Insurance-based Disparities in Outcomes and Extracorporeal Membrane Oxygenation Utilization for Hospitalized COVID-19 Patients.

BACKGROUND: The objective of this study was to examine insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization in patients hospitalized with COVID-19. METHODS: Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, nonhome discharge, and extracorporeal membrane oxygenation utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0 to 5.0%; 5.1 to 10%, 10.1 to 20%, 20.1 to 30%, and 30.1% and greater) was evaluated. Modeling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased. RESULTS: Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had nonhome discharges, 75,703 were mechanically ventilated, and 2,642 underwent extracorporeal membrane oxygenation. The adjusted odds of death were higher in patients with Medicare (adjusted odds ratio, 1.28 [95% CI, 1.21 to 1.35]; P < 0.0005), dually enrolled (adjusted odds ratio, 1.39 [95% CI, 1.30 to 1.50]; P < 0.0005), Medicaid (adjusted odds ratio, 1.28 [95% CI, 1.20 to 1.36]; P < 0.0005), and no insurance (adjusted odds ratio, 1.43 [95% CI, 1.26 to 1.62]; P < 0.0005) compared to patients with private insurance. Patients with Medicare (adjusted odds ratio, 0.47; [95% CI, 0.39 to 0.58]; P < 0.0005), dually enrolled (adjusted odds ratio, 0.32 [95% CI, 0.24 to 0.43]; P < 0.0005), Medicaid (adjusted odds ratio, 0.70 [95% CI, 0.62 to 0.79]; P < 0.0005), and no insurance (adjusted odds ratio, 0.40 [95% CI, 0.29 to 0.56]; P < 0.001) were less likely to be placed on extracorporeal membrane oxygenation than patients with private insurance. Mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased. CONCLUSIONS: Among patients with COVID-19, insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.

Nurse state legislators, 2013 to 2023.

BACKGROUND: Electing nurse legislators can help states make sound health policy. PURPOSE: To document the distribution of American nurses elected to state-level offices in 2023 and compare it to data from 2013. METHODS: We developed a directory of 2023 nurses elected to state legislatures. Data collected include state, year elected, party, committees, re-election date, and full/part-time state legislature. FINDINGS: In 2023, there were 72 nurse legislators in 36 states. These nurse legislators' affiliations were divided almost evenly between the two major parties (38 Republicans and 34 Democrats). Sixty legislators serve on health committees; 32 on finance committees. Fourteen serve in states that have full-time legislatures. The majority (n = 60) are up for re-election in 2024. In 2013, there were 97 legislators in 39 states. DISCUSSION: Over the last decade, the number of nurse legislators has declined. CONCLUSION: State legislatures play key roles in funding and regulating health policy. Identifying where nurses currently serve provides actionable information for those seeking to recruit, train, and elect nurse candidates.

Systematic review of conceptual and theoretical frameworks used in palliative care and end-of-life care research studies.

BACKGROUND: Frameworks are the conceptual underpinnings of the study. Both conceptual and theoretical frameworks are often used in palliative and end-of-life care studies to help with study design, guide, and conduct investigations. While an increasing number of investigators have included frameworks in their study, to date, there has not been a comprehensive review of frameworks that were utilized in palliative and end-of-life care research studies. AIM: To summarize conceptual and theoretical frameworks used in palliative and end-of-life care research studies. And to synthesize which of eight domains from the National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care (fourth edition) each framework belongs to. DESIGN: Systematic review. DATA SOURCES: Four electronic databases (EMBASE, the Cumulative Index to Nursing and Allied Health, PsychINFO, and PubMed) were searched from July 2010 to September 2021. RESULTS: A total 2231 citations were retrieved, of which 44 articles met eligibility. Across primary studies, 33,801 study participants were captured. Twenty-six investigators (59.1%) proposed previously unpublished frameworks. In 10 studies, investigators modified existing frameworks, mainly to overcome inherent limitations. In eight studies, investigators utilized existing frameworks referenced in previously published studies. There were eight orientations identified among 44 frameworks we reviewed (e.g. system, patient, patient-doctor). CONCLUSIONS: We examined palliative and end-of-life research studies to identify and characterize conceptual or theoretical frameworks proposed or utilized. Of 44 frameworks we reviewed, 21 studies (47.7%) were aligned with a Clinical Practice Guideline's single domain, while the rest two or more of eight guidelines in quality palliative care domains.

