare case mix index to adjust for patient acuity, even though it was developed originally based on medical diagnoses and may not accurately reflect patients' needs for nursing care. OBJECTIVES: The aim of this study was to examine the differences between unadjusted measures of nurse staffing (registered nurses per 1,000 adjusted patient days) and case mix adjusted nurse staffing and nurse staffing adjusted with nursing intensity weights, which were developed to reflect patients' needs for nursing care. METHOD: Secondary data were used from 579 hospitals in 13 states from 2000 to 2006. Included were three measures of nurse staffing and hospital characteristics including ownership, geographic location, teaching status, hospital size, and percent Medicare inpatient days. RESULTS: Measures of nurse staffing differed in important ways. The differences between the measures were related systematically to ownership, geographic location, teaching status, hospital size, and percentage Medicare inpatient days. DISCUSSION: Without an accurate method to incorporate acuity into measurement of nurse staffing, research on the relationship between staffing and quality of care will not reach the full potential to inform practice.

Nurse staffing and quality of care with direct measurement of inpatient staffing.

BACKGROUND: Studies of the impact of registered nurse (RN) staffing on hospital quality of care for hospital inpatients often rely on data sources that do not distinguish inpatient from outpatient staffing, thus requiring imputation of staffing level. As a result, estimates of the impact of staffing on quality may be biased. OBJECTIVE: To estimate the impact of changes in RN staffing on changes in quality of care with direct measurement of staffing levels. RESEARCH DESIGN: Longitudinal regression analysis of California general acute care hospitals where inpatient staffing is measured directly. SUBJECTS: Estimation sample reflects outcomes for 11,945,276 adult inpatients at 283 hospitals from 1996 to 2001. MEASURES: Patient outcomes are in-hospital mortality ratio and surgical failure-to-rescue ratio after nurse-sensitive complications with risk adjustment through calculation of the expected number of adverse outcomes using the Medstat disease staging algorithm. Staffing levels were measured as the number of full-time equivalent nurses per 1000 inpatient days. RESULTS: Estimates suggest that changes in RN staffing were associated with reductions in mortality and failure to rescue. At 2.97 RN full-time equivalents per 1000 inpatient days, a 1-unit increase in staffing was associated with a 0.043 decrease in the mortality ratio (P < 0.05), and the estimated effect was smaller at hospitals with higher staffing levels. Estimates for failure to rescue ratio were statistically significant only at higher staffing levels. CONCLUSIONS: Results are compared with those from similar studies, including studies using imputation of inpatient staffing, and are found to be consistent with attenuation bias induced by imputation.

Is quality of cardiac hospital care a public or private good?

BACKGROUND: There are many studies examining the effects of financial pressure from different payment sources on hospital quality of care, but most have assumed that quality of care is a public good in that payment changes from one payer will affect all hospital patients rather than just those directly associated with the payer. Although quality of hospital care can be either a public or private good, few studies have tested which of these scenarios are more likely to hold. OBJECTIVES: To examine whether the change in the magnitude of in-hospital mortality for Medicare and managed care patients is different based on financial pressure resulting from the Balanced Budget Act and growing managed care market penetration; and to examine what role hospital competition may play in affecting these changes. DATA AND METHODS: The unit of analysis for the study was the hospital. Multiple data sources were used including the Agency for Healthcare Research and Quality State Inpatient Databases, American Hospital Association Annual Surveys, Area Resource File, and health maintenance organization data from InterStudy. A difference-in-difference-in-difference model was applied for a 2-period panel design. RESULTS: In general, Balanced Budget Act financial pressure and managed care market share did not magnify the difference in in-hospital mortality rates between Medicare and managed care patients. The results suggest that quality of cardiac care in the hospital setting is more likely to be a public good; however, more investigation using other quality indicators and the role of hospital competition under different payment systems is recommended.

Nurse staffing and post-surgical complications using the present on admission indicator.

