A review of the effectiveness and experiences of welfare advice services co-located in health settings: A critical narrative systematic review.

We conducted a narrative systematic review to assess the health, social and financial impacts of co-located welfare services in the UK and to explore the effectiveness of and facilitators and barriers to successful implementation of these services, in order to guide future policy and practice. We searched Medline, EMBASE and other literature sources, from January 2010 to November 2020, for literature examining the impact of co-located welfare services in the UK on any outcome. The review identified 14 studies employing a range of study designs, including: one non-randomised controlled trial; one pilot randomised controlled trial; one before-and-after-study; three qualitative studies; and eight case studies. A theory of change model, developed a priori, was used as an analytical framework against which to map the evidence on how the services work, why and for whom. All studies demonstrated improved financial security for participants, generating an average of £27 of social, economic and environmental return per £1 invested. Some studies reported improved mental health for individuals accessing services. Several studies attributed subjective improvements in physical health to the service addressing key social determinants of health. Benefits to the health service were also demonstrated through reduced workload for healthcare professionals. Key components of a successful service included co-production during service development and ongoing enhanced multi-disciplinary collaboration. Overall, this review demonstrates improved financial security for participants and for the first time models the wider health and welfare benefits for participants and for health service from these services. However, given the generally poor scientific quality of the studies, care must be taken in drawing firm conclusions. There remains a need for more high quality research, using experimental methods and larger sample sizes, to further build upon this evidence base and to measure the strength of the proposed theoretical pathways in this area.

The Born in Bradford COVID-19 Research Study: Protocol for an adaptive mixed methods research study to gather actionable intelligence on the impact of COVID-19 on health inequalities amongst families living in Bradford.

The UK COVID-19 lockdown has included restricting social movement and interaction to slow the spread of disease and reduce demand on NHS acute services. It is likely that the impacts of restrictions will hit the least advantaged disproportionately and will worsen existing structural inequalities amongst deprived and ethnic minority groups. The aim of this study is to deliver rapid intelligence to enable an effective COVID-19 response, including co-production of interventions, that address key issues in the City of Bradford, UK, and nationally. In the longer term we aim to understand the impacts of the response on health trajectories and inequalities in these. In this paper we describe our approach and protocol. We plan an adaptive longitudinal mixed methods approach embedded with Born in Bradford (BiB) birth cohorts which have rich existing data (including questionnaire, routine health and biobank). All work packages (WP) interact and are ongoing. WP1 uses co-production and engagement methods with communities, decision-makers and researchers to continuously set (changing) research priorities and will, longer-term, co-produce interventions to aid the City's recovery. In WP2 repeated quantitative surveys will be administered during lockdown (April-June 2020), with three repeat surveys until 12 months post-lockdown with an ethnically diverse pool of BiB participants (parents, children aged 9-13 years, pregnant women: total sample pool N=7,652, N=5,154, N=1,800). A range of health, social, economic and education outcomes will be assessed. In WP3 priority topics identified in WP1 and WP2 will be explored qualitatively. Initial priority topics include children's mental wellbeing, health beliefs and the peri/post-natal period. Feedback loops will ensure findings are fed directly to decision-makers and communities (via WP1) to enable co-production of acceptable interventions and identify future priority topic areas. Findings will be used to aid development of local and national policy to support recovery from the pandemic and minimise health inequalities.

Experiences of lockdown during the Covid-19 pandemic: descriptive findings from a survey of families in the Born in Bradford study.

Background: Lockdown measures implemented to contain the Covid-19 virus may be increasing health inequalities, with families from deprived and ethnically diverse backgrounds most likely to be adversely affected. This paper presents findings of the experiences of the Covid-19 lockdown on families living in the multi-ethnic and deprived city of Bradford, England. Methods: Questionnaire surveys were sent during the Covid-19 UK lockdown (10th April to 30 th June 2020) to parents in two prospective birth cohort studies. Cross tabulations explored variation by ethnicity and employment status. Text from open questions were analysed using thematic analysis. Results: Of 7,652 families invited, 2,144 (28%) participated. Ethnicity of respondents was: 957 (47%) Pakistani heritage, 715 (35%) White British and 356 (18%) other. 971 (46%) live in the most deprived decile of material deprivation in England. 2,043 (95%) were mothers and 101 were partners. The results summarised below are based on the mothers' responses. Many families live in poor quality (N=574, 28%), and overcrowded (N=364, 19%) housing; this was more common in families of Pakistani heritage and other ethnicities. Financial (N=738 (37%), food (N=396, 20%), employment (N=728, 37%) and housing (N=204, 10%) insecurities were common, particularly in those who were furloughed, self-employed not working or unemployed. Clinically significant depression and anxiety symptoms were reported by 372 (19%) and 318 (16%) of the mothers and were more common in White British mothers and those with economic insecurity. Open text responses corroborated these findings and highlighted high levels of anxiety about becoming ill or dying from Covid-19. Conclusions: The experiences of the Covid-19 lockdown in this ethnically diverse and deprived population highlight a large number of families living in poor housing conditions, suffering from economic insecurity and poor mental health. There is a need for policy makers and commissioners to better support these families.

