Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care.

BACKGROUND: Hospitals are resurrecting the outdated "team nursing" model of staffing that substitutes lower-wage staff for registered nurses (RNs). OBJECTIVES: To evaluate whether reducing the proportion of RNs to total nursing staff in hospitals is in the best interest of patients, hospitals, and payers. RESEARCH DESIGN: Cross-sectional, retrospective. SUBJECTS: In all, 6,559,704 Medicare patients in 2676 general acute-care US hospitals in 2019. MEASURES: Patient outcomes: in-hospital and 30-day mortality, 30-day readmission, length of stay, and patient satisfaction. Avoidable Medicare costs associated with readmissions and cost savings to hospitals associated with shorter stays are projected. RESULTS: A 10 percentage-point reduction in RNs was associated with 7% higher odds of in-hospital death, 1% higher odds of readmission, 2% increase in expected days, and lower patient satisfaction. We estimate a 10 percentage-point reduction in RNs would result in 10,947 avoidable deaths annually and 5207 avoidable readmissions, which translates into roughly $68.5 million in additional Medicare costs. Hospitals would forgo nearly $3 billion in cost savings annually because of patients requiring longer stays. CONCLUSIONS: Reducing the proportion of RNs in hospitals, even when total nursing personnel hours are kept the same, is likely to result in significant avoidable patient deaths, readmissions, longer lengths of stay, and decreased patient satisfaction, in addition to excess Medicare costs and forgone cost savings to hospitals. Estimates represent only a 10 percentage-point dilution in skill mix; however, the team nursing model includes much larger reductions of 40-50 percentage-points-the human and economic consequences of which could be substantial.

Left Without Being Seen: Nurse Work Environment and Timely Outcomes in New York and Illinois Emergency Departments.

INTRODUCTION: This study determined the relationship between the emergency nurse work environment and emergency department patient left without being seen rates and lengths of stay. METHODS: Cross-sectional analysis of 215 New York and Illinois emergency departments. The work environment (abbreviated Practice Environment Scale of the Nursing Work Index) was measured by emergency nurses in the 2021 RN4CAST-NY/IL survey and linked with outcomes from Hospital Compare. Regression models estimated the relationship between the nurse work environment and emergency department patient left without being seen rates, median length of stay (in minutes), and median behavioral health patient length of stay. Model coefficients were used to estimate expected additional care minutes gained if emergency department work environments improved. RESULTS: "Mixed" work environments had the longest median overall length of stay (3.4 hours) and the highest median left without being seen rates (2.2%), while "poor" work environments had the longest median length of stay for behavioral health patients (6 hours). Improving the emergency department work environment from poor to mixed (and mixed to better) was associated with a 13-minute reduction in overall length of stay (P ≤ .05), a 33-minute reduction in behavioral health length of stay (P ≤ .01), and a 19% reduction in left without being seen rates (P ≤ .01). We estimated 11,824 to 41,071 additional patients could be seen in emergency departments associated with work environment improvements from "poor" to "better," depending on annual patient volumes. DISCUSSION: Hospital administrators should consider investing in nurse work environments as a foundation to improve timely outcomes.

Mortality Among the Dementia Population in Not-For-Profit Hospitals with Better Nursing Resources.

The dementia population has higher rates of mortality during hospital stays than those without dementia. The aim of this study is to examine the relationship between ownership status (i.e. for-profit vs. not-for-profit) and nursing resources (i.e. nurse work environment, nurse-to-patient staffing, and nurse education) on 30-day mortality among post-surgical older adults with dementia. A cross-sectional analysis of linked American Hospital Association, Medicare claims, and nurse survey data was conducted using multi-level logistic regression models. We examined these models to assess the relationship between ownership status and 30-day mortality after adjusting patient and hospital characteristics. We also analyzed the relationship between the hospital ownership status and the 30-day mortality, after considering the three nursing resources. Older adults with dementia who received care in hospitals with not-for-profit status were less likely to die within 30 days of admission following surgery compared to those treated in hospitals with for-profit hospital status (i.e. odds ratio 0.82, 95% confidence interval 0.73-0.92, p = <.001). In addition, the odds ratios estimating the association between ownership and mortality were similar across the different models of the three nursing resources with and without those controls (i.e. 0.88 vs. 0.83 vs. 0.82). Surgical patients with dementia had better outcomes when cared for in not-for-profit hospitals, particularly with greater levels of nurse education and nurse staffing. The relationship between profit status and mortality was partly explained by the lower levels of nurse staffing and education in for-profit vs. not-for-profit hospitals.

