The impact of defense counsel at bail hearings.

Roughly half of U.S. counties do not provide defense counsel at bail hearings, and few studies have documented the potential impacts of legal representation at this stage. This paper presents the results from a field experiment in Allegheny County, Pennsylvania, that provided a public defender at a defendant's initial bail hearing. The presence of a public defender decreased the use of monetary bail and pretrial detention without increasing failure to appear rates at the preliminary hearing. The intervention did, however, result in a short-term increase in rearrests on theft charges, although a theft incident would have to be at least 8.5 times as costly as a day in detention for jurisdictions to find this tradeoff undesirable.

Nurse Aide Retention in Nursing Homes.

BACKGROUND AND OBJECTIVES: The association of nurse aide retention with three quality indicators is examined. Retention is defined as the proportion of staff continuously employed in the same facility for a defined period of time. RESEARCH DESIGN AND METHODS: Data used in this investigation came from survey responses from 3,550 nursing facilities, Certification and Survey Provider Enhanced Reporting data, and the Area Resource File. Staffing characteristics, quality indicators, facility, and market information from these data sources were all measured in 2016. Nurse aide retention was measured at 1, 2, and 3 years of employment. The quality indicators examined were a count of all deficiency citations, quality of care deficiency citations, and J, K, L deficiency citations. Negative binomial regression analyses were used to study the associations between the three different retention measures and these three quality indicators. RESULTS: The 1-, 2-, and 3-year nurse aide retention measures were 53.2%, 41.4%, and 36.1%, respectively. The regression analyses show low levels of retention to be generally associated with poor performance on the three deficiency citation quality indicators examined. DISCUSSION AND IMPLICATIONS: The research presented starts to provide information on nurse aide retention as an important workforce challenge and its potential impact on quality. Retention may be an additional staffing characteristic of nursing facilities with substantial policy and practice relevance.

Organizational and Geographic Nursing Home Characteristics Associated With Increasing Prevalence of Resident Obesity in the United States.

Nursing home resident obesity increases the complexity of nursing care, and nursing homes report avoiding residents with obesity when choosing which prospective residents to accept. The objective of this study was to examine the associations between nursing home obesity prevalence rate and nursing home organizational, staffing, resident, and geographic factors within a profit maximization framework. The study cohort included U.S. Centers for Medicare and Medicaid Services data from U.S. nursing homes in 2013. Study findings supported hypothesized associations between obesity prevalence rate and higher occupancy, higher bed capacity, and multi-facility affiliation, but findings did not support a relationship between obesity prevalence rate and for-profit status.

Nursing Home Patient Safety Culture Perceptions Among US and Immigrant Nurses.

Patient safety is a global concern, yet little is known about how and whether perceptions of patient safety culture (PSC) vary by nurses' countries of origin and preparation. This is particularly important in American nursing homes (NHs), which are increasingly hiring non-US born and prepared nurses to fill staffing needs. OBJECTIVES: This study compared the PSC perceptions of foreign and domestic born and trained nurses working in urban NHs in 5 states to analyze how nurses' PSC perceptions corresponded to their personal and professional characteristics. METHODS: We distributed 3539 surveys to registered nurses and licensed practical/vocational nurses employed in 98 urban NHs across 5 states with higher percentages of internationally prepared nurse workers. Respondents' perceptions of their workplace safety culture were measured with the NH Survey on PSC survey from the Agency for Healthcare Research and Quality (AHRQ) and examined 12 dimensions of PSC. A total of 1629 returned surveys indicated a 46% returned rate. RESULTS: Results from 1133 analyzed surveys indicated that nurses born and educated abroad exhibited more favorable PSC perceptions in their workplaces, followed by nurses born abroad and educated in the United States. Nurses born and educated in the United States demonstrated the lowest perceptions of workplace PSC overall (P < 0.001). CONCLUSIONS: Although foreign born and trained nurses report higher PSC perceptions than domestically born and educated nurses, further research is needed to understand why these differences occur.