Starting school: educational development as a function of age of entry and prematurity.

OBJECTIVE: To estimate the impact on early development of prematurity and summer birth and the potential 'double disadvantage' created by starting school a year earlier than anticipated during pregnancy, due to being born preterm. DESIGN, SETTING AND PATIENTS: We investigated the impact of gestational and school-entry age on the likelihood of failing to achieve a 'Good Level of Development' (GLD) on the Early Years Foundation Stage Profile in 5-year-old children born moderate-to-late preterm using data from the Born in Bradford longitudinal birth cohort. We used hierarchical logistic regression to control for chronological maturity, and perinatal and socioeconomic factors. RESULTS: Gestational age and school-entry age were significant predictors of attaining a GLD in the 10 337 children who entered school in the correct academic year given their estimated date of delivery. The odds of not attaining a GLD increased by 1.09 (95% CI 1.06 to 1.11) for each successive week born early and by 1.17 for each month younger within the year group (95% CI 1.16 to 1.18). There was no interaction between these two effects. Children starting school a year earlier than anticipated during pregnancy were less likely to achieve a GLD compared with (1) other children born preterm (fully adjusted OR 5.51 (2.85-14.25)); (2) term summer births (3.02 (1.49-6.79)); and (3) preterm summer births who remained within their anticipated school-entry year (3.64 (1.27-11.48)). CONCLUSIONS: These results confirm the developmental risks faced by children born moderate-to-late preterm, and-for the first time-illustrate the increased risk associated with 'double disadvantage'.

Development of a Clinical Decision Rule for the Early Safe Discharge of Patients with Mild Traumatic Brain Injury and Findings on Computed Tomography Brain Scan: A Retrospective Cohort Study.

International guidelines recommend routine hospital admission for all patients with mild traumatic brain injury (TBI) who have injuries on computed tomography (CT) brain scan. Only a small proportion of these patients require neurosurgical or critical care intervention. We aimed to develop an accurate clinical decision rule to identify low-risk patients safe for discharge from the emergency department (ED) and facilitate earlier referral of those requiring intervention. A retrospective cohort study of case notes of patients admitted with initial Glasgow Coma Scale 13-15 and injuries identified by CT was completed. Data on a primary outcome measure of clinically important deterioration (indicating need for hospital admission) and secondary outcome of neurosurgery, intensive care unit admission, or intubation (indicating need for neurosurgical admission) were collected. Multi-variable logistic regression was used to derive models and a risk score predicting deterioration using routinely reported clinical and radiological candidate variables identified in a systematic review. We compared the performance of this new risk score with the Brain Injury Guideline (BIG) criteria, derived in the United States. A total of 1699 patients were included from three English major trauma centers. A total of 27.7% (95% confidence interval [CI], 25.5-29.9) met the primary and 13.1% (95% CI, 11.6-14.8) met the secondary outcomes of deterioration. The derived clinical decision rule suggests that patients with simple skull fractures or intracranial bleeding <5 mm in diameter who are fully conscious could be safely discharged from the ED. The decision rule achieved a sensitivity of 99.5% (95% CI, 98.1-99.9) and specificity of 7.4% (95% CI, 6.0-9.1) to the primary outcome. The BIG criteria achieved the same sensitivity, but lower specificity (5%). Our empirical models showed good predictive performance and outperformed the BIG criteria. This would potentially allow ED discharge of 1 in 20 patients currently admitted for observation. However, prospective external validation and economic evaluation are required.

