Access to Mental Health and Substance Use Treatment in Comprehensive Primary Care Plus.

Importance: To meet increasing demand for mental health and substance use services, the Centers for Medicare & Medicaid Services launched the 5-year Comprehensive Primary Care Plus (CPC+) demonstration in 2017, requiring primary care practices to integrate behavioral health services. Objective: To examine the association of CPC+ with access to mental health and substance use treatment before and during the COVID-19 pandemic. Design, Setting, and Participants: Using difference-in-differences analyses, this retrospective cohort study compared adults attributed to CPC+ and non-CPC+ practices, from January 1, 2018, to June 30, 2022. The study included adults aged 19 to 64 years who had depression, anxiety, or opioid use disorder (OUD) and were enrolled with a private health insurer in Pennsylvania. Data were analyzed from January to June 2023. Exposure: Receipt of care at a practice participating in CPC+. Main Outcomes and Measures: Total cost of care and the number of primary care visits for evaluation and management, community mental health center visits, psychiatric hospitalizations, substance use treatment visits (residential and nonresidential), and prescriptions filled for antidepressants, anxiolytics, buprenorphine, naltrexone, or methadone. Results: The 188 770 individuals in the sample included 102 733 adults (mean [SD] age, 49.5 [5.6] years; 57 531 women [56.4%]) attributed to 152 CPC+ practices and 86 037 adults (mean [SD] age, 51.6 [6.6] years; 47 321 women [54.9%]) attributed to 317 non-CPC+ practices. Among patients diagnosed with OUD, compared with patients attributed to non-CPC+ practices, attribution to a CPC+ practice was associated with filling more prescriptions for buprenorphine (0.117 [95% CI, 0.037 to 0.196] prescriptions per patient per quarter) and anxiolytics (0.162 [95% CI, 0.005 to 0.319] prescriptions per patient per quarter). Among patients diagnosed with depression or anxiety, attribution to a CPC+ practice was associated with more prescriptions for buprenorphine (0.024 [95% CI, 0.006 to 0.041] prescriptions per patient per quarter). Conclusions and Relevance: Findings of this cohort study suggest that individuals with an OUD who received care at a CPC+ practice filled more buprenorphine and anxiolytics prescriptions compared with patients who received care at a non-CPC+ practice. As the Centers for Medicare & Medicaid Innovation invests in advanced primary care demonstrations, it is critical to understand whether these models are associated with indicators of high-quality primary care.

The Early Impact of the COVID-19 Pandemic on Hospital Finances.

GOAL: The COVID-19 pandemic has caused both short- and long-term impacts on every aspect of society. Hospitals are among the most critical frontliners and have had to continually navigate the challenges caused by the pandemic. In this study, we examined hospitals' financial performance following the onset of the pandemic. METHODS: We used data from the Centers for Medicare & Medicaid Services Healthcare Cost Report Information System. The study sample included all general acute care and critical access hospitals that receive Medicare payments. The primary outcomes included operating margins, net patient revenues, operating expenses, and uncompensated care costs. We tested for average changes from 2019 to 2020 in hospitals' financial outcomes. We also tested for changes in financial outcomes across samples stratified by hospital characteristics: ownership type (investor-owned, nonprofit, and public), Medicaid disproportionate share hospital status, rural status, county uninsured rate quartile, and Medicaid expansion status. PRINCIPAL FINDINGS: Our sample consisted of a balanced panel of 4,059 hospitals (8,118 observations) with data spanning 2019 and 2020. Across the full sample of hospitals, operating margins declined by an average of 5.3 percentage points between 2019 and 2020, equating to a 130% reduction from 2019 levels. Underlying these margin declines, net patient revenues declined by 3.2% on average, while operating expenses increased by 1.5%. We observed no changes in uncompensated care costs despite the large number of job losses that accompanied the pandemic. When stratifying the analysis by hospital characteristics, differences were observed across ownership types. Notably, investor-owned facilities were less affected financially than nonprofit and public hospitals. Although safety-net and rural hospitals generally fared no worse than their non-safety-net and nonrural counterparts, hospitals located in Medicaid expansion states experienced steeper declines in operating margins relative to hospitals located in nonexpansion states, driven by larger relative declines in patient revenues. PRACTICAL APPLICATIONS: The operating margin declines we observed can be attributed to supply-chain issues, persistent labor shortages, and suspension of elective services. The Affordable Care Act reforms in health insurance markets likely helped to insulate hospitals from increases in uncompensated care costs. In the shifting context of the pandemic, it is important to understand hospitals' financial performance so that measures can be taken to address further financial distress that may eventually lead to increased consolidation, hospital closures, and lower quality of care. Our findings stress the need for targeted responses that are tailored to underlying hospital characteristics. Temporary and targeted increases in inpatient and outpatient service prices can help offset revenue losses from the deferment of nonurgent care. Other policies can address the ongoing workforce challenges and supply-chain issues.