One size fits all? Disentangling the effects of tobacco taxes, laws, and control spending on adult subgroups in the United States.

Background: To determine the relative impact of each of the 3 state-level tobacco control policies (cigarette taxation, tobacco control spending, and smoke-free air [SFA] laws) on adult smoking rate overall and separately for adult subgroups in the United States. Methods: A difference-in-differences analysis was conducted with generalized propensity scores. State-level policies were merged with the individual-level Behavioral Risk Factor Surveillance System in 1995-2009. Results: State cigarette taxation was the only policy that significantly impacted smoking among the general adult population, with a 1-standard deviation increase in taxes (i.e., $0.68 in constant 2014 dollars) lowering the adult smoking rate by about a quarter of a percentage point. The taxation impact was consistent, regardless of the presence of, or interactions with, other policies. Taxation was also the only policy that significantly reduced smoking for some adult subgroups, including females, non-Hispanic whites, adults aged 51 or older, and adults with more than a high school education. However, other adult subgroups responded to the other 2 types of policies, either by mediating the taxation effect or by reducing smoking independently. Specifically, tobacco control spending reduced smoking among young adults (ages 18-25 years) and Hispanics. SFA laws affected smoking among men, young adults, non-Hispanic blacks, and Hispanics. Conclusions: State cigarette taxation is the single most important policy for reducing smoking among the general adult population. However, adult subgroups' reactions to taxes are diverse and mediated by tobacco control spending and SFA laws.

Obesity and intensive staffing needs of nursing home residents.

The objective of this study is to examine how increasing body mass index (BMI) among nursing home residents affects the amount of staffing assistance needed for activities of daily living (ADL). We analyzed 1,627,141 US nursing home residents reported in the 2013 Minimum Data Set in seven BMI categories, from underweight (BMI < 18.5 kg/m2) to obesity Class IIIB (≥50 kg/m2). Logistic regression models estimated the odds of nursing home-reported need for extensive (≥2 staff member) assistance needed for ADLs. The adjusted odds increased from 1.07 (95% Confidence Interval (95%CI) 1.06-1.08) for Class I, 1.16 (95%CI 1.14-1.17) for Class II, 1.33 (95%CI 1.31-1.35) for Class IIIA, and 1.90 (95%CI 1.86-1.95) for Class IIIB obesity residents compared to residents of normal weight. As a nursing home resident's BMI increases, especially for BMI ≥40 kg/m2, the need for extensive staffing assistance with ADLs also increases substantially.

The Impact of Worksite Clinics on Teacher Health Care Utilization and Cost, Self-Reported Health Status, and Student Academic Achievement Growth in a Public School District.

OBJECTIVE: The aim of this study was to examine the impact of worksite clinics on health care utilization and cost, self-reported health status, and student achievement growth in a public school district. METHODS: We used insurance claims, health risk assessment, and student achievement growth data for active teachers during 2007 to 2015. A difference-in-differences approach was applied to measure the impact of worksite clinics. RESULTS: Compared with using a community-based clinic as the usual source of primary care, using a worksite clinic was associated with significantly lower inpatient admissions (53 vs 31 per 1000 teacher years), annual health care cost ($5043 vs $4298 in 2016 US dollars, a difference of $62 per teacher per month), and annual absent work hours (63 vs 61). No significant differences were detected in self-reported health status or student achievement growth. CONCLUSION: Worksite clinics reduce teacher health care cost and absenteeism.

Satisfaction of Discharged Nursing Home Residents.

The psychometric properties of The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Nursing Home survey: Discharged Resident Instrument (NHCAHPS-D) are examined. A random sample of 550 nursing homes was selected from across the United States and 365 agreed to participate (participation rate = 66%). From 7,020 surveys sent to discharged residents, 4,926 were returned (response rate = 70%). The psychometric properties of the resident responses and the survey items were robust. Confirmatory factor analyses model fit statistics met the criterion for good conformance. Five of the initial NHCAHPS-D instrument domains were identified (environment, care, communication and respect, autonomy, and activities), along with a sixth (transitions) added by the authors. The standardization and reliability that NHCAHPS-D provides could facilitate the same benefits we have seen in other industries for the CAHPS family of instruments (i.e., quality improvement, reimbursement, public reporting, and benchmarking) and also become an industry standard.