We evaluated the relationship between registered nurse (RN) staffing and six post-surgical complications: pneumonia, septicemia, urinary tract infections, thrombophlebitis, fluid overload, and decubitus ulcers, in a dataset that contained the present on admission (POA) indicator. We analyzed a longitudinal panel of 283 acute care hospitals in California from 1996 to 2001. Using an adaptation of the Quality Health Outcomes Model, we found no statistically significant relationships between RN staffing and the complications. In addition, the signs of the relationships were opposite to those expected. That is, as staffing increased, so did some of the complications. We discuss potential reasons for these anomalous results, including the possibility that increases in RN staffing may result in earlier detection of complications. Other explanations include issues with risk adjustment, the lack of nurse level variables in the model, and issues with the POA indicator itself.

Variations in inpatient mortality among hospitals in different system types, 1995 to 2000.

BACKGROUND: Relatively few studies focused on the impact of system formation and hospital merger on quality, and these studies reported typically little or no quality effect. OBJECTIVE: To study associations among 5 main types of health systems--centralized, centralized physician/insurance, moderately centralized, decentralized, and independent--and inpatient mortality from acute myocardial infarction (AMI), congestive heart failure, stroke, and pneumonia. DATA AND METHODS: Panel data (1995-2000) were assembled from 11 states and multiple sources: Agency for Healthcare Research and Quality State Inpatient Database, American Hospital Association Annual Surveys, Area Resource File, HMO InterStudy, and the Centers for Medicare and Medicaid Services. We applied a panel study design with fixed effects models using information on variation within hospitals. RESULTS: We found that centralized health systems are associated with lower AMI, congestive heart failure, and pneumonia mortality. Independent hospital systems had better AMI quality outcomes than centralized physician/insurance and moderately centralized health systems. We found no difference in inpatient mortality among system types for the stroke outcome. Thus, for certain types of clinical service lines and patients, hospital system type matters. Research that focuses only on system membership may mask the impact of system type on the quality of care.

Preventable Hospital Admissions and 30-Day All-Cause Readmissions: Does Hospital Participation in Accountable Care Organizations Improve Quality of Care?

This study evaluates quality performance of hospitals participating in Medicare Shared Savings and Pioneer Accountable Care Organization (ACO) programs relative to nonparticipating hospitals. Overall, 198 ACO participating and 1210 propensity score matched, nonparticipating hospitals were examined in a difference-in-difference analysis, using data from 17 states in the years 2010-2013. The authors studied preventable hospitalizations for conditions sensitive to high-quality ambulatory care-chronic obstructive pulmonary disease (COPD) and asthma, chronic heart failure (CHF), complications of diabetes-and 30-day all-cause readmissions potentially influenced by hospital care. A decrease was found in preventable hospitalizations for COPD and asthma and for diabetes complications for ACO participating hospitals, but no significant differences for preventable CHF hospitalizations and 30-day readmissions. Mixed results may be attributable to insufficient incentives for ACO participating hospitals to decrease 30-day readmissions, whereas disease-focused initiatives may have a beneficial effect on preventable hospitalizations for COPD and asthma and complications of diabetes.

Generosity and Duration of Medicaid Expansion Waivers and Access to Care.

INTRODUCTION: Prior to expansion of Medicaid under the Affordable Care Act, some states obtained Section 1115 waivers from the federal government that allowed them to expand eligibility for Medicaid to adult populations that were not covered previously. Expansion waivers in these states differed in their generosity and year of implementation, creating variation in coverage availability and program longevity across states. This study examined the association between generosity and duration of Medicaid expansion waivers and access to preventive services. METHODS: The 2012 Medical Expenditure Panel Survey data were used to estimate adjusted logistic models in 2016, comparing outcomes among low-income non-elderly adults living in generous (Medicaid eligibility threshold ≥138% federal poverty level) and moderate (Medicaid eligibility threshold <138% federal poverty level) waiver states, relative to no-waiver states. RESULTS: Moderate and generous waivers were associated with statistically significant (p<0.001) increases in probabilities of having a usual source of care and a blood pressure check, relative to states without a waiver to expand. Low-income individuals living in states with longer waiver durations had better access to healthcare services than a similar group living in comparison states. CONCLUSIONS: Not only is Medicaid waiver generosity associated with improving access to healthcare services, but the combination of generosity and longer duration of a waiver also intensifies the association. As states gain flexibility in designing their Medicaid programs, the healthcare benefits associated with both generosity and duration of waivers are important considerations for policy makers.