Repercussions of the labor reform on nursing work in the context of the covid-19 pandemic.

OBJECTIVE: To reflect on the repercussions of the Labor Reform on nursing work during the COVID-19 pandemic. METHODS: This is a reflective study based on the legal aspects of the Labor Reform in dialog with scientific productions pertaining to nursing work. RESULTS: With the rise of the COVID-19 pandemic, the flexibilization of labor is being intensified, legally backed up by the Labor Reform. For nursing workers, the repercussions are felt in the work relationship, during the workday, in the salary, in union action, and in job protection. FINAL CONSIDERATIONS: It is evident that, after the legislative changes, there's no certainty that the flexibilization of labor and social security laws will bring favorable results in terms of economic growth, reduction of inequalities, and lower unemployment rates for the nursing workers. Therefore, the political organization of the professional categories is the way to overcome this scenario.

The Differential Impact of Medicaid Expansion on Disparities in Outcomes Following Peripheral Vascular Intervention.

BACKGROUND: Peripheral artery disease (PAD) disproportionately affects nonwhite, Hispanic/Latino, and low socioeconomic status patients, who are less likely to have insurance and routine healthcare visits. Medicaid expansion (ME) has improved insurance rates and access to care, potentially benefitting these patients. We sought to assess the impact of ME on disparities in outcomes after peripheral vascular intervention (PVI) for PAD. METHODS: A retrospective analysis of prospectively-collected Vascular Quality Initiative PVI procedures between 2011 and 2019 was conducted. The sample was restricted to first-record procedures in adults under the age 65 in states that expanded Medicaid on January 1, 2014 (ME group) or had not expanded before January 1, 2019 (non-expansion [NE] group). ME and NE groups were compared between pre-expansion (2011-2013) and post-expansion (2014- 2019) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors and clinical center and year fixed effects. Our primary outcome was 1-year major amputation. Secondary outcomes included trends in presentation, 30-day mortality, 1-year mortality, and 1-year primary and secondary patency. Outcomes were stratified by race and ethnicity. RESULTS: We examined 34,313 PVI procedures, including 20,378 with follow-up data. Rates of Medicaid insurance increased post-expansion in ME and NE states (ME 16.7% to 23.0%, P < 0.001; NE 10.0% to 11.9%, P = 0.013) while rates of self-pay decreased in ME states only (ME 4.6% to 1.8%, P < 0.001; NE 8.1% to 8.4%, P = 0.620). Adjusted difference-in-differences analysis revealed lower odds of urgent/emergent PVI among all patients and all nonwhite patients in ME states post-expansion compared to NE states (all: odds ratio [OR] 0.53 [95% confidence interval 0.33-0.87], P = 0.011; nonwhite: OR 0.41 [0.19-0.88], P = 0.023). No differences were observed for 1-year major amputation (OR 0.70 [0.43-1.14], P = 0.152), primary patency (OR 0.93 [0.63-1.38], P = 0.726), or secondary patency (OR 1.29 [0.69-2.41], P = 0.431). Odds of 1-year mortality were higher in ME states post-expansion compared to NE states (OR 2.50 [1.07-5.87], P = 0.035), although 30-day mortality was not different (OR 2.04 [0.60-6.90], P = 0.253). Notably, odds of 1-year major amputation among Hispanic/Latino patients decreased in ME states post-expansion compared to NE states (OR 0.11 [0.01-0.86], P = 0.036). CONCLUSIONS: ME was associated with lower odds of 1-year major amputation among Hispanic/Latino patients who underwent PVI for PAD. ME was also associated with lower odds of urgent/emergent procedures among patients overall and nonwhite patients specifically. However, 1-year mortality increased in the overall cohort. Further study is needed to corroborate our findings that ME may have benefits for certain underserved populations with PAD.

Medicaid Expansion and Not-For-Profit Hospitals' Financial Status: National and State-Level Estimates Using IRS and CMS Data, 2011-2016.

Several studies have shown that Medicaid expansion has improved hospital financial performance. All of these studies have either used data from the Internal Revenue Service (IRS) or the Centers for Medicare and Medicaid Services (CMS), and none of them has examined the state-level impact of expansion on hospital finances. Using data for not-for-profit hospitals from both IRS and CMS for 2011-2016, we described the difference in costs related to uncompensated care and Medicaid shortfalls. We then estimated the impact of Medicaid expansion on hospitals' financial status nationally and by state. Nationally, the estimated net effect of expansion reduced not-for-profit hospital costs by 2 percentage points based on IRS data and 0.83 percentage points based on CMS data. Across expansion states, the estimated net effects varied widely with approximately a 10-fold difference for hospitals based on IRS data and a 2-fold difference based on CMS data. Future studies should further explore the differences across IRS and CMS data.