Resident and Facility Factors Associated With the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set.

OBJECTIVE: This research examined resident and facility-specific factors associated with a diagnosis of a urinary tract infection (UTI) in the nursing home setting. METHOD: Minimum Data Set and Online Survey, Certification and Reporting system data were used to identify all nursing home residents in the United States on April 1, 2006, who did not have a UTI ( n = 1,138,418). Residents were followed until they contracted a UTI (9.5%), died (8.3%), left the nursing home (33.2%), or the year ended (49.0%). A Cox proportional hazards model was estimated, controlling for resident and facility characteristics and for the state of residence. RESULT: The presence of an indwelling catheter was the primary predictor of whether a resident contracted a UTI (adjusted incidence ratio = 3.35, p < .001), but only 6.1% of the residents in the sample had such a catheter. Therefore, only one eighth of the UTIs were contracted by residents with a catheter. Thus, subsequent analysis examined the populations with and without catheters separately. Demographic characteristics (such as age) have a much greater association with incidence among residents without catheters. The association with facility factors such as percentage of Medicaid residents, for-profit, and chain status was less significant. Estimates regarding staffing levels indicate that increased contact hours with more highly educated nursing staff are associated with less catheter use. DISCUSSION: Several facility-specific risk factors are of significance. Of significance, UTIs may be reduced by modifying factors such as staffing levels.

Disentangling Disadvantage: Can We Distinguish Good Teaching from Classroom Composition?

This paper investigates the use of teacher value-added estimates to assess the distribution of effective teaching across students of varying socioeconomic disadvantage in the presence of classroom composition effects. We examine, via simulations, how accurately commonly-used teacher-value added estimators recover the rank correlation between true and estimated teacher effects and a parameter representing the distribution of effective teaching. We consider various scenarios of teacher assignment, within-teacher variability in classroom composition, importance of classroom composition effects, and presence of student unobserved heterogeneity. No single model recovers without bias estimates of the distribution parameter in all the scenarios we consider. Models that rank teacher effectiveness most accurately do not necessarily recover distribution parameter estimates with less bias. Since true teacher sorting in real data is seldom known, we recommend that analysts incorporate contextual information into their decisions about model choice and we offer some guidance on how to do so.

Opportunity costs of ambulatory medical care in the United States.

OBJECTIVES: The typical focus in discussions of healthcare spending is on direct medical costs such as physician reimbursement. The indirect costs of healthcare-patient opportunity costs associated with seeking care, for example-have not been adequately quantified. We aimed to quantify the opportunity costs for adults seeking medical care for themselves or others. STUDY DESIGN: Secondary analysis of the 2003-2010 American Time Use Survey (ATUS). METHODS: We used the nationally representative 2003-2010 ATUS to estimate opportunity costs associated with ambulatory medical visits. We estimated opportunity costs for employed adults using self-reported hourly wages and for unemployed adults using a Heckman selection model. We used the Medical Expenditure Panel Survey to compare opportunity costs with direct costs (ie, patient out-of-pocket, provider reimbursement) in 2010. RESULTS: Average total time per visit was 121 minutes (95% CI, 118-124), with 37 minutes (95% CI, 36-39) of travel time and 84 minutes (95% CI, 81-86) of clinic time. The average opportunity cost per visit was $43, which exceeds the average patient's out-of-pocket payment. Total opportunity costs per year for all physician visits in the United States were $52 billion in 2010. For every dollar spent in visit reimbursement, an additional 15 cents were spent in opportunity costs. CONCLUSIONS: In the United States, opportunity costs associated with ambulatory medical care are substantial. Accounting for patient opportunity costs is important for examining US healthcare system efficiency and for evaluating methods to improve the efficient delivery of patient-centered care.