Health Information Technology Adoption at U.S. Home Health Care Agencies: Results from a Multi-Methods Study.

Health information technology (HIT) holds potential to transform Home Health Care (HHC), yet, little is known about its adoption in this setting. In the context of infection prevention and control, we aimed to: (1) describe challenges associated with the adoption of HIT, for example, electronic health records (EHR) and telehealth and (2) examine HHC agency characteristics associated with HIT adoption. We conducted in-depth interviews with 41 staff from 13 U.S. HHC agencies (May-October 2018), then surveyed a stratified random sample of 1506 agencies (November 2018-December 2019), of which 35.6% participated (N = 536 HHC agencies). We applied analytic weights, generating nationally-representative estimates, and computed descriptive statistics, bivariate and multivariable analyses. Four themes were identified: (1) Reflections on providing HHC without EHR; (2) Benefits of EHR; (3) Benefits of other HIT; (4) Challenges with HIT and EHR. Overall, 10% of the agencies did not have an EHR; an additional 2% were in the process of acquiring one. Sixteen percent offered telehealth, and another 4% were in the process of acquiring telehealth services. In multivariable analysis, EHR use varied significantly by geographic location and ownership, and telehealth use varied by geographic location, ownership, and size. Although HIT use has increased, our results indicate that many HHC agencies still lack the HIT needed to implement technological solutions to improve workflow and quality of care. Future research should examine the impact of HIT on patient outcomes and the impact of the COVID-19 pandemic on HIT use in HHC.

Symptom management in Chinese adults with end stage renal disease (ESRD).

BACKGROUND: With over $50 billion spent annually in the United Sates (U.S.) on patients with chronic kidney diseases, and an incidence of end-stage renal disease (ESRD) in Asian Americans that is 1.5 times higher than in Caucasians, there is a compelling need to improve symptom management strategies for this population. AIMS: 1) To identify common, bothersome symptoms and both Eastern and Western symptom-management strategies in older Chinese-American ESRD patients. 2) To validate the effectiveness of these symptom-management strategies through literature review and an expert panel. METHODS: 1) Older Chinese-Americans were surveyed to assess common ESRD symptoms and management strategies. 2) An umbrella review of patients' symptom-management strategies was conducted, and findings were confirmed by experts. RESULTS: 1) Thirty Chinese-American ESRD patients with an average age of 80 (SD = 13.08) reported strategies to manage fatigue, pain, sleep disturbance, dyspnea, anxiety, nausea and vomiting, constipation, and pruritus. 2) A total of 55 studies were included in the umbrella review. Evidence of varying quality and confirmation by experts supported the effectiveness of 33 symptom-management strategies used by Chinese-American ESRD patients. CONCLUSION: Further study is needed to understand why Chinese-American patients, on average, reported fewer symptoms compared with the general population but scored lower on quality of life measures; to validate reported amelioration strategies; to explore strategy effectiveness; and to uncover additional symptoms and strategies among older Chinese-Americans living with ESRD.

Advanced cognitive impairment among older nursing home residents.

BACKGROUND: Though work has been done studying nursing home (NH) residents with either advanced Alzheimer's disease (AD) or Alzheimer's disease related dementia (ADRD), none have distinguished between them; even though their clinical features affecting survival are different. In this study, we compared mortality risk factors and survival between NH residents with advanced AD and those with advanced ADRD. METHODS: This is a retrospective observational study, in which we examined a sample of 34,493 U.S. NH residents aged 65 and over in the Minimum Data Set (2011-2013). Incident assessment of advanced disease was defined as the first MDS assessment with severe cognitive impairment (Cognitive Functional Score equals to 4) and diagnoses of AD or ADRD. Demographics, functional limitations, and comorbidities were evaluated as mortality risk factors using Cox models. Survival was characterized with Kaplan-Maier functions. RESULTS: Of those with advanced cognitive impairment, 35 % had AD and 65 % ADRD. At the incident assessment of advanced disease, those with AD had better health compared to those with ADRD. Mortality risk factors were similar between groups (shortness of breath, difficulties eating, substantial weight-loss, diabetes mellitus, heart failure, chronic obstructive pulmonary disease, and pneumonia; all p < 0.01). However, stroke and difficulty with transfer (for women) were significant mortality risk factors only for those with advanced AD. Urinary tract infection, and hypertension (for women) only were mortality risk factors for those with advanced ADRD. Median survival was significantly shorter for the advanced ADRD group (194 days) compared to the advanced AD group (300 days). CONCLUSIONS: There were distinct mortality and survival patterns of NH residents with advanced AD and ADRD. This may help with care planning decisions regarding therapeutic and palliative care.