Brain imaging factors associated with progression of subcortical hyperintensities in CADASIL over 2-year follow-up.

BACKGROUND AND PURPOSE: Mutations in the NOTCH3 gene cause cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), a cerebral small vessel disease manifesting with stroke, migraine and dementia in adults. The disease displays significant phenotypic variability that is incompletely explained. Early abnormalities in vascular function have been shown in animal models. We postulated that studying changes in vascular function may offer insights into disease progression. METHODS: Twenty-two subjects with CADASIL [50% female, 50 (±11) years] from 19 pedigrees were included in a longitudinal multimodality study using brain magnetic resonance imaging (MRI), clinical measures, neuropsychology and measures of peripheral vascular function. MRI studies included measurement of structural brain changes, cerebral blood flow (CBF) and cerebrovascular reactivity by arterial spin labelling and a CO2 respiratory challenge. RESULTS: Over 2 years, new stroke or transient ischaemic attack (TIA) occurred in five (23%) subjects and new significant disability in one (5%). There were significant increases in number of lacunes, subcortical hyperintensity volume and microbleeds, and a decrease in brain volume. CBF declined by 3.2 (±4.5) ml/100 g/min over 2 years. CBF and carotid-femoral pulse wave velocity at baseline predicted change in subcortical hyperintensity volume at follow-up. Carotid intima-media thickness and age predicted brain atrophy. Baseline CBF was lower in subjects who showed a decline in attention and working memory. CONCLUSIONS: Cerebral blood flow predicts radiological progression of hyperintensities and thus is a potential biomarker of disease progression in CADASIL. Over 2 years, there were changes in several relevant imaging biomarkers (CBF, brain volume, lacunes, microbleeds and hyperintensity volume). Future studies in CADASIL should consider assessment of CBF as prognostic factor.

Polypharmacy, functional outcome and treatment effect of intravenous alteplase for acute ischaemic stroke.

BACKGROUND AND PURPOSE: Polypharmacy is an important challenge in clinical practice. Our aim was to determine the effect of polypharmacy on functional outcome and treatment effect of alteplase in acute ischaemic stroke. METHODS: This was a post hoc analysis of the randomized, placebo-controlled WAKE-UP trial of magnetic resonance imaging guided intravenous alteplase in unknown onset stroke. Polypharmacy was defined as an intake of five or more medications at baseline. Comorbidities were assessed by the Charlson Comorbidity Index (CCI). The primary efficacy variable was favourable outcome defined by a score of 0-1 on the modified Rankin Scale at 90 days. Logistic regression analysis was used to test for an association of polypharmacy with functional outcome, and for interaction of polypharmacy and the effect of thrombolysis. RESULTS: Polypharmacy was present in 133/503 (26%) patients. Patients with polypharmacy were older (mean age 70 vs. 64 years; p < 0.0001) and had a higher score on the National Institutes of Health Stroke Scale at baseline (median 7 vs. 5; p = 0.0007). A comorbidity load defined by a CCI score ≥ 2 was more frequent in patients with polypharmacy (48% vs. 8%; p < 0.001). Polypharmacy was associated with lower odds of favourable outcome (adjusted odds ratio 0.50, 95% confidence interval 0.30-0.85; p = 0.0099), whilst the CCI score was not. Treatment with alteplase was associated with higher odds of favourable outcome in both groups, with no heterogeneity of treatment effect (test for interaction of treatment and polypharmacy, p = 0.29). CONCLUSION: In stroke patients, polypharmacy is associated with worse functional outcome after intravenous thrombolysis independent of comorbidities. However, polypharmacy does not interact with the beneficial effect of alteplase.