Private and social time preference for health outcomes: A general population survey in Iran.

Despite the recent increase in economic evaluations of health care programs in low and middle income countries, there is still a surprising gap in evidence on the appropriate discount rate and the discounting of health outcomes such as quality adjusted life years (QALYs). Our study aimed to calculate the implied time preference rate for health outcomes in Iran and its key determinants. Data were gathered from one family member from each of the 650 households randomly selected in Tehran. The respondents' private and social preferences for health outcomes were calculated using the time trade-off (TTO) technique based on the discounted utility model. We investigated the main assumptions of the discounted utility model through equality of mean comparison, and the association between private time preference and key socio-economic determinants using multilevel regression analysis. The mean and median implied rates were 5.8% and 4.9% for private time preference and 25.6% and 20% for social time preference respectively. Our study confirmed that magnitude, framing and time effects have a significant impact on implied discount rates, which means that the conventional discounted utility model's main assumptions are violated in the Iranian general population. Other models of discounting which apply lower rates for far health outcomes might provide a more sensible solution to discounting health interventions with long-term impacts.

A reporting framework for describing and a typology for categorizing and analyzing the designs of health care pay for performance schemes.

BACKGROUND: Pay for Performance (P4P) has increasingly being adopted in different countries as a provider payment mechanism to improve health system performance. Evaluations of pay for performance (P4P) schemes across several countries show significant variation in effectiveness, which may be explained by differences in design. There is however no reliable framework to structure the reporting of the design or a typology to help analyse and interpret results of P4P schemes. This paper reports the development of a reporting framework and a typology of P4P schemes. METHODS: P4P design features were identified from literature and then explored using relevant theories from behavioural and economic science. These design features were then combined with the help of multidimensional tables to produce a reporting framework and a typology which was tested using 74 P4P studies. The inter-rater reliability of the typology was assessed using Fleiss' Kappa. RESULTS: A Healthcare Incentive Scheme Reporting Framework (HISReF) was developed consisting of nine design features. This was collapsed into a typology consisting of 4 items/design features. There was good inter-rater reliability on all the four items on the typology (kappa > 0.7). CONCLUSION: The HISReF provides an important first step towards establishing a common language in which intervention designers can clearly specify the content of P4P designs. Our typology may be used to aid evidence synthesis and interpretation of results of P4P schemes.

The identification and treatment of women with hyperglycaemia in pregnancy: an analysis of individual participant data, systematic reviews, meta-analyses and an economic evaluation.

BACKGROUND: Gestational diabetes mellitus (GDM) is associated with a higher risk of important adverse outcomes. Practice varies and the best strategy for identifying and treating GDM is unclear. AIM: To estimate the clinical effectiveness and cost-effectiveness of strategies for identifying and treating women with GDM. METHODS: We analysed individual participant data (IPD) from birth cohorts and conducted systematic reviews to estimate the association of maternal glucose levels with adverse perinatal outcomes; GDM prevalence; maternal characteristics/risk factors for GDM; and the effectiveness and costs of treatments. The cost-effectiveness of various strategies was estimated using a decision tree model, along with a value of information analysis to assess where future research might be worthwhile. Detailed systematic searches of MEDLINE® and MEDLINE In-Process & Other Non-Indexed Citations®, EMBASE, Cumulative Index to Nursing and Allied Health Literature Plus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment database, NHS Economic Evaluation Database, Maternity and Infant Care database and the Cochrane Methodology Register were undertaken from inception up to October 2014. RESULTS: We identified 58 studies examining maternal glucose levels and outcome associations. Analyses using IPD alone and the systematic review demonstrated continuous linear associations of fasting and post-load glucose levels with adverse perinatal outcomes, with no clear threshold below which there is no increased risk. Using IPD, we estimated glucose thresholds to identify infants at high risk of being born large for gestational age or with high adiposity; for South Asian (SA) women these thresholds were fasting and post-load glucose levels of 5.2 mmol/l and 7.2 mmol/l, respectively and for white British (WB) women they were 5.4 and 7.5 mmol/l, respectively. Prevalence using IPD and published data varied from 1.2% to 24.2% (depending on criteria and population) and was consistently two to three times higher in SA women than in WB women. Lowering thresholds to identify GDM, particularly in women of SA origin, identifies more women at risk, but increases costs. Maternal characteristics did not accurately identify women with GDM; there was limited evidence that in some populations risk factors may be useful for identifying low-risk women. Dietary modification additional to routine care reduced the risk of most adverse perinatal outcomes. Metformin (Glucophage,® Teva UK Ltd, Eastbourne, UK) and insulin were more effective than glibenclamide (Aurobindo Pharma - Milpharm Ltd, South Ruislip, Middlesex, UK). For all strategies to identify and treat GDM, the costs exceeded the health benefits. A policy of no screening/testing or treatment offered the maximum expected net monetary benefit (NMB) of £1184 at a cost-effectiveness threshold of £20,000 per quality-adjusted life-year (QALY). The NMB for the three best-performing strategies in each category (screen only, then treat; screen, test, then treat; and test all, then treat) ranged between -£1197 and -£1210. Further research to reduce uncertainty around potential longer-term benefits for the mothers and offspring, find ways of improving the accuracy of identifying women with GDM, and reduce costs of identification and treatment would be worthwhile. LIMITATIONS: We did not have access to IPD from populations in the UK outside of England. Few observational studies reported longer-term associations, and treatment trials have generally reported only perinatal outcomes. CONCLUSIONS: Using the national standard cost-effectiveness threshold of £20,000 per QALY it is not cost-effective to routinely identify pregnant women for treatment of hyperglycaemia. Further research to provide evidence on longer-term outcomes, and more cost-effective ways to detect and treat GDM, would be valuable. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013004608. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Variation and ethnic inequalities in treatment of common mental disorders before, during and after pregnancy: combined analysis of routine and research data in the Born in Bradford cohort.