Repercussions of the labor reform on nursing work in the context of the covid-19 pandemic / Repercusiones de la reforma laboral sobre el trabajo en enfermería en el contexto de la pandemia de COVID-19 / Repercussões da reforma trabalhistas sobre o trabalho em enfermagem no contexto da pandemia de Covid-19

ABSTRACT Objective: To reflect on the repercussions of the Labor Reform on nursing work during the COVID-19 pandemic. Methods: This is a reflective study based on the legal aspects of the Labor Reform in dialog with scientific productions pertaining to nursing work. Results: With the rise of the COVID-19 pandemic, the flexibilization of labor is being intensified, legally backed up by the Labor Reform. For nursing workers, the repercussions are felt in the work relationship, during the workday, in the salary, in union action, and in job protection. Final considerations: It is evident that, after the legislative changes, there's no certainty that the flexibilization of labor and social security laws will bring favorable results in terms of economic growth, reduction of inequalities, and lower unemployment rates for the nursing workers. Therefore, the political organization of the professional categories is the way to overcome this scenario.

RESUMEN Objetivo: Reflexionar sobre las repercusiones de la Reforma Laboral en la enfermería durante la pandemia de COVID-19. Métodos: Estudio del tipo reflexivo basado en los aspectos legales de la Reforma Laboral en diálogo con producciones científicas acerca del trabajo en enfermería. Resultados: Con la ascensión de la pandemia de COVID-19, observado el provocamiento de flexibilidad laboral, amparado jurídicamente por la Reforma Laboral. Para los/las trabajadores/as de enfermería, las repercusiones se producen en el vínculo de trabajo, en la jornada laboral, en el salario, en la actuación sindical y en la protección al empleo. Consideraciones finales: Evidenciado que, para los/las trabajadores/as de enfermería, tras los cambios legislativos, no hay seguridad de que la flexibilidad de las leyes laborales y previsiones traigan resultados favorables para el crecimiento económico, reducción de desigualdades y menores tasas de desempleo. Así, la organización política de las categorías es la vía para el enfrentamiento de ese escenario.

RESUMO Objetivo: Refletir sobre as repercussões da Reforma Trabalhista no trabalho em enfermagem durante a pandemia de COVID-19. Métodos: Trata-se de um estudo do tipo reflexivo com base nos aspectos legais da Reforma Trabalhista em diálogo com produções científicas acerca do trabalho em enfermagem. Resultados: Com a ascensão da pandemia de COVID-19, observa-se o acirramento da flexibilização do trabalho, amparado juridicamente pela Reforma Trabalhista. Para os/as trabalhadores/as da enfermagem, as repercussões dão-se no vínculo de trabalho, na jornada de trabalho, no salário, na atuação sindical e na proteção ao emprego. Considerações finais: Evidencia se que, para os/as trabalhadores/as da enfermagem, após as mudanças legislativas, não há segurança de que a flexibilização das leis trabalhistas e previdenciárias tragam resultados favoráveis para o crescimento econômico, redução das desigualdades e menores taxas de desemprego. Com isso, a organização política das categorias é a via para o enfrentamento desse cenário.

Nonprofit Hospital Community Benefits: Collaboration With Local Health Departments to Address the Drug Epidemic.

BACKGROUND: Nonprofit hospitals (NFPs) are required to provide community benefits, which have been historically focused on provision of medical care, to keep their tax exemption status. To increase hospital investment in community health, the Patient Protection and Affordable Care Act required NFPs to conduct community health needs assessments and address identified needs. Some states have leveraged this provision to encourage collaboration between NFPs and local health departments (LHDs) in local health planning. OBJECTIVE: The objective of this study was to examine the association of NFP-LHD collaboration in local health planning targeting drug use, with drug-induced mortality. RESEARCH DESIGN: We conducted difference-in-differences analyses using drug-induced mortality data from 2009 to 2016, encompassing the first 3 years after NFP-LHD collaboration in local health planning specific to drug use. We evaluated drug-induced mortality in 22 counties in which collaboration was required in comparison with that in 198 control counties. We used data collected from implementation strategy reports by NFPs and combined it with data on hospital characteristics, as well as state-level and county-level factors associated with drug-induced mortality. MEASURES: The primary outcome was county-level drug-induced mortality per 100,000 population. RESULTS: Counties, in which NFP-LHD collaboration in local health planning was required and in which NFPs and LHDs jointly prioritized drug use, experienced a deceleration in drug-induced mortality of ~8 deaths per 100,000 population compared with the mortality rate they would have experienced without collaboration. CONCLUSIONS: Collaboration between NFPs and LHDs to address drug use was associated with a deceleration in drug-induced mortality. Policymakers can leverage community benefit regulation to encourage NFP-LHD collaboration in local health planning.