Correction: External validation of risk prediction models for incident colorectal cancer using UK Biobank.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Baseline factors associated with early and late death in intracerebral haemorrhage survivors.

BACKGROUND AND PURPOSE: The aim of this study was to determine whether early and late death are associated with different baseline factors in intracerebral haemorrhage (ICH) survivors. METHODS: This was a secondary analysis of the multicentre prospective observational CROMIS-2 ICH study. Death was defined as 'early' if occurring within 6 months of study entry and 'late' if occurring after this time point. RESULTS: In our cohort (n = 1094), there were 306 deaths (per 100 patient-years: absolute event rate, 11.7; 95% confidence intervals, 10.5-13.1); 156 were 'early' and 150 'late'. In multivariable analyses, early death was independently associated with age [per year increase; hazard ratio (HR), 1.05, P = 0.003], history of hypertension (HR, 1.89, P = 0.038), pre-event modified Rankin scale score (per point increase; HR, 1.41, P < 0.0001), admission National Institutes of Health Stroke Scale score (per point increase; HR, 1.11, P < 0.0001) and haemorrhage volume >60 mL (HR, 4.08, P < 0.0001). Late death showed independent associations with age (per year increase; HR, 1.04, P = 0.003), pre-event modified Rankin scale score (per point increase; HR, 1.42, P = 0.001), prior anticoagulant use (HR, 2.13, P = 0.028) and the presence of intraventricular extension (HR, 1.73, P = 0.033) in multivariable analyses. In further analyses where time was treated as continuous (rather than dichotomized), the HR of previous cerebral ischaemic events increased with time, whereas HRs for Glasgow Coma Scale score, National Institutes of Health Stroke Scale score and ICH volume decreased over time. CONCLUSIONS: We provide new evidence that not all baseline factors associated with early mortality after ICH are associated with mortality after 6 months and that the effects of baseline variables change over time. Our findings could help design better prognostic scores for later death after ICH.

Pulse pressure variability is associated with unfavorable outcomes in acute ischaemic stroke patients treated with intravenous thrombolysis.

BACKGROUND AND PURPOSE: Blood pressure (BP) variability has been associated with worse neurological outcomes in acute ischaemic stroke (AIS) patients receiving treatment with intravenous thrombolysis (IVT). However, no study to date has investigated whether pulse pressure (PP) variability may be a superior indicator of the total cardiovascular risk, as measured by clinical outcomes. METHODS: Pulse pressure variability was calculated from 24-h PP measurements following tissue plasminogen activator bolus in AIS patients enrolled in the Combined Lysis of Thrombus using Ultrasound and Systemic Tissue Plasminogen Activator for Emergent Revascularization (CLOTBUST-ER) trial. The outcomes of interest were the pre-specified efficacy and safety end-points of CLOTBUST-ER. All associations were adjusted for potential confounders in multivariable regression models. RESULTS: Data from 674 participants was analyzed. PP variability was identified as the BP parameter with the most parsimonious fit in multivariable models of all outcomes, and was independently associated (P < 0.001) with lower likelihood of both 24-h neurological improvement and 90-day independent functional outcome. PP variability was also independently related to increased odds of any intracranial bleeding (P = 0.011) and 90-day mortality (P < 0.001). Every 5-mmHg increase in the 24-h PP variability was independently associated with a 36% decrease in the likelihood of 90-day independent functional outcome (adjusted odds ratio 0.64, 95% confidence interval 0.52-0.80) and a 60% increase in the odds of 90-day mortality (adjusted odds ratio 1.60, 95% confidence interval 1.23-2.07). PP variability was not associated with symptomatic intracranial bleeding at either 24 or 36 h after IVT administration. CONCLUSIONS: Increased PP variability appears to be independently associated with adverse short-term and long-term functional outcomes of AIS patients treated with IVT.