BACKGROUND: Common mental disorders (CMD) such as anxiety and depression during the maternal period can cause significant morbidity to the mother in addition to disrupting biological, attachment and parenting processes that affect child development. Pharmacological treatment is a first-line option for moderate to severe episodes. Many women prescribed pharmacological treatments cease them during pregnancy but it is unclear to what extent non-pharmacological options are offered as replacement. There are also concerns that treatments offered may not be proportionate to need in minority ethnic groups, but few data exist on treatment disparities in the maternal period. We examined these questions in a multi-ethnic cohort of women with CMD living in Bradford, England before, during and up to one year after pregnancy. METHODS: We searched the primary care records of women enrolled in the Born in Bradford cohort for diagnoses, symptoms, signs ('identification'), referrals for treatment, non-pharmacological and pharmacological treatment and monitoring ('treatment') related to CMD. Records were linked with maternity data to classify women identified with a CMD as treated prior to, and one year after, delivery. We examined rates and types of treatment during pregnancy, and analysed potential ethnic group differences using adjusted Poisson and multinomial logistic regression models. RESULTS: We analysed data on 2,234 women with indicators of CMD. Most women were discontinued from pharmacological treatment early in pregnancy, but this was accompanied by recorded access to non-drug treatments in only 15 % at the time of delivery. Fewer minority ethnic women accessed treatments compared to White British women despite minority ethnic women being 55-70 % more likely than White British women to have been identified with anxiety in their medical record. CONCLUSIONS: Very few women who discontinued pharmacological treatment early in their pregnancy were offered other non-pharmacological treatments as replacement, and most appeared to complete their pregnancy untreated. Further investigation is warranted to replicate the finding that minority ethnic women are more likely to be identified as being anxious or having anxiety and understand what causes the variation in access to treatments.

Evaluation of ethnic disparities in detection of depression and anxiety in primary care during the maternal period: combined analysis of routine and cohort data.

BACKGROUND: There are limited data on detection disparities of common mental disorders in minority ethnic women. AIMS: Describe the natural history of common mental disorders in primary care in the maternal period, characterise women with, and explore ethnic disparities in, detected and potentially missed common mental disorders. METHOD: Secondary analyses of linked birth cohort and primary care data involving 8991 (39.4% White British) women in Bradford. Common mental disorders were characterised through indications in the electronic medical record. Potentially missed common mental disorders were defined as an elevated General Health Questionnaire (GHQ-28) score during pregnancy with no corresponding common mental disorder markers in the medical record. RESULTS: Estimated prevalence of pre-birth common mental disorders was 9.5%, rising to 14.0% 3 years postnatally. Up to half of cases were potentially missed. Compared with White British women, minority ethnic women were twice as likely to have potentially missed common mental disorders and half as likely to have a marker of screening for common mental disorders. CONCLUSIONS: Common mental disorder detection disparities exist for minority ethnic women in the maternal period.