Federal requirements for nursing homes to include certified nursing assistants in resident care planning and interdisciplinary teams: A policy analysis.

Starting in 2016, Centers for Medicare and Medicaid Services implemented the first phase of a 3-year multi-phase plan revising the manner in which nursing homes are regulated. In this revision, attention was placed on the importance of certified nursing assistants (CNAs) to resident care and the need to empower these frontline workers. Phase II mandates that CNAs be included as members of the nursing home interdisciplinary team that develops care plans for the resident that are person-centered and comprehensive and reviews and revises these care plans after each resident assessment. While these efforts are laudable, there are no direct guidelines for how to integrate CNAs in the interdisciplinary team. We recommend the inclusion of direct guidelines, in which this policy revision clarifies the expected contributions from CNAs, their responsibilities, their role as members of the interdisciplinary team, and the expected patterns of communication between CNAs and other members of the interdisciplinary team.

Community-Based Advance Care Planning Interventions for Minority Older Adults: A Systematic Review.

Racial/ethnic minority older adults in the United States often experience access, language, and cultural barriers to advance care planning. For the current study, a systematic review was conducted to summarize and appraise the current science on community-based interventions aimed at increasing advance care planning in racial/ethnic minority older adults. Five articles met the inclusion criteria, which represented four unique interventions in Asian American (n = 2) and Hispanic (n = 2) communities. Two interventions were nurse-led workshops and two were one-onone social worker-led sessions. Outcomes measured were intention to or completion of advance directive or advance care planning discussion; and improvement in advance directive knowledge, beliefs, attitudes, and comfort related to advance care planning. Interventions increased intention to or completion of advance directives and improved advance care planning knowledge, beliefs, and attitudes. Results were inconclusive regarding promoting advance care planning discussions. Further research is needed to address the diverse needs of racial/ethnic minority older adults and barriers to advance care planning. [Journal of Gerontological Nursing, 47(5), 26-36.].

Differences in Care Provided in Urban and Rural Nursing Homes in the United States: Literature Review.

Despite evidence acknowledging disadvantages in care provided to older adults in rural nursing homes (NHs) in the United States, since 2010, no literature review has focused on differences in care provided in urban versus rural NHs. In the current study, we examined these differences by searching U.S. English-language peer-reviewed articles published after 2010 on differences in care quality in urban and rural NHs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used the Newcastle-Ottawa Scale for quality appraisal. We conducted full-text abstraction of 56 (of 286) articles, identifying 10 relevant studies. Metric specification of urban/rural location varied, and care quality measures were wide-ranging, making it difficult to interpret evidence. Limited evidence supported that rural NHs, compared to urban NHs, provided sparse mental health support and limited access to hospice care after controlling for facility and resident characteristics. Our review highlights the need for more research examining differences in quality of care between urban and rural NHs and raises several issues in current research examining urban/rural NH differences where future work is needed. [Journal of Gerontological Nursing, 47(12), 48-56.].

Palliative care and infection management at end of life in nursing homes: A descriptive survey.

BACKGROUND: Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics. AIM: The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation. DESIGN: This is a cross-sectional survey of nationally representative US nursing homes. SETTING/PARTICIPANTS: Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation. RESULTS: Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics. CONCLUSION: The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.

Nurse Staffing and Healthcare-Associated Infection, Unit-Level Analysis.

OBJECTIVE: To examine whether healthcare-associated infections (HAIs) and nurse staffing are associated using unit-level staffing data. BACKGROUND: Previous studies of the association between HAIs and nurse staffing are inconsistent and limited by methodological weaknesses. METHODS: Cross-sectional data between 2007 and 2012 from a large urban hospital system were analyzed. HAIs were diagnosed using the Centers for Disease Control and Prevention's National Healthcare Safety Network definitions. We used Cox proportional-hazards regression model to examine the association of nurse staffing (2 days before HAI onset) with HAIs after adjusting for individual risks. RESULTS: Fifteen percent of patient-days had 1 shift understaffed, defined as staffing below 80% of the unit median for a shift, and 6.2% had both day and night shifts understaffed. Patients on units with both shifts understaffed were significantly more likely to develop HAIs 2 days later. CONCLUSIONS: Understaffing is associated with increased risk of HAIs.