Coronary artery calcification is associated with mortality independent of pulmonary embolism severity: a retrospective cohort study.

AIM: To assess coronary artery calcification (CAC) and vascular calcification in patients with pulmonary embolism (PE) and correlate this with mortality. MATERIALS AND METHODS: PE severity was quantified using computed tomography pulmonary angiography (CTPA) in 400 consecutive cases using the modified Miller score (1-5, mild; 6-11, moderate; 12-16, severe). Right ventricle strain was assessed using the right/left ventricle diameter (RV/LV) ratio. CAC score (CACS) was assessed using a four-point scale (CACS mild 1-3, moderate 4-8, severe 9-12) for each vessel and summed to give the total CACS. Follow-up for mortality was obtained at 3 years. RESULTS: PE severity was classified as mild in 48%, moderate in 21%, and severe in 32% of cases. The median modified Miller score was 6 (Interquartile range [IQR] 2, 14) and median total CACS was 2 (IQR 0, 7). All-cause mortality occurred in 128 (32%) patients. Patients with CAC were three times more likely to die than patients without CAC (Hazard ratio [HR] 2.96; 95% CI 1.84, 4.77; p<0.001), and patients with severe CAC were at the highest risk (HR 4.62; 95% CI 2.73, 7.83, p<0.001). Gender, modified Miller score and RV/LV ratio were not predictive of mortality. In multivariate analysis both CACS and age were independent predictors of 3-year all-cause mortality. Of the patients with CAC who died, the presence of coronary artery disease was only documented in 34 (32%). CONCLUSION: CACS is an independent predictor of all-cause mortality in patients with PE, and has important implications for subsequent patient management.

External validation of risk prediction models for incident colorectal cancer using UK Biobank.

BACKGROUND: This study aimed to compare and externally validate risk scores developed to predict incident colorectal cancer (CRC) that include variables routinely available or easily obtainable via self-completed questionnaire. METHODS: External validation of fourteen risk models from a previous systematic review in 373 112 men and women within the UK Biobank cohort with 5-year follow-up, no prior history of CRC and data for incidence of CRC through linkage to national cancer registries. RESULTS: There were 1719 (0.46%) cases of incident CRC. The performance of the risk models varied substantially. In men, the QCancer10 model and models by Tao, Driver and Ma all had an area under the receiver operating characteristic curve (AUC) between 0.67 and 0.70. Discrimination was lower in women: the QCancer10, Wells, Tao, Guesmi and Ma models were the best performing with AUCs between 0.63 and 0.66. Assessment of calibration was possible for six models in men and women. All would require country-specific recalibration if estimates of absolute risks were to be given to individuals. CONCLUSIONS: Several risk models based on easily obtainable data have relatively good discrimination in a UK population. Modelling studies are now required to estimate the potential health benefits and cost-effectiveness of implementing stratified risk-based CRC screening.

The Cambridge Prognostic Groups for improved prediction of disease mortality at diagnosis in primary non-metastatic prostate cancer: a validation study.