The opportunity costs of informal elder-care in the United States: new estimates from the American Time Use Survey.

OBJECTIVES: To provide nationally representative estimates of the opportunity costs of informal elder-care in the United States. DATA SOURCES: Data from the 2011 and 2012 American Time Use Survey. STUDY DESIGN: Wage is used as the measure of an individual's value of time (opportunity cost), with wages being imputed for nonworking individuals using a selection-corrected regression methodology. PRINCIPAL FINDINGS: The total opportunity costs of informal elder-care amount to $522 billion annually, while the costs of replacing this care by unskilled and skilled paid care are $221 billion and $642 billion, respectively. CONCLUSIONS: Informal caregiving remains a significant phenomenon in the United States with a high opportunity cost, although it remains more economical (in the aggregate) than skilled paid care.

Nursing home administrators' opinions of pay for performance.

The research presented here provides some descriptive information of nursing home pay for performance (P4P) initiatives and an examination of the opinions of nursing home administrators (NHAs) about P4P. Opinions on three common elements of P4P were examined: the incentive format, program format, and quality format. Information came from a mail survey of 2,426 NHAs. Most of the summary scores show that few NHAs gave positive responses to P4P. Very few NHAs believed that P4P would increase their revenues. NHAs were skeptical that P4P systems were for quality improvement and instead believed they were developed for purposes of cost reduction. Relatively few NHAs believed that P4P would improve quality of care. Given that we have limited experience with setting performance goals and incentive formats for NHAs, the findings presented may prove useful in modeling future P4P systems.

The effects of Arkansas master settlement spending on disparities in smoking.

OBJECTIVES: We assessed the effect of Master Settlement Agreement (MSA) spending on smoking disparities in Arkansas, which distinguished itself from other states by investing all of its MSA funds in health-related programs. METHODS: In 1996-2009 data from the Behavioral Risk Factor Surveillance System, we specified multivariate logistic models to examine gender and racial/ethnic disparities in smoking rates within Arkansas (a pre-post analysis) and between Arkansas and its 6 neighboring states. RESULTS: Before the MSA programs started in 2001, male Arkansans smoked more than did female Arkansans (P < .05). After the programs, smoking declined significantly among men (but not women), eliminating the gender disparity by 2009. Smoking among men in Arkansas also declined more than it did in neighboring states (P < .05). Hispanics showed a greater decline in smoking than did non-Hispanic Whites in Arkansas (but not in neighboring states). In 2001, Hispanic Arkansans smoked more than did non-Hispanic Whites (P < .05); by 2009, Hispanic Arkansans smoked significantly less than did non-Hispanic Whites (P < .05). CONCLUSIONS: MSA-funded programs were more effective in some segments of the Arkansas population than in others. Policymakers should consider targeting future MSA tobacco control programs to populations most resistant to change.

Evaluation of the Arkansas Tobacco Settlement Program: Progress During 2008 and 2009.

The Tobacco Settlement Proceeds Act, a referendum passed by Arkansans in the November 2000 election, invests Arkansas' share of the tobacco Master Settlement Agreement funds in seven health-related programs. RAND was contracted to perform a comprehensive evaluation of the progress of the seven programs in fulfilling their missions, as well as the effects of the programs on smoking and other health-related outcomes. This article discusses the Arkansas Tobacco Settlement Commission's activities and its responses to recommendations by RAND in the earlier evaluation reports and documents continued activity and progress by the seven funded programs for 2008 and 2009. The article evaluates the progress of each of the funded programs, including assessing progress in achieving programmatic goals and tracking the programs' activities and indicators. It also updates trends in outcome measures developed to monitor the effects of the funded programs on smoking and other health-related outcomes. Finally, it provides both program-specific and statewide recommendations for future program activities and funding, including ongoing strategic planning, developing evaluation measures, collaboration with other programs, and sustaining funding and growth.