The dysfunctional consequences of a performance measurement system: the case of the Iranian national hospital grading programme.

OBJECTIVES: Performance measurement systems are increasingly used to reward and improve provider performance. However, such initiatives may also inadvertently induce a range of unintended and dysfunctional side-effects. This study explores the unintended and adverse consequences induced by the Iranian national hospital grading programme, which incorporates financial incentives for meeting nationally defined standards. METHODS: We interviewed key informants across four key groups with a legitimate interest in healthcare performance: four purposively selected hospitals; four health insurance organizations; the Iranian hospital accreditation body; and one grading agency. The transcribed interviews and field notes were analysed thematically, and subsequently, member checking was conducted. RESULTS: Seven dysfunctional consequences were identified: misrepresentation of data by hospitals; increased anxiety and stress among hospital employees; tunnel vision; financial pressures on poorly graded hospitals; incentives to purchase unnecessary equipment; erosion of public trust; and restricting access to hospital services by patients. These were caused by the way the grading system was implemented: poor standards of audit; the way in which the audit process was conducted; and the timing of audits. The pay for performance element of the grading system and the focus on structural aspects in the standards made improvement in grading particularly difficult for those hospitals that had been assessed as under-performing. CONCLUSION: Although the Iranian hospital grading system has resulted in a significant increase in the adoption of national standards, it has nevertheless induced a range of perverse outcomes. To mitigate these requires further refinement and recalibration of the system.

Impact of the Iranian hospital grading system on hospitals' adherence to audited standards: an examination of possible mechanisms.

INTRODUCTION: All Iranian hospitals have been subject to a grading system which determines the payments they can charge. We examined all possible pathways through which the grading system could influence hospitals' adherence to audited standards. METHODS: Using a mixed methods study we examined five stakeholder groups: hospital staff, patients, general practitioners, health insurance organisations and surveyor organisations. Data were collected via semi-structured interviews, a questionnaire survey, observation and documentary analysis. FINDINGS: Patients and general practitioners were generally unaware of the hospital grading. Hospital staff and insurance organisations were informed, but this was not found to influence the hospital staff's choice of where to work nor the insurance organisations contracting behaviour. The grading system was criticised for the performance standards' validity and the validity of hospitals' awarded results. Hospitals responded to financial and reputational incentives for achieving better grades, although gaming and misrepresentation was also reported. CONCLUSION: Pay-for-performance was the main influential factor in shaping hospitals' adherence to audit standards. Other potential mechanisms for influencing hospital behaviour, the selection mechanism and intrinsic motives, were not found to be sufficient to affect hospital behaviour.

Role of pay-for-performance in a hospital performance measurement system: a multiple case study in Iran.

Pay for performance (P4P) is becoming increasingly popular in the health care sector as a tool for encouraging performance (especially quality) improvement. Evidence about the effect of policies in hospitals is rare and generally confined to developed countries. The Iranian hospital grading system, which links the charges hospitals can make for patient stay to the results of their annual performance grading, is one of the earliest examples of P4P in the world. We report here the first evaluation of the impact of the Iranian P4P system. We conducted a multiple case study using semi-structured interviews and observation in four hospitals with different ownership and grading results, to explore responses to the grading system and the P4P policy. The data were analysed using framework analysis assisted by Atlas-ti software. The findings showed hospital behaviour was influenced by and changed in response to P4P policy, despite serious concerns about the validity of the grading standards. The main driver for such changes was hospital revenue, which acted as a direct financial incentive for private hospital managers and as a factor for public hospital managers' sense of success and reputation. Frontline staff were motivated indirectly by higher revenue flowing into investment in better facilities and working environment. Other potential mechanisms by which the grading system could have influenced behaviour [such as patient and General Practitioner (GP) referral choice] did not appear to influence hospital behaviour.

Environmental assessment and modification to prevent falls in older people.