BACKGROUND: The purpose of this study is to validate a new five-tiered prognostic classification system to better discriminate cancer-specific mortality in men diagnosed with primary non-metastatic prostate cancer. METHODS: We applied a recently described five-strata model, the Cambridge Prognostic Groups (CPGs 1-5), in two international cohorts and tested prognostic performance against the current standard three-strata classification of low-, intermediate- or high-risk disease. Diagnostic clinico-pathological data for men obtained from the Prostate Cancer data Base Sweden (PCBaSe) and the Singapore Health Study were used. The main outcome measure was prostate cancer mortality (PCM) stratified by age group and treatment modality. RESULTS: The PCBaSe cohort included 72,337 men, of whom 7162 died of prostate cancer. The CPG model successfully classified men with different risks of PCM with competing risk regression confirming significant intergroup distinction (p < 0.0001). The CPGs were significantly better at stratified prediction of PCM compared to the current three-tiered system (concordance index (C-index) 0.81 vs. 0.77, p < 0.0001). This superiority was maintained for every age group division (p < 0.0001). Also in the ethnically different Singapore cohort of 2550 men with 142 prostate cancer deaths, the CPG model outperformed the three strata categories (C-index 0.79 vs. 0.76, p < 0.0001). The model also retained superior prognostic discrimination in the treatment sub-groups: radical prostatectomy (n = 20,586), C-index 0.77 vs. 074; radiotherapy (n = 11,872), C-index 0.73 vs. 0.69; and conservative management (n = 14,950), C-index 0.74 vs. 0.73. The CPG groups that sub-divided the old intermediate-risk (CPG2 vs. CPG3) and high-risk categories (CPG4 vs. CPG5) significantly discriminated PCM outcomes after radical therapy or conservative management (p < 0.0001). CONCLUSIONS: This validation study of nearly 75,000 men confirms that the CPG five-tiered prognostic model has superior discrimination compared to the three-tiered model in predicting prostate cancer death across different age and treatment groups. Crucially, it identifies distinct sub-groups of men within the old intermediate-risk and high-risk criteria who have very different prognostic outcomes. We therefore propose adoption of the CPG model as a simple-to-use but more accurate prognostic stratification tool to help guide management for men with newly diagnosed prostate cancer.

Expression of immunogenic structural proteins of cyprinid herpesvirus 3 in vitro assessed using immunofluorescence.

Cyprinid herpesvirus 3 (CyHV-3), also called koi herpesvirus (KHV), is the aetiological agent of a fatal disease in carp and koi (Cyprinus carpio L.), referred to as koi herpesvirus disease. The virus contains at least 40 structural proteins, of which few have been characterised with respect to their immunogenicity. Indirect immunofluorescence assays (IFAs) using two epitope-specific monoclonal antibodies (MAbs) were used to examine the expression kinetics of two potentially immunogenic and diagnostically relevant viral antigens, an envelope glycoprotein and a capsid-associated protein. The rate of expression of these antigens was determined following a time-course of infection in two CyHV-3 susceptible cell lines. The results were quantified using an IFA, performed in microtitre plates, and image analysis was used to analyse confocal micrographs, enabling measurement of differential virus-associated fluorescence and nucleus-associated fluorescence from stacks of captured scans. An 8-tenfold increase in capsid-associated protein expression was observed during the first 5 days post-infection compared to a ≤ 2-fold increase in glycoprotein expression. A dominant protein of ~100 kDa reacted with the capsid-associated MAb (20F10) in western blot analysis. This band was also recognised by sera obtained from carp infected with CyHV-3, indicating that this capsid-associated protein is produced in abundance during infection in vitro and is immunogenic to carp. Mass spectrometry carried out on this protein identified it as a previously uncharacterised product of open reading frame 84. This abundantly expressed and immunogenic capsid-associated antigen may be a useful candidate for KHV serological diagnostics.

Ten years of imaging for pulmonary embolism: too many scans or the tip of an iceberg?

AIM: To examine the number and nature of investigations performed for suspected pulmonary embolism (PE) in a large teaching hospital and the change in incidence and severity of PE over a decade. MATERIALS AND METHODS: In this retrospective study, all patients investigated for suspected PE using computed tomography pulmonary angiography (CTPA) or lung scintigraphy during 10 years to March 2012 were identified and their records reviewed. In the final year, all reportedly positive CTPA cases were reviewed and PE severity calculated, for comparison with similar historical data. RESULTS: From 2002 to 2012, total annual investigations for suspected acute PE increased by 163% (805 to 2121). CTPA increased by 325% (475 to 2019). Detection of PE increased by 121% (193 to 426 per annum), with stable distribution of severity scores. The positive scan rate decreased from 24% to 20%. The mean age of patients being investigated for PE increased from 56 to 63 years. CONCLUSIONS: Increased detection of PE is not due to disproportionate increase in small PEs, but to increased detection of PE of all severities. This finding supports the hypothesis that PE is more common in the general population than previously appreciated, which may represent an iceberg phenomenon of previously undetected disease.