Do laboratory frontal crash test programs predict driver fatality risk? Evidence from within vehicle line variation in test ratings.

A number of studies have examined whether the National Highway Traffic Safety Administration's (NHTSA) frontal crash test results reliably indicate the risk of fatality or injury in serious crashes. The conclusions of these studies are mixed. Generally, studies that examine crashes in the circumstances as close as possible to those of the laboratory test find that crash test results do predict real-world risk, but studies of crashes outside those specific circumstances find either no support for the predictive validity of crash test results or limited support with important inconsistencies. We provide a new test of the predictive validity of the crash test results using information from multiple crash tests within vehicle lines, thus controlling for systematic differences in driver behavior across vehicle lines. Among drivers of passenger cars, we find large, statistically significant differences in fatality risk for vehicles with one- to four-star NHTSA ratings versus a five-star rating. We also examine the Insurance Institute for Highway Safety's frontal offset crash test, though our sample of vehicle lines tested twice or more is considerably smaller than for NHTSA ratings. Our results also support the predictive validity of the frontal offset crash test results for passenger cars, but not for trucks.

Nurse staffing, mortality, and length of stay in for-profit and not-for-profit hospitals.

The issue of differential quality in for-profit (FP) and not-for-profit (NFP) hospitals remains a critical health policy question. With research demonstrating a relationship between nurse staffing and quality, the question arises whether the relationship differs in these hospital types. Using Healthcare Cost and Utilization Project data from the period 1990-1995, we found that case mix-adjusted registered nurse (RN) staffing was significantly lower in FPs than in NFPs, and we found a superior distribution of outcomes (mortality and length of stay) obtained with a lower level of RN staffing. The differences in mortality and length of stay disappeared, however, after controlling for population and market characteristics.

Addressing measurement error bias in nurse staffing research.

OBJECTIVE: To assess the extent of measurement error bias due to methods used to allocate nursing staff to the acute care inpatient setting and to recommend estimation methods designed to overcome this bias. DATA SOURCES/STUDY SETTING: Secondary data obtained from the California Office of Statewide Health Planning and Development (OSHPD) and the Centers for Medicare and Medicaid Services' Healthcare Cost Report Information System for 279 general acute care hospitals from 1996 to 2001. STUDY DESIGN: California OSHPD provides detailed nurse staffing data for acute care inpatients. We estimate the measurement error and the resulting bias from applying different staffing allocation methods. Estimates of the measurement errors also allow insights into the best choices for alternate estimation strategies. PRINCIPAL FINDINGS: The bias induced by the adjusted patient days method (and its modification) is smaller than for other methods, but the bias is still substantial: in the benchmark simple regression model, the estimated coefficient for staffing level on quality of care is expected to be one-third smaller than its true value (and the bias is larger in a multiple regression model). Instrumental variable estimation, using one staffing allocation measure as an instrument for another, addresses this bias, but only particular choices of staffing allocation measures and instruments are suitable. CONCLUSIONS: Staffing allocation methods induce substantial attenuation bias, but there are easily implemented estimation methods that overcome this bias.

Medicaid expansion and access to care among cancer survivors: a baseline overview.

