Identifying optimal labor and delivery nurse staffing: The case of cesarean births and nursing hours.

BACKGROUND: Numerous studies have identified a relationship between nurse staffing and adverse patient outcomes in medical / surgical patient populations. However, little is known about the impact of labor and delivery (L&D) nurse staffing and adverse birth outcomes, such as unintended cesarean delivery, in low-risk term-gestation women. PURPOSE: We examined nurse staffing patterns on the likelihood of cesarean sections (C-sections) among low- risk, full gestation births and provided a testing framework to distinguish optimal from ineffective levels of nurse staffing. METHODS: This retrospective descriptive study used hours of productive nursing time per delivery as the treatment variable to determine direct nursing time per delivery and its impact on the likelihood of a C-section. For comparisons, we also assessed the likelihood of augmentations and of inductions, as well as the number of neonatal intensive care unit (NICU) hours per birth. We limited our sample to those births between 37 and 42 weeks of gestation. Two complimentary models (the quadratic and piecewise regressions) distinguishing optimal staffing patterns from ineffective staffing patterns were developed. The study was implemented in eleven hospitals that are part of a large, integrated healthcare system in the Southwest. DISCUSSION: While a simple linear regression of the likelihood of a C-section on nursing hours per delivery indicated no statistically distinguishable effect, our 'optimal staffing' model indicated that nurse staffing hours employed by using a large sample of hospitals were actually minimizing C-sections (robustness checks are provided using similar model comparisons for the likelihood of augmentation and induction, and NICU hours). Where the optimal staffing models did not appear to be effective for augmentations, inductions, and NICU hours, we found significant differences between facilities (i.e., significant fixed effects for hospitals). In all specifications, we also controlled for weeks of gestation, race, sex of the child, and mother's age.

Adjusting rehabilitation costs and benefits for health capital: the case of low back occupational injuries.

INTRODUCTION: Case-mix adjustments for treatment/rehabilitation costs and benefits of non-traumatic injuries, such as occupational back pain, are much more difficult than adjustments for traumatic injuries. We present a new method for adjusting for severity differences in the costs and benefits of treating occupational low back injuries. METHODS: Using initial post-injury differences in the health capital of prospective sample of 1,831 occupational related back pain patients, we combine survey data with workers' compensation claim files and medical billing information to adjust the costs and benefits of treatment using multivariate techniques. RESULTS: We find that large differences in the net benefits of treatment between the three lowest cost provider groups virtually disappear once adjustments are made for worker's health capital (injury severity) at entry into treatment. CONCLUSIONS: Once adjustments are made for initial health capital immediately after injury, the net benefits of treating occupational low back pain are virtually identical for physician only care, physician plus physical therapy care, and chiropractic care. Net benefits of care are lower for combined physician/chiropractic care, and lowest for all other forms of care (principally, treatment by orthopedic surgeons). Our method is readily adapted for comparisons among individual health care/occupational rehabilitation professionals or among group practices and other health care organizations.

Satisfaction with low back pain care.

BACKGROUND: By using a unique, prospective study of occupational back pain claims, we examined health-care satisfaction by provider type and its effect on return to work. PURPOSE: We estimated satisfaction differentials by provider type, decomposing overall satisfaction into two components: bedside manner and effectiveness of care. We also examined how health-care satisfaction affects the duration of jobless claims. STUDY DESIGN: The Arizona State University Healthy Back Study (HBS) is a prospective study of work-related back pain; 1,831 workers completed a baseline interview, with follow-up interviews at 1 month, 6 months, and 1 year. The HBS merged demographic and claim characteristics from the workers' compensation claim files with self-reported severity measures, measures of satisfaction, and postonset employment from worker interviews. OUTCOME MEASURES: Overall and detailed satisfaction with treatment and workers' compensation claim duration. METHODS: We performed a nonparametric descriptive analysis of satisfaction by provider type and used multivariate regressions to decompose overall satisfaction into component parts. The duration analysis links differentials in health care satisfaction to differences in claim durations. RESULTS: Workers treated by surgeons, chiropractors (DCs), or physical therapists are more satisfied with their health care than those treated by MDs. Workers are more concerned with the effectiveness of care than with the bedside manner of their provider. A one standard deviation improvement in satisfaction with the health-care provider reduces claim duration by about 25%. CONCLUSIONS: Satisfaction with health care has a significant impact on jobless spells and varies significantly between provider types.

Self-reported severity measures as predictors of return-to-work outcomes in occupational back pain.

INTRODUCTION: We test an array of biopsychosocial, cognitive-behavioral, and work-related factors to identify the best predictors of work disability following a back injury. METHODS: We test the validity of alternative severity measures in predicting the likelihood of four distinct, mutually exclusive patterns of post-injury employment in the first year after onset of back pain. The study sample includes 959 participants in the ASU Healthy Back Study, a prospective cohort study of workers who filed claims for occupational back pain between 1999 and 2002. Self-reported severity measures include: NRS-101 measures of the intensity of back or leg pain, Roland-Morris scale of functional disability, and mental and physical components of the SF-12. RESULTS: All the severity measures have significant predictive power on return-to-work outcomes even after 1 year. Baseline physical functioning and overall mental and physical health status are more predictive of specific patterns of post-injury employment than pain intensity measures, possibly because there is considerable idiosyncratic variation in the pain intensity measures. The mental component of the SF-12, in particular, is relatively robust to alternate specifications, consistently statistically significant, and has the lowest probability significance level in explaining patterns of employment 1 year after injury.