Applying the resources and supports in self-management framework to examine ophthalmologist-patient communication and glaucoma medication adherence.

Little is known about how ophthalmologist-patient communication over time is associated with glaucoma patient long-term adherence. The purpose of our study was to examine the association between provider use of components of the resources and supports in self-management model when communicating with patients and adherence to glaucoma medications measured electronically over an 8-month period. In this longitudinal prospective cohort study, the main variables studied were ophthalmologist communication-individualized assessment, collaborative goal setting and skills enhancement. Patients with glaucoma who were newly prescribed or on glaucoma medications were recruited from six ophthalmology clinics. Patients' baseline and next follow-up visits were videotape-recorded. Patients were interviewed after their visits. Patients used medication event monitoring systems (MEMS) for 8 months after enrollment into the study, and adherence was measured electronically using MEMS for 240 days after their visits. Two hundred and seventy-nine patients participated. Patient race and regimen complexity were negatively associated with glaucoma medication adherence over an 8-month period. Provider communication behaviors, including providing education and positive reinforcement, can improve patient adherence to glaucoma medications over an 8-month period.

Association between low cortical bone mineral density, soft-tissue calcification, vascular calcification and chondrocalcinosis: a case-control study.

OBJECTIVES: To examine the association between bone mineral density (BMD), soft-tissue calcification, vascular calcification and chondrocalcinosis (CC). METHODS: A case-control study within the Genetics of Osteoarthritis and Lifestyle (GOAL) database (n=3170). All GOAL participants completed a questionnaire self-reporting current and early adult life exposures. Radiographs of knees, hands and pelvis were scored for osteoarthritis (OA), CC, pelvic vascular calcification, peri-articular knee calcification and metacarpal index (MCI-measure of cortical BMD). Calcaneal dual-energy X-ray absorptiometry (DEXA) was performed. Cases had radiographic CC, while controls did not have CC at any radiographed site. OR, 95% CI were used to measure association between risk factors and CC. Logistic regression was used to adjust for confounding and to estimate the adjusted OR (aOR). RESULTS: Low MCI (aOR (95%) for CC in 1st tertile 1.41 (1.06 to 1.89), with 3rd tertile referent), soft-tissue calcification (aOR (95%) for CC 1.81 (1.36 to 2.42)), and vascular calcification (aOR (95%) for CC 1.76 (1.13 to 2.75)) independently associated with CC. There was a negative association between body mass index and CC (aOR (95%) for CC in 2nd and 3rd tertiles 0.68 (0.53 to 0.89), and 0.67 (0.51 to 0.88) respectively with 1st tertile referent). Age and OA associated with CC. However, only age and low MCI independently associated with CC at >1 joint. Self-reported meniscectomy, low cortical BMD, vascular calcification, and soft-tissue calcification independently associated with knee CC. CONCLUSIONS: This study identifies several novel associations of CC including low cortical BMD. The association between vascular calcification, soft-tissue calcification, and CC suggests a generalised constitutional predisposition to calcium crystal formation.

Changing clinical patterns and increasing prevalence in CADASIL.

OBJECTIVES: CADASIL is a monogenic small vessel vasculopathy causing recurrent stroke. Early descriptions suggested dementia and disability were common from the 5th decade but there is evidence of marked phenotypic variability. We investigated the prevalence and clinical features of CADASIL in the west of Scotland. METHODS: We undertook a retrospective review of clinical records of patients with confirmed CADASIL identified through a specialist clinic. Patients were divided to examine the effect of date of diagnosis on clinical outcomes and the characteristics at different ages. The location of pedigree members was used to estimate prevalence. RESULTS: Twenty-one different CADASIL-causing NOTCH3 mutations were identified in 49 pedigrees (61% in exon 4). Disease prevalence in Glasgow was 4.6/100,000 adults. Mutation prevalence was estimated at 10.7/100,000 population. Median age at first stroke in women (57 years) was higher than previous estimates, and stroke age in men was higher in patients diagnosed more recently (pre 2006 46 years, post 2006 56 years, P=0.034). In patients over 58 years of age, 13/34 (38%) were living independently and 17/28 (61%) were mobile without aids when last seen. CONCLUSIONS: CADASIL prevalence is at least 4.6 per 100,000 adults. Median age of first stroke may be older than previously thought. Clinicians should consider CADASIL in the differential diagnosis even in older patients with stroke.