Cost-Effectiveness of Advanced Practice Nurses Compared to Physician-Led Care for Chronic Diseases: A Systematic Review.

Globally, advanced practice nurses (APNs) provide high-quality chronic disease care to patients, yet the cost-effectiveness of their services is minimally explored. This review aims to determine the cost-effectiveness of chronic disease care provided by APNs compared to physicians globally.

Hospital Staffing and Health Care-Associated Infections: A Systematic Review of the Literature.

BACKGROUND: Previous literature has linked the level and types of staffing of health facilities to the risk of acquiring a health care-associated infection (HAI). Investigating this relationship is challenging because of the lack of rigorous study designs and the use of varying definitions and measures of both staffing and HAIs. METHODS: The objective of this study was to understand and synthesize the most recent research on the relationship of hospital staffing and HAI risk. A systematic review was undertaken. Electronic databases MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for studies published between January 1, 2000, and November 30, 2015. RESULTS: Fifty-four articles were included in the review. The majority of studies examined the relationship between nurse staffing and HAIs (n = 50, 92.6%) and found nurse staffing variables to be associated with an increase in HAI rates (n = 40, 74.1%). Only 5 studies addressed non-nurse staffing, and those had mixed results. Physician staffing was associated with an increased HAI risk in 1 of 3 studies. Studies varied in design and methodology, as well as in their use of operational definitions and measures of staffing and HAIs. CONCLUSION: Despite the lack of consistency of the included studies, overall, the results of this systematic review demonstrate that increased staffing is related to decreased risk of acquiring HAIs. More rigorous and consistent research designs, definitions, and risk-adjusted HAI data are needed in future studies exploring this area.

Nursing Home Infection Control Program Characteristics, CMS Citations, and Implementation of Antibiotic Stewardship Policies: A National Study.

Recently, the Centers for Medicare & Medicaid Services (CMS) final rule required that nursing homes (NHs) develop an infection control program that includes an antibiotic stewardship component and employs a trained infection preventionist (IP). The objectives of this study were to provide a baseline assessment of (1) NH facility and infection control program characteristics associated with having an infection control deficiency citation and (2) associations between IP training and the presence of antibiotic stewardship policies, controlling for NH characteristics. A cross-sectional survey of 2514 randomly sampled US NHs was conducted to assess IP training, staff turnover, and infection control program characteristics (ie, frequency of infection control committee meetings and the presence of 7 antibiotic stewardship policies). Responses were linked to concurrent Certification and Survey Provider Enhanced Reporting data, which contain information about NH facility characteristics and citations. Descriptive statistics and multivariable regression analyses were conducted to account for NH characteristics. Surveys were received from 990 NHs; 922 had complete data. One-third of NHs in this sample received an infection control deficiency citation. The NHs that received deficiency citations were more likely to have committees that met weekly/monthly versus quarterly ( P < .01). The IPs in 39% of facilities had received specialized training. Less than 3% of trained IPs were certified in infection control. The NHs with trained IPs were more likely to have 5 of the 7 components of antibiotic stewardship in place (all P < .05). The IP training, although infrequent, was associated with the presence of antibiotic stewardship policies. Receiving an infection control citation was associated with more frequent infection control committee meetings. Training and support of IPs is needed to ensure infection control and antibiotic stewardship in NHs. As the CMS rule becomes implemented, more research is warranted. There is a need for increase in trained IPs in US NHs. These data can be used to evaluate the effectiveness of the CMS final rule on infection management processes in US NHs.