Can Collaboration Between Nonprofit Hospitals and Local Health Departments Influence Population Health Investments by Nonprofit Hospitals?

BACKGROUND: The patient protection and Affordable Care Act (ACA) sought to improve population health by requiring nonprofit hospitals (NFPs) to conduct triennial community health needs assessments and address the identified needs. In this context, some states have encouraged collaboration between hospitals and local health department (LHD) to increase the focus of community benefit spending onto population health. OBJECTIVES: The aim was to examine whether a 2012 state law that required NFPs to collaborate with LHDs in local health planning influenced hospital population health improvement spending. RESEARCH DESIGN: We merged Internal Revenue Service data on NFP community benefit spending with data on hospital, county and state-level characteristics and estimated a difference-in-differences specification of hospital population health spending in 2009-2016 that compared the difference between hospitals that were required to collaborate with LHDs to those that were not, before and after the requirement. MEASURES: The primary outcome was population health spending divided by operating expenses. RESULTS: We found that the requirement for hospital-LHD collaboration was associated with increased mean population health spending of ∼$393,000-$786,000 (P=0.03). This association was significant in 2015-2016, perhaps reflecting the lag between assessments and implementation. Urban hospitals were responsible for most of the increased spending. CONCLUSIONS: Policymakers have sought to encourage hospitals to increase their investment in population health; however, overall community benefit spending on population health has remained flat. We found that requiring hospital-LHD collaboration was associated with increased hospital investment in population health. It may be that hospitals increase population health spending because collaboration improves expected effectiveness or increases hospital accountability.

Nurse contribution to the construction of health policy in the state of Bahia (1925-1930).

OBJECTIVE: to analyze the contribution of nurses to the construction of health policy in the state of Bahia, from 1925 to 1930. METHODS: qualitative research, from a historical nature. Data were retrieved from five public archives, organized in a documentary corpus, and analyzed based on the health political analysis and the social control concepts, health policy and public health. RESULTS: from 1925 to 1930, the State seized the work of the woman/nurse and established it in public health. This fact enabled the nurse's contribution to the construction of the health policy of the state of Bahia, which took place by the implementation of sanitary education actions, home visits and hygienic surveillance. FINAL CONSIDERATIONS: the female nurse's work made the health policy of the state of Bahia viable and was an ideal instrument to access homes and instruct/advise people in their daily lives to adopt behaviors that prevent the occurrence and, above all, the spread of diseases.

Renda e hábito alimentar de pessoas hipertensas / Ingresos y hábitos alimenticios de las personas hipertensas / Income and eating habits of hypertensive people

Objetivo verificar associação entre renda e hábitos alimentares de pessoas hipertensas em Multicentro de Saúde na cidade de Salvador, Bahia. Método estudo transversal, com 221 hipertensos. Coletaram-se dados sociodemográficos e de hábitos alimentares, por meio de entrevista e instrumento padronizado, no período de julho a dezembro de 2017. Realizou-se análise bivariada utilizando teste Qui-quadrado de Pearson. O nível de significância estatístico adotado foi de 5%. Resultados predominou consumo de verduras ou legumes (69,1%) e frutas (57,6%) em frequência menor que cinco dias/semana, e uso de produtos substitutivos do sal (69,6%) por pessoas com renda inferior a um salário mínimo; constatadas associações estatisticamente significantes (p=0,027, p=0,003, p=0,043, respectivamente). Conclusão a associação entre renda e hábitos alimentares de pessoas hipertensas mostrou que aquelas com renda menor que um salário mínimo consumiam com menor frequência frutas e verduras ou legumes e faziam uso de produtos substitutivos do sal.

Objetivo verificar una asociación entre los ingresos y los hábitos alimenticios de las personas hipertensas en Multicentro de Saúde en la ciudad de Salvador, Bahía. Método estudio transversal con 221 pacientes hipertensos. Los datos sociodemográficos y de hábitos alimenticios se recopilaron a través de entrevistas y un instrumento estandarizado de julio a diciembre de 2017. El análisis bivariante se realizó mediante la prueba Chi-square de Pearson. El nivel de significación estadística adoptado fue del 5%. Resultados predominio del consumo de hortalizas (69,1%) y frutas (57,6%) menos de cinco días/semana, y el uso de productos sustitutos de la sal (69,6%) por personas con ingresos inferiores a un salario mínimo; se encontraron asociaciones estadísticamente significativas (p=0,027, p=0,003, p=0,043, respectivamente). Conclusión la asociación entre los ingresos y los hábitos alimenticios de las personas hipertensas demostró que aquellos con ingresos más lentos que un salario mínimo consumían frutas y verduras con menos frecuencia y usaban productos sustitutos de la sal.