Mapping Segregation Patterns of Hospital Care among Patients with Limited English Proficiency.

Individuals with limited English proficiency (LEP) are disproportionately more likely to experience suboptimal care outcomes compared to English-proficient individuals, attributed to multi-level social determinants of health, including the quality of the hospital where LEP patients are more likely to receive care. Evidence demonstrates that racial minority patients are more often admitted to lower-quality hospitals serving high proportions of minority patients, despite living closer to higher-quality hospitals. Less is known about where individuals with LEP reside, where they seek hospital care, and the quality of care in these hospitals. Using Geographic Information Systems (GIS) methods, we developed a density map characterizing residential patterns of the LEP population across zip code tabulation areas in New Jersey and designated hospitals as high, middle, or low-LEP volume. We described differences in 30-day hospital wide readmission rates for hospitals across varying LEP volume status using Centers for Medicare and Medicaid Services Hospital Care Compare Data. Most hospitals in ZCTAs with higher LEP populations serve a high proportion of LEP patients (i.e. their patients' demographics are reflective of the community in which they are located). However, our results also show instances in which LEP patients may be forgoing receiving care at closer hospitals to instead receive care at further-distanced, high-LEP volume hospitals. significant. High-LEP volume hospitals have higher 30-day hospital wide readmission rates (20.1%) compared to middle (15%) and low (11.3%)-LEP volume hospitals (p < .001), indicating lower quality of care within high-LEP volume hospitals.

Examining the economic impacts of caregiving among families of children of medical complexity: A qualitative study to inform inclusive economic models.

BACKGROUND: Children with medical complexity (CMC) represent a heterogeneous group of children with multiple, chronic healthcare conditions. Caregivers of CMC experience a high intensity of caregiving that is often variable, extends across several networks of care, and often lasts for the entirety of the child's life. The economic impacts of caregiving are yet understudied in the CMC context. There have been recognized limitations to the sole use of quantitative methods when developing economic models of disease because they lack direct caregiver voice and context of caregiving activities and existing methods have been noted to be ableist. OBJECTIVE: The purpose of this study was to explore the economic spillover impacts of caregiving among families of CMC using their own words and perspectives with the intent of expanding caregiver-centered perspectives when developing economic models. METHODS: This study was a secondary analysis of a qualitative study that was conducted to examine family management practices among caregivers of CMC and their social networks. Caregivers of CMC were recruited through a Pediatric Complex Care clinic at an academic medical center in the mid-Atlantic region, USA. This study used inductive qualitative descriptive methods and the use of a template to define features of the person impacted and to define the economic construct as either a direct or indirect/spillover cost. RESULTS: Twenty caregivers were included in this study. Perspectives from the caregivers of CMC revealed several key themes: (1) time investment in caregiving - impacting the primary caregivers; (2) physical and mental health impacts - impacting the child themselves, siblings, and the primary caregivers; (3) impacts to leisure activities and self-care - impacting the child themselves, siblings, and the primary caregivers; (4) impacts to the social network/social capital. CONCLUSIONS: The themes described can be operationalized into inclusive family-centered models that represent the impacts of caregiving in the context of the family units of CMC. The use of qualitative methods to expand our development of quantitative economic models can be adapted to other populations where caregivers are involved in care. Caregivers can and should have an active voice in preference-based assessments that are operationalized in economic contexts to make them more inclusive. CLINICALTRIAL: n/a. INTERNATIONAL REGISTERED REPORT: RR2-10.2196/14810.