The longitudinal study of turnover and the cost of turnover in emergency medical services.

BACKGROUND: Few studies have examined employee turnover and associated costs in emergency medical services (EMS). OBJECTIVE: To quantify the mean annual rate of turnover, total median cost of turnover, and median cost per termination in a diverse sample of EMS agencies. METHODS: A convenience sample of 40 EMS agencies was followed over a six-month period. Internet, telephone, and on-site data-collection methods were used to document terminations, new hires, open positions, and costs associated with turnover. The cost associated with turnover was calculated based on a modified version of the Nursing Turnover Cost Calculation Methodology (NTCCM). The NTCCM identified direct and indirect costs through a series of questions that agency administrators answered monthly during the study period. A previously tested measure of turnover to calculate the mean annual rate of turnover was used. All calculations were weighted by the size of the EMS agency roster. The mean annual rate of turnover, total median cost of turnover, and median cost per termination were determined for three categories of agency staff mix: all-paid staff, mix of paid and volunteer (mixed) staff, and all-volunteer staff. RESULTS: The overall weighted mean annual rate of turnover was 10.7%. This rate varied slightly across agency staffing mix (all-paid = 10.2%, mixed = 12.3%, all-volunteer = 12.4%). Among agencies that experienced turnover (n = 25), the weighted median cost of turnover was $71,613.75, which varied across agency staffing mix (all-paid = $86,452.05, mixed = $9,766.65, and all-volunteer = $0). The weighted median cost per termination was $6,871.51 and varied across agency staffing mix (all-paid = $7,161.38, mixed = $1,409.64, and all-volunteer = $0). CONCLUSIONS: Annual rates of turnover and costs associated with turnover vary widely across types of EMS agencies. The study's mean annual rate of turnover was lower than expected based on information appearing in the news media and EMS trade magazines. Findings provide estimates of two key workforce measures--turnover rates and costs--where previously none have existed. Local EMS directors and policymakers at all levels of government may find the results and study methodology useful toward designing and evaluating programs targeting the EMS workforce.

An examination of special focus facility nursing homes.

PURPOSE: Nursing facilities that are determined to have a greater number of quality problems, more serious problems than average, and a demonstrated pattern of quality problems are included in the Special Focus Facility (SFF) initiative. The purpose of this research was to provide descriptive information on these SFFs and to examine the quality characteristics of these facilities. DESIGN AND METHODS: The 1997 through 2008 On-line Survey, Certification And Reporting data and 2003 through 2008 Nursing Home Compare data were used. Descriptive analyses, including t tests, were used to compare the 2 groups of facilities (i.e., SFF nursing facilities and non-SFF nursing facilities). RESULTS: Staffing for registered nurses and nurse aides was lower in SFFs; all citations, quality of care citations, and J, K, and L citations were more frequent in SFFs; and quality indicators such as pressure ulcers and use of antipsychotic drugs were more prevalent in SFFs. IMPLICATIONS: SFF targeting would appear to be accurate with respect to nursing facilities having multiple poor quality issues and chronic poor quality.

The health consequences of using physical restraints in nursing homes.

BACKGROUND: Using a national longitudinal sample of nursing homes residents (N = 264,068), we examine whether physical restraint use contributes to subsequent physical or psychological health decline. METHODS: The minimum data set, the on-line survey certification and recording system, and the area resource file were the data sources used. This data represented the period of 2004 and 2005. To control for the difference in characteristics between residents who were subsequently physically restrained and who were not, we use a propensity score matching method. RESULTS: For all outcomes examined (except depression), that is, behavior issues, cognitive performance, falls, walking dependence, activities of daily living, pressure ulcers, and contractures, were all significantly worse for restrained residents compared with matched residents who were not restrained. DISCUSSION: Physical restraint use represents poor clinical practice, and the benefits to residents of further reducing physical restraint use in nursing homes are substantial.