Objective to verify an association between income and eating habits of hypertensive people in Health Multicenter (Multicentro de Saúde in Portuguese) in the city of Salvador, Bahia. Method cross-sectional study with 221 hypertensive patients. Sociodemographic and eating habits data were collected through interviews and a standardized instrument from July to December 2017. Bivariate analysis was performed using Pearson's Chi-square test. The level of statistical significance adopted was 5%. Results predominance of consumption of vegetables (69.1%) and fruits (57.6%) less than five days/week, and use of salt substitute products (69.6%) by people with an income of less than one minimum wage; statistically significant associations were found (p=0.027, p=0.003, p=0.043, respectively). Conclusion the association between income and eating habits of hypertensive people showed that those with income lower than a minimum wage consumed fruits and vegetables less frequently and used salt substitute products.

Assessment of Dental Caries and Intervention in the First Permanent Molars of Brazilian Children

ABSTRACT Objective: To evaluate the prevalence of caries stages and interventions on first permanent molars (FPM) in Brazilian children. Material and Methods: Data from FPM were extracted from dental records of children aged 5-14 years of age that attended the UERJ Pediatric Dentistry Clinic. Data include patient age, sex, biofilm index, presence of carious lesions in all stages, and the treatments. Data was analyzed using the SPSS® 20.0 program. Results: A total of 158 dental records were analyzed, 587 registers were related to the caries stage and 601 related to the interventions; mean age of 8.26 (±1.4 years) and 53.2% were girls. The prevalence of active/inactive white spot(AWS/IWS) varied from 14.3% to 21.6% in right upper and lower left FPM, respectively. Enamel/dentin lesions without pulp involvement were also more prevalent in the lower arch and ranged from 3.4% for the right upper to 11.5% for the lower right FPM. Cavities with pulp involvement or indicated extraction ranged from 0% to 1.4%. Treatment included dental sealants, varying from 17.1 to 24.0% (n=126) and restorations, varying from 1.3 to 11.8% (n=38). The lower right were the most affected teeth. Conclusion: First permanent molars presented a higher prevalence of dental caries in early stages and the most prevalent treatment was related to the initial carious process, fluor therapy and sealants.

Nurse contribution to the construction of health policy in the state of Bahia (1925-1930) / Participación de la enfermera en la construcción de la política de salud en Bahia (1925-1930) / Participação da enfermeira na construção da política de saúde na Bahia (1925-1930)

ABSTRACT Objective: to analyze the contribution of nurses to the construction of health policy in the state of Bahia, from 1925 to 1930. Methods: qualitative research, from a historical nature. Data were retrieved from five public archives, organized in a documentary corpus, and analyzed based on the health political analysis and the social control concepts, health policy and public health. Results: from 1925 to 1930, the State seized the work of the woman/nurse and established it in public health. This fact enabled the nurse's contribution to the construction of the health policy of the state of Bahia, which took place by the implementation of sanitary education actions, home visits and hygienic surveillance. Final considerations: the female nurse's work made the health policy of the state of Bahia viable and was an ideal instrument to access homes and instruct/advise people in their daily lives to adopt behaviors that prevent the occurrence and, above all, the spread of diseases.

RESUMEN Objetivos: analizar la participación de la enfermera en la construcción de la política de salud en Bahia entre 1925 y 1930. Métodos: investigación cualitativa de carácter histórico. Los datos fueron recolectados en cinco archivos públicos, organizados en un corpus documental y analizados a partir del análisis político en salud y los conceptos de control social, política de salud y salud pública. Resultados: entre 1925 y 1930, el Estado se apropió del trabajo de la mujer/enfermera y lo institucionalizó en el campo de la salud pública. Este hecho dio lugar a la participación de la enfermera en la construcción de la política de salud en Bahia, que se dio a través de la operacionalización de acciones de educación en salud, visitas domiciliarias y vigilancia higiénica. Consideraciones Finales: el trabajo de la enfermera hizo viable la política de salud en Bahia y fue un instrumento ideal para ingresar a los hogares y enseñar/asesorar a las personas en su vida diaria a adoptar comportamientos para prevenir la ocurrencia de enfermedades y, sobre todo, su propagación.