PURPOSE: Medicaid expansion under the Affordable Care Act facilitates access to care among vulnerable populations, but 21 states have not yet expanded the program. Medicaid expansions may provide increased access to care for cancer survivors, a growing population with chronic conditions. We compare access to health care services among cancer survivors living in non-expansion states to those living in expansion states, prior to Medicaid expansion under the Affordable Care Act. METHODS: We use the 2012 and 2013 Behavioral Risk Factor Surveillance System to estimate multiple logistic regression models to compare inability to see a doctor because of cost, having a personal doctor, and receiving an annual checkup in the past year between cancer survivors who lived in non-expansion states and survivors who lived in expansion states. RESULTS: Cancer survivors in non-expansion states had statistically significantly lower odds of having a personal doctor (adjusted odds ratio [AOR] 0.76, 95 % confidence interval [CI] 0.63-0.92, p < 0.05) and higher odds of being unable to see a doctor because of cost (AOR 1.14, 95 % CI 0.98-1.31, p < 0.10). Statistically significant differences were not found for annual checkups. CONCLUSIONS: Prior to the passage of the Affordable Care Act, cancer survivors living in expansion states had better access to care than survivors living in non-expansion states. Failure to expand Medicaid could potentially leave many cancer survivors with limited access to routine care. IMPLICATIONS FOR CANCER SURVIVORS: Existing disparities in access to care are likely to widen between cancer survivors in Medicaid non-expansion and expansion states.

The influence of institutional pressures on hospital electronic health record presence.

Electronic health records (EHR) are a promising form of health information technology that could help US hospitals improve on their quality of care and costs. During the study period explored (2005-2009), high expectations for EHR diffused across institutional stakeholders in the healthcare environment, which may have pressured hospitals to have EHR capabilities even in the presence of weak technical rationale for the technology. Using an extensive set of organizational theory-specific predictors, this study explored whether five factors - cause, constituents, content, context, and control - that reflect the nature of institutional pressures for EHR capabilities motivated hospitals to comply with these pressures. Using information from several national data bases, an ordered probit regression model was estimated. The resulting predicted probabilities of EHR capabilities from the empirical model's estimates were used to test the study's five hypotheses, of which three were supported. When the underlying cause, dependence on constituents, or influence of control were high and potential countervailing forces were low, hospitals were more likely to employ strategic responses that were compliant with the institutional pressures for EHR capabilities. In light of these pressures, hospitals may have acquiesced, by having comprehensive EHR capabilities, or compromised, by having intermediate EHR capabilities, in order to maintain legitimacy in their environment. The study underscores the importance of our assessment for theory and policy development, and provides suggestions for future research.

A longitudinal examination of hospital registered nurse staffing and quality of care.

OBJECTIVE: To evaluate previous research findings of the relationship between nurse staffing and quality of care by examining the effects of change in registered nurse staffing on change in quality of care. DATA SOURCES/STUDY SETTING: Secondary data from the American Hospital Association (AHA)(nurse staffing, hospital characteristics), InterStudy and Area Resource Files (ARF) (market characteristics), Centers for Medicare and Medicaid Services (CMS) (financial performance), and Healthcare Cost and Utilization Project (HCUP) (quality measures-in-hospital mortality ratio and the complication ratios for decubitus ulcers, pneumonia, and urinary tract infection, which were risk-adjusted using the Medstat disease staging algorithm). STUDY DESIGN: Data from a longitudinal cohort of 422 hospitals were analyzed from 1990-1995 to examine the relationships between nurse staffing and quality of care. DATA COLLECTION/EXTRACTION METHODS: A generalized method of moments estimator for dynamic panel data was used to analyze the data. Principal Findings. Increasing registered nurse staffing had a diminishing marginal effect on reducing mortality ratio, but had no consistent effect on any of the complications. Selected hospital characteristics, market characteristics, and financial performance had other independent effects on quality measures. CONCLUSIONS: The findings provide limited support for the prevailing notion that improving registered nurse (RN) staffing unconditionally improves quality of care.