Emergency Nurses' Reasons for Not Recommending Their Hospital to Clinicians as a Good Place to Work.

Importance: Half of emergency nurses report high burnout and intend to leave their job in the next year. Whether emergency nurses would recommend their workplace to other clinicians may be an important indicator of a hospital's ability to recruit clinicians. Objective: To examine why emergency nurses do not recommend their hospital to other clinicians as a good place to work. Design, Setting, and Participants: This qualitative study used directed content analysis of open-text responses (n = 142) from the RN4CAST-NY/IL survey of registered nurses licensed in New York and Illinois between April 13 and June 22, 2021. Inductive and deductive analytic approaches guided study theme development informed by the Social Ecological Model. The collected data were analyzed from April to June 2023. Main Outcomes and Measures: Nurses who answered "probably not" or "definitely not" to the survey question, "Would you recommend your place of employment as a good place to work?" were prompted to provide a rationale in an open-text response. Results: In this qualitative study of 142 emergency nurses (mean [SD] age, 43.5 [12.5] years; 113 [79.6%] female; mean [SD] experience, 14.0 [12.2] years), 94 (66.2%) were licensed to work in New York and the other 48 (33.8%) in Illinois. Five themes and associated subthemes emerged from the data. Themes conveyed understaffing of nurses and ancillary support (theme 1: unlimited patients with limited support); inadequate responsiveness from unit management to work environment safety concerns (theme 2: unanswered calls for help); perceptions that nurses' licenses were in jeopardy given unsafe working conditions and compromised care quality (theme 3: license always on the line); workplace violence on a patient-to-nurse, clinician-to-nurse, and systems level (theme 4: multidimensional workplace violence); and nurse reports of being undervalued by hospital management and unfulfilled at work in delivering suboptimal care to patients in unsafe working conditions (theme 5: undervalued and unfulfilled). Conclusions and Relevance: This study found that emergency department nurses did not recommend their workplace to other clinicians as a good place to work because of poor nurse and ancillary staffing, nonresponsive hospital leadership, unsafe working conditions, workplace violence, and a lack of feeling valued. These findings inform aspects of the work environment that employers can address to improve nurse recruitment and retention.

Top Factors in Nurses Ending Health Care Employment Between 2018 and 2021.

Importance: The increase in new registered nurses is expected to outpace retirements, yet health care systems continue to struggle with recruiting and retaining nurses. Objective: To examine the top contributing factors to nurses ending health care employment between 2018 and 2021 in New York and Illinois. Design, Setting, and Participants: This cross-sectional study analyzed survey data (RN4CAST-NY/IL) from registered nurses in New York and Illinois from April 13 to June 22, 2021. Differences in contributing factors to ending health care employment are described by nurses' age, employment status, and prior setting of employment and through exemplar nurse quotes. Main Outcomes and Measures: Nurses were asked to select all that apply from a list of contributing factors for ending health care employment, and the percentage of nurse respondents per contributing factor were reported. Results: A total of 7887 nurses (mean [SD] age, 60.1 [12.9] years; 7372 [93%] female) who recently ended health care employment after a mean (SD) of 30.8 (15.1) years of experience were included in the study. Although planned retirement was the leading factor (3047 [39%]), nurses also cited burnout or emotional exhaustion (2039 [26%]), insufficient staffing (1687 [21%]), and family obligations (1456 [18%]) as other top contributing factors. Among retired nurses, 2022 (41%) ended health care employment for reasons other than planned retirement, including burnout or emotional exhaustion (1099 [22%]) and insufficient staffing (888 [18%]). The age distribution of nurses not employed in health care was similar to that of nurses currently employed in health care, suggesting that a demographically similar, already existing supply of nurses could be attracted back into health care employment. Conclusions and Relevance: In this cross-sectional study, nurses primarily ended health care employment due to systemic features of their employer. Reducing and preventing burnout, improving nurse staffing levels, and supporting nurses' work-life balance (eg, childcare needs, weekday schedules, and shorter shift lengths) are within the scope of employers and may improve nurse retention.