RESUMO Objetivos: analisar a participação da enfermeira na construção da política de saúde na Bahia entre 1925 e 1930. Métodos: pesquisa qualitativa de natureza histórica. Os dados foram coletados em cinco arquivos públicos, organizados em um corpus documental e analisados com base na análise política em saúde e nos conceitos de controle social, política de saúde e saúde pública. Resultados: entre 1925 e 1930, o Estado apropriou-se do trabalho da mulher/enfermeira e o institucionalizou no campo da saúde pública. Esse fato ensejou a participação da enfermeira na construção da política de saúde baiana, que ocorreu por meio da operacionalização das ações de educação sanitária, visita domiciliar e vigilância higiênica. Considerações Finais: o trabalho da enfermeira viabilizou a política de saúde baiana e foi um instrumento ideal para adentrar nos domicílios e ensinar/aconselhar as pessoas em seu cotidiano a adotarem condutas que evitassem a ocorrência e, sobretudo, a propagação das doenças.

Non-profit Hospital Targeted Health Priorities and Collaboration With Local Health Departments in the First Round Post-ACA: A National Descriptive Study.

We examined the community health needs assessments (CHNA) and implementation strategies of a national sample of 785 non-profit hospitals (NFPs) from the first round after the ACA. We found that the priorities targeted in the implementation strategies were well-aligned with the top community health priorities identified in CHNAs as reported in previous studies. The top five targeted priorities included obesity, access to care, diabetes, cancer, and mental health. We also found that 34% of sample NFPs collaborated with their local health department (LHD) to produce a single CHNA for their jurisdiction. Non-profit hospitals that collaborated with a LHD on the CHNA had higher odds of selecting behavioral health community issues (i.e., substance abuse, alcohol, and mental health), while hospitals located in counties with high uninsurance rates had lower odds of targeting these community issues. Our contribution was 3-fold; first, we examined a large sample of implementation strategies to extend on previous work that examined CHNAs only. This gives a more complete picture of which community issues identified in the CHNA are actually targeted for implementation. Second, this study was the first to present information on the status of NPF collaboration with LHDs to produce a single CHNA (from the NFP perspective). Third, we examined the association between targeted priorities with NFP and county-level characteristics. The community benefit requirement and Section 9007 of the ACA present an opportunity to nudge NFPs to improve the conditions for health in the communities they serve. The ACA has also challenged institutions in the health care sector to approach health through the social determinants of health framework. This framework moves beyond the provision of acute health services and emphasizes other inputs that improve population health. In this context, NFPs are particularly well-positioned to shift their contribution to improve population health beyond their four walls. Section 9007 is one mechanism to achieve such shift and has shown some promising changes among NFPs since its passage as reflected in the findings of this study. This study can inform future research related to NPF community benefit and local health planning.

State Laws and Nonprofit Hospital Community Benefit Spending.

OBJECTIVE: To determine the association of state laws on nonprofit hospital community benefit spending. DESIGN: We used multivariate models to estimate the association between different types of state-level community benefit laws and nonprofit hospital community benefit spending from tax filings. SETTING: All 50 US states. PARTICIPANTS: A total of 2421 nonprofit short-term acute care hospital organizations that filled an internal revenue service Form 990 and Schedule H for calendar during years 2009-2015. RESULTS: Between 2009 and 2015, short-term acute care hospitals spent an average of $46 billion per year in total, or $20 million per hospital on community benefit activities. Exposure to a state-level community benefit law of any type was associated with an $8.42 (95% confidence interval: 1.20-15.64) per $1000 of total operating expense greater community benefit spending. Spending amounts and patterns varied on the basis of the type of community benefit law and hospital urbanicity. CONCLUSIONS: State laws are associated with nonprofit hospital community benefit spending. Policy makers can use community benefit laws to increase nonprofit hospital engagement with public health.

Job insecurity among nurses, nursing technicians and nursing aides in public hospitals / Precarización del trabajo de enfermeras, técnicas y auxiliares de enfermería en los hospitales públicos / Precarização do trabalho de enfermeiras, técnicas e auxiliares de Enfermagem nos hospitais públicos

ABSTRACT Objective: To identify the contribution of all the dimensions involved in job insecurity among nursing professionals in Brazilian state public hospitals. Method: This was a quantitative descriptive study conducted between March 2015 and February 2016, with nurses, nursing technicians and nursing aides. The data were analyzed using exploratory factor analysis. Results: The sample consisted of 265 nurses (n=161 with job security and n=104 outsourced) and 810 nursing technicians and nursing aides (n=597 with job security and n=213 outsourced). Among the nurses, "Working conditions" accounted for 46.8% of their job insecurity. Among nursing technicians and nursing aides "intensity of work due to work process organization" best explained the construct of job insecurity (51.2%). Conclusion: Job insecurity is expressed differently depending on the type of nursing professional. The difference in the distribution of the dimensions showed that job insecurity is related to the hierarchical position of each nursing professional in the technical division of nursing work and the role of each professional in the work process.