Differences in work environment for staff as an explanation for variation in central line bundle compliance in intensive care units.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are a common and costly quality problem, and their prevention is a national priority. A decade ago, researchers identified an evidence-based bundle of practices that reduce CLABSIs. Compliance with this bundle remains low in many hospitals. PURPOSE: The aim of this study was to assess whether differences in core aspects of work environments-workload, quality of relationships, and prioritization of quality-are associated with variation in maximal CLABSI bundle compliance, that is, compliance 95%-100% of the time in intensive care units (ICUs). METHODOLOGY/APPROACH: A cross-sectional study of hospital medical-surgical ICUs in the United States was done. Data on work environment and bundle compliance were obtained from the Prevention of Nosocomial Infections and Cost-Effectiveness Refined Survey completed in 2011 by infection prevention directors, and data on ICU and hospital characteristics were obtained from the National Healthcare Safety Network. Factor and multilevel regression analyses were conducted. FINDINGS: Reasonable workload and prioritization of quality were positively associated with maximal CLABSI bundle compliance. High-quality relationships, although a significant predictor when evaluated apart from workload and prioritization of quality, had no significant effect after accounting for these two factors. PRACTICE IMPLICATIONS: Aspects of the staff work environment are associated with maximal CLABSI bundle compliance in ICUs. Our results suggest that hospitals can foster improvement in ensuring maximal CLABSI bundle compliance-a crucial precursor to reducing CLABSI infection rates-by establishing reasonable workloads and prioritizing quality.

Quality Measures: A Stakeholder Analysis.

For quality measures, confusion and discontentment have increased, as availability of electronic data and data collection tools has expanded. We examined current issues with quality measures across 4 stakeholder groups: developers, regulators/endorsers, data collectors, and consumer advocates. There are missing quality measures, issues with data quality and purpose, questionable usability of electronic health records, and an increased measurement burden and cost. Policymakers, administrators, health care professionals, and consumers need to collaborate on measure development and selection.

Implementation of Electronic Health Records in US Nursing Homes.

While electronic health records have emerged as promising tools to help improve quality of care, nursing homes have lagged behind in implementation. This study assessed electronic health records implementation, associated facility characteristics, and potential impact on quality indicators in nursing homes. Using national Centers for Medicare & Medicaid Services and survey data for nursing homes, a cross-sectional analysis was conducted to identify variations between nursing homes that had and had not implemented electronic health records. A difference-in-differences analysis was used to estimate the longitudinal effect of electronic health records on commonly used quality indicators. Data from 927 nursing homes were examined, 49.1% of which had implemented electronic health records. Nursing homes with electronic health records were more likely to be nonprofit/government owned (P = .04) and had a lower percentage of Medicaid residents (P = .02) and higher certified nursing assistant and registered nurse staffing levels (P = .002 and .02, respectively). Difference-in-differences analysis showed greater quality improvements after implementation for five long-stay and two short-stay quality measures (P = .001 and .01, respectively) compared with those who did not implement electronic health records. Implementation rates in nursing homes are low compared with other settings, and better-resourced facilities are more likely to have implemented electronic health records. Consistent with other settings, electronic health records implementation improves quality in nursing homes, but further research is needed to better understand the mechanism for improvement and how it can best be supported.

Comparative and cost-effectiveness research: Competencies, opportunities, and training for nurse scientists.

BACKGROUND: Comparative and cost-effectiveness research develops knowledge on the everyday effectiveness and value of treatments and care delivery models. PURPOSE: To describe comparative and cost-effectiveness research; identify needed competencies for this research; identify federal funding; and describe current training opportunities. METHODS: Published recommended competencies were reviewed. Current federal funding and training opportunities were identified. A federally funded training program and other training opportunities are described. DISCUSSION: Fourteen core competencies were identified that have both analytic and theoretical foci from nursing and other fields. There are multiple sources of federal funding for research and training. Interdisciplinary training is needed. CONCLUSION: Comparative and cost-effectiveness research has the opportunity to transform health care delivery and improve the outcomes of patients. Nurses, as clinicians and scientists, are in a unique position to contribute to this important research. We encourage nurses to seek the needed interdisciplinary research training to participate in this important endeavor. We also encourage educators to use the competencies and processes identified in current training programs to help shape their doctoral programs.

Changing of the Guard: What's in Store for Healthcare Policy?

Repealing the Affordable Care Act (ACA) was a promise made by President-elect Donald Trump. Altering the ACA is a complex process and it is likely to be at least 2019 before any new program would be in place completely. We can hope there will still be an emphasis on providing high-quality healthcare efficiently, which promotes healthcare institutions to use nurses to their full scope of practice.