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1.
Sociol Health Illn ; 2021 Aug 26.
Artigo em Inglês | MEDLINE | ID: mdl-34435691

RESUMO

Theories of physician dominance are a foundational contribution of medical sociology to the study of health care, but must be revisited in the light of ongoing changes in medicine. As non-physician specialists like nurse practitioners grow in number and acquire more autonomy, increasing medical profession differentiation presents a challenge for traditional physician dominance theories. After evaluating potential theoretical explanations for subordinate occupations' autonomy gains, we conduct a state-level quantitative analysis of variation in nursing policies across U.S. states. We construct our dependent variable, nursing autonomy, using seven state-level advanced practice nursing policies adopted from 2001-2017. Using an ordered scale, we code nurse practitioner, nurse anaesthetist, nurse midwife and clinical-nurse-specialist practice and prescription polices according to each policy's autonomy level. We then use time-series regression to examine theory-driven propositions regarding nursing autonomy change. Nursing autonomy has increased over time, signalling a general erosion of physician dominance. However, we find differential patterns of policy adoption, indicating that erosion is not uniform. Physicians have maintained dominance in relatively prestigious specialties (e.g. anaesthesiology) while dominance declined in others (e.g. obstetrician). Factors external to the profession, such as consumer power, continue to influence within-profession dynamics. Examining ongoing professional differentiation in medicine illustrates how physician dominance depends on shifting social and professional contexts.

2.
J Healthc Manag ; 66(1): 48-61, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33411486

RESUMO

EXECUTIVE SUMMARY: Financial distress is a persistent problem in U.S. hospitals, leading them to close at an alarming rate over the past two decades. Given the potential adverse effects of hospital closures on healthcare access and public health, interest is growing in understanding more about the financial health of U.S. hospitals. In this study, we set out to explore the extent to which relevant organizational and environmental factors potentially buffer financially distressed hospitals from closure, and even at the brink of closure, enable some to merge with other hospitals. We tested our hypotheses by first examining how factors such as slack resources, environmental munificence, and environmental complexity affect the likelihood of survival versus closing or merging with other organizations. We then tested how the same factors affect the likelihood of merging relative to closing for financially distressed hospitals that undergo one of these two events. We found that different types of slack resources and environmental forces impact different outcomes. In this article, we discuss the implications of our findings for hospital stakeholders.


Assuntos
Fechamento de Instituições de Saúde , Hospitais , American Hospital Association , Estados Unidos
3.
Health (London) ; 25(5): 596-612, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33322938

RESUMO

Case management is a representation of managed care, cost-containment organizational practices in healthcare, where managed care and its constitutive parts are situated against physician autonomy and decision-making. As a professional field, case management has evolved considerably, with the role recently taken up increasingly by Advanced Practice Nurses in various health care settings. We look at this evolution of a relatively new work task for Advanced Practice Nurses using a countervailing powers perspective, which allows us to move beyond discussions of case management effectiveness and best practices, and draw connections to trends in the social organization of healthcare, especially hospitals. We evaluated organizational (hospital-level) and environmental (county and state-level) characteristics associated with hospitals' use of Advanced Practice Nurses as case managers, using data from U.S. community acute care hospitals for 2016-2018, collected from three data sources: American Hospital Association annual survey (AHA), Centers for Medicare and Medicaid Services (CMS), and Area Resource File. Among organizational characteristics, we found that hospitals that are a part of established Accountable Care Organizations (OR = 2.55, p = 0.009; 95% CI = 1.26-5.14) and those that serve higher acuity patients, as indicated by possessing a higher Case Mix Index (OR = 1.32, p = 0.001; 95% CI = 1.13-1.55), were more likely to use Advanced Practice Nurses as case managers. Among environmental characteristics, having higher local Advanced Practice Nurses concentrations (OR = 1.24, p < 0.001; 95% CI = 1.11-1.39) was associated with hospital Advanced Practice Nurses case management service provision. Beyond the health impacts of Covid-19, its associated recession is placing families, governments and insurers under unprecedented financial stress. Governments and insurers alike are looking to reduce costs anywhere possible. This will inevitably result in increasing amounts of managed care, and decreasing reimbursements to hospitals, likely resulting in higher demand for APRN patient navigators.