RESUMEN Objetivo: Identificar la contribución de las dimensiones que componen la precarización laboral en Enfermería en los hospitales públicos estaduales. Método: Estudio cuantitativo, descriptivo, realizado entre marzo de 2015 y febrero de 2016, con enfermeras, técnicas y auxiliares de enfermería. Los datos fueron analizados mediante el Análisis Factorial Exploratorio. Resultados: La muestra se constituyó de 265 enfermeras (n=161 empleadas estatutarias y n=104 tercerizadas) y 810 técnicas y auxiliares de Enfermería (n=597 empleadas estatutarias y n=213 tercerizadas). Para las enfermeras, la dimensión Condiciones laborales contribuyó en el 46,8% para la explicación de la precarización. Entre las técnicas y auxiliares, la Intensidad laboral por la organización de su proceso fue la dimensión que más explicó el constructo precarización (51,2%). Conclusión: La precarización laboral se expresa de forma distinta entre las trabajadoras. La diferencia en la distribución de las dimensiones demostró que la precarización guarda relación con la posición jerárquica de cada trabajadora en la división técnica del trabajo en Enfermería y con el lugar ocupado en el proceso laboral.

RESUMO Objetivo: Identificar a contribuição das dimensões que compõem a precarização do trabalho em Enfermagem nos hospitais públicos estaduais. Método: Estudo quantitativo, descritivo, realizado entre março de 2015 e fevereiro de 2016, com enfermeiras, técnicas e auxiliares de. Os dados foram analisados por meio da Análise Fatorial Exploratória. Resultados: A amostra constituiu-se de 265 enfermeiras (n=161 estatutárias e n=104 terceirizadas) e 810 técnicas e auxiliares de Enfermagem (n=597 estatutárias e n=213 terceirizadas). Para as enfermeiras, a dimensão Condições de trabalho contribuiu com 46,8% para a explicação da precarização. Entre as técnicas e auxiliares, a Intensidade do trabalho pela organização do seu processo foi a dimensão que mais explicou o constructo precarização (51,2%). Conclusão: A precarização do trabalho se expressa de forma distinta entre as trabalhadoras. A diferença na distribuição das dimensões demonstrou que a precarização guarda relação com a posição hierárquica de cada trabalhadora na divisão técnica do trabalho em Enfermagem e com o lugar ocupado no processo de trabalho.

Incidentes com medicamentos em unidade de urgência e emergência: análise documental / Incidentes con fármacos en unidad de urgencia y emergencia: análisis documental / Medication incidents in an outpatient emergency service: documental analysis

RESUMO Objetivo: Caracterizar incidentes com medicamentos ocorridos em unidade de urgência e emergência. Método: Pesquisa descritiva, documental, retrospectiva e quantitativa. A Classificação Internacional para a Segurança do Paciente constituiu referencial teórico para construção do instrumento de coleta e análise do conteúdo de 119 fichas de notificação e investigação de incidentes ocorridos em 2014 em hospital de ensino. Os dados foram coletados duas vezes, comparados, corrigidos e transcritos para planilha Excel. Utilizou-se do Programa SPSS 19.0 e do teste não paramétrico de Mann-Whitney para análise; valores de p<0,05 indicaram significância estatística. Resultados: Foram analisados 142 incidentes, a maioria envolvendo a equipe de enfermagem; 93,7% evitáveis; um terço com medicamentos potencialmente perigosos; a maior parte de uso parenteral. Os danos, embora raros, foram proporcionais ao tempo de detecção do erro. Prevaleceram falhas de administração, principalmente a omissão. Conclusão: A maioria dos incidentes analisados caracterizou-se como potencialmente danoso e evitável, com destaque aos fatores de pessoal como contribuintes.

RESUMEN Objetivo: Caracterizar incidentes con fármacos ocurridos en unidad de urgencia y emergencia. Método: Investigación descriptiva, documental, retrospectiva y cuantitativa. La Clasificación Internacional para a Seguridad del Paciente constituyó marco de referencia teórico para la construcción del instrumento de recolección y análisis del contenido de 119 fichas de notificación e investigación de incidentes ocurridos en 2014 en hospital de enseñanza. Los datos fueron recogidos dos veces, comparados, corregidos y transcritos en la planilla Excel. Se utilizó el Programa SPSS 19.0 y la prueba no paramétrica de Mann-Whitney para análisis; valores de p<0,05 señalaron significación estadística. Resultados: Fueron analizados 142 incidentes, la mayoría involucrando al equipo de enfermería; el 93,7% evitables; un tercio con fármacos potencialmente peligrosos; la mayor parte de uso parenteral. Los daños, aunque raros, fueron proporcionales al tiempo de detección del error. Prevalecieron fallos de administración, especialmente la omisión. Conclusión: La mayoría de los incidentes analizados se caracterizó como potencialmente dañoso y evitable, con énfasis en los factores de personal como contribuyentes.