UNLABELLED: To assess the effectiveness of an environmental falls prevention intervention delivered by qualified occupational therapists or unqualified trained assessors. DESIGN: A pilot three-armed randomized controlled trial. SETTING: Airedale National Health Service Trust catchment, North and West Yorkshire, England. PARTICIPANTS: Two hundred thirty-eight community-dwelling adults aged 70 and older with a history of falls in the previous year. INTERVENTION: Assessment and modification of the home environment of people at greater risk of falls. MEASUREMENTS: Fear of falling was the primary outcome measure, and an analysis of covariance was conducted on the area under the curve at 12 months. As a secondary outcome, falls were analysed using negative binomial regression. Quality of life and independence in activities of daily living (ADLs) were also measured. RESULTS: The intervention had no effect on fear of falling (P=.63). The occupational therapy group had significantly fewer falls than controls 12 months after the assessment (incidence rate ratio (IRR)=0.54, 95% confidence interval (CI)=0.36-0.83, P=.005). There was no significant effect on falls in the trained assessor group (IRR=0.78, 95% CI=0.51-1.21, P=.34). CONCLUSION: Environmental assessment had no effect on fear of falling. Environmental assessment prescribed by an occupational therapist significantly reduced the number of falls in high-risk individuals whereas that prescribed by a trained assessor did not. Further research in other settings is needed to confirm this, to explore the mechanisms, and to estimate cost-effectiveness.

Accuracy of child morbidity data in demographic and health surveys.

BACKGROUND: The Demographic and Health Surveys (DHSs) have been used throughout the developing world for the last 20 years to provide data on the distribution of disease in order to inform planning. Data on child illness and death are reported by mothers and are susceptible to error. METHODS: We conducted an in-depth study of the Iranian DHS carried out in 2000-2001 and reviewed 110 DHS carried out around the world to check for bias by assessing the social gradient in reported child morbidity and mortality. RESULTS: We found that the reported under-5 child morbidity and mortality rates for the 28 Iranian provinces were inversely correlated (r = -0.592, P < 0.001) and that the adjusted social gradient of child morbidity implied increased illness in those who had literate vs illiterate mothers (OR = 1.26, 95% CI 1.20-1.32) compared with a decrease in mortality with increased literacy (OR = 0.52, 95% CI 0.46-0.59). Many of the other DHSs also show increased rates of reported child diarrhoea in households with higher levels of maternal education, access to piped water and urban (vs rural) dwellings, the reverse of what is found with mortality rates. CONCLUSIONS: This suggests that there may be significant recall and reporting bias in under-5 childhood morbidity in DHSs. Caution should be used in the interpretation and use of data from DHSs and the survey methods should be reviewed.

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.

OBJECTIVE: To evaluate the performance of a routine incident reporting system in identifying patient safety incidents. DESIGN: Two stage retrospective review of patients' case notes and analysis of data submitted to the routine incident reporting system on the same patients. SETTING: A large NHS hospital in England. POPULATION: 1006 hospital admissions between January and May 2004: surgery (n=311), general medicine (n=251), elderly care (n=184), orthopaedics (n=131), urology (n=61), and three other specialties (n=68). MAIN OUTCOME MEASURES: Proportion of admissions with at least one patient safety incident; proportion and type of patient safety incidents missed by routine incident reporting and case note review methods. RESULTS: 324 patient safety incidents were identified in 230/1006 admissions (22.9%; 95% confidence interval 20.3% to 25.5%). 270 (83%) patient safety incidents were identified by case note review only, 21 (7%) by the routine reporting system only, and 33 (10%) by both methods. 110 admissions (10.9%; 9.0% to 12.8%) had at least one patient safety incident resulting in patient harm, all of which were detected by the case note review and six (5%) by the reporting system. CONCLUSION: The routine incident reporting system may be poor at identifying patient safety incidents, particularly those resulting in harm. Structured case note review may have a useful role in surveillance of routine incident reporting and associated quality improvement programmes.

Nurse staffing and healthcare outcomes: a systematic review of the international research evidence.

The relationship between quality of care and the cost of the nursing workforce is of concern to policymakers. This study assesses the evidence for a relationship between the nursing workforce and patient outcomes in the acute sector through a systematic review of international research produced since 1990 involving acute hospitals and adjusting for case mix. Twenty-two large studies of variable quality were included. They strongly suggest that higher nurse staffing and richer skill mix (especially of registered nurses) are associated with improved patient outcomes, although the effect size cannot be estimated reliably. The association appears to show diminishing marginal returns.