ABSTRACT Objective: To characterize medication incidents occurred in an outpatient emergency service. Method: Descriptive, documental, retrospective and quantitative research. The International Classification for Patient Safety was the theoretical reference for the construction of the instrument used to collect and analyze the data from 119 notification and investigation forms of incidents occurred in 2014 in a teaching hospital. Data were collected twice, compared, corrected and transcribed to an Excel worksheet. The SPSS 19.0 Software and the non-parametric Mann-Whitney test were used in the analysis; p<0.05 indicated statistical significance. Results: A total of 142 incidents were analyzed, most of them involving the nursing team; 93.7% were avoidable; one-third involved high-alert medications; the majority involved parenteral administration. Harm was rare but proportional to the time elapsed for error detection. Management failures prevailed, especially omission. Conclusion: Most of the incidents analyzed were characterized as potentially harmful and avoidable, with emphasis on personnel factors as contributors.

Força de trabalho da enfermeira em serviços estaduais com gestão direta: Revelando a precarização / Nurse workforce in state services with direct management: Revealing precarization

Objetivo: Analisar a força de trabalho da enfermeira sob gestão direta da Secretaria da Saúde do Estado da Bahia. Métodos: Quantitativo analítico, censitário (N = 2.305), dados secundários de 2013. Resultados: Predominam vínculos estatutários, maioria mulheres (93,84%), com maior incorporação de homens nos últimos anos (58,45%). Trabalhadoras com muito tempo de serviço ou recentemente admitidas. Homens se encontram mais nos hospitais enquanto mulheres, nos setores administrativos. Os vencimentos se concentram em até 2 salários mínimos (61,56%). Na faixa salarial mais alta, os homens têm maior proporção e o cargo comissionado é o fator que mais agrega valor ao salário. A carga horária de 40 horas semanais é exercida por 41% das trabalhadoras. Conclusões: Enfermeiras, mesmo concursadas, vivenciam um processo de precarização do trabalho, com baixos salários e extensa carga horária. Prevalecem diferenças de gênero quanto ao tipo de serviço, valor dos salários e assunção de cargos.

Significado da regulamentação da jornada de trabalho em enfermagem / Meaning of the regulation of work day in nursing / Significado de la regulación de la jornada de trabajo en enfermería

O objetivo deste artigo foi refletir sobre o significado da regulamentação da jornada de trabalho para os trabalhadores em enfermagem. As entidades da enfermagem brasileira empreendem lutas pela regulamentação da sua jornada de trabalho há quase meio século. Atualmente, com o Projeto de Lei no 2295/2000, se pretende obter a jornada de trabalho diária de 6 horas e de 30 horas semanais. Questiona-se neste ensaio, quais implicações a regulamentação desta jornada trará para os trabalhadores? A possibilidade de maior tempo livre será utilizado para o crescimento cultural, político e técnico dos trabalhadores ou servirá para o acúmulo de mais vínculos empregatícios e de mais tempo dedicado ao consumo? Ao final as autoras tentam responder a estas perguntas e apontar suas consequências.

The purpose of this article was to reflect on the meaning of the regulation of working hours for workers in nursing. Currently, the Draft Law no 2295/2000, the objective is to ensure the workday to 6 hours daily and 30 weekly hours. One may wonder what implications this assay the regulation of this journey will bring to nursing: the possibility of more free time will be used for the cultural and technical staff of nurses and serv only for the accumulation of more employment relationships and dedicated to the consumer? At the end, we present possible answers to this question and its consequences.

El propósito de este artículo es reflexionar sobre el sentido de la regulación de las horas de trabajo para los trabajadores de enfermería. Los profesionales de enfermería brasileros emprendieron sus luchas por la reglamentación de la jornada de trabajo hace casi medio siglo. Actualmente, con el Proyecto de Ley no 2295/200, se busca garantizar una jornada laboral diaria de 6 horas y de 30 horas semanales. Preguntase en este ensayo ¿Qué implicaciones traerá para losenfermeros la reglamentación de la jornada de trabajo? La posibilidad de mayor tiempo libre será utilizado en el crecimiento cultural, político y técnico de los profesionales de enfermería o servirá apenas para acumular otros vínculos laborales y dedicación al consumo? Al final, se dan las posibles respuestas a este interrogante y sus consecuencias.