Assuntos
Prática Avançada de Enfermagem/estatística & dados numéricos , Gerentes de Casos/estatística & dados numéricos , Administração Hospitalar , Organizações de Assistência Responsáveis/organização & administração , Organizações de Assistência Responsáveis/estatística & dados numéricos , Prática Avançada de Enfermagem/organização & administração , Gerentes de Casos/organização & administração , Grupos Diagnósticos Relacionados , Mão de Obra em Saúde/estatística & dados numéricos , Humanos , Papel do Profissional de Enfermagem , Gravidade do Paciente , Fatores Socioeconômicos , Estados Unidos
4.
J Rural Health ; 37(4): 684-691, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-32613667

RESUMO

BACKGROUND: Shortages of anesthesia providers in rural areas have long resulted in access limitations in many US states. This situation prompted federal legislation designed to promote increased usage of certified registered nurse anesthetists (CRNAs) in hospitals. Starting in 2001, state governors were afforded the option to adopt "opt-out" provisions, giving facilities in their states flexibility in utilizing CRNAs; specifically, adopting the opt-out policy removes physician oversight requirements for Medicare billing purposes. METHODS: We used mixed effects generalized linear models to identify predictors of CRNA service provision in hospitals from 2011-2015. RESULTS: We found that being located in an opt-out state does not result in increased odds of CRNA service provision in US hospitals. Higher levels of deprivation in counties, being located in rural geographic areas, and being a teaching hospital all influenced CRNA service provision. CONCLUSIONS: Given that we found no evidence that being in an opt-out state increases the odds of using CRNAs in hospitals, we contribute to the growing literature suggesting that states adopting the opt-out policy have not realized increased health care access or reduced health care costs. As a result of other contextual restrictions on hospitals' decision-making, simply adopting the opt-out policy has not been enough to address anesthesia provider shortages.


Assuntos
Adoção , Anestesia , Idoso , Hospitais , Humanos , Medicare , Políticas , Estados Unidos
5.
Rural Remote Health ; 20(4): 6068, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33264566

RESUMO

CONTEXT: Rural hospitals in the USA are often served by advanced practice nurses, due to the difficulty for such facilities to recruit physicians. In order to facilitate a full range of services for patients, some states permit advanced practice nurses to practice with full independence. However, many states limit their scopes of practice, resulting in the potential for limited healthcare access in underserved areas. The COVID-19 pandemic temporarily upended these arrangements for several states, as 17 governors quickly passed waivers and suspensions of physician oversight restrictions. ISSUES: Physician resistance is a primary hurdle for states that limit advanced practice nurse scopes of practice. Longstanding restrictions were removed, however, in a short period of time. The pandemic demonstrated that even governors with strong political disagreements agreed on one way that healthcare access could potentially be improved. LESSONS LEARNED: Despite longstanding concerns over patient safety when advanced practice nurses practice with full autonomy, governors quickly removed practice restrictions when faced with a crisis situation. Implied in such behavior are that policymakers were aware of advanced practice nurses' capabilities prior to the pandemic, but chose not to implement full practice authority, and that governors appeared to disagree as to whether to temporarily waive specific restrictions or suspend restrictions entirely, consistent with their political affiliation. We propose more research into understanding whether or not such changes should become permanent.


Assuntos
Prática Avançada de Enfermagem/legislação & jurisprudência , COVID-19/terapia , Acesso aos Serviços de Saúde/normas , Papel do Profissional de Enfermagem , Recursos Humanos de Enfermagem no Hospital/legislação & jurisprudência , Padrões de Prática em Enfermagem/estatística & dados numéricos , Prática Avançada de Enfermagem/estatística & dados numéricos , COVID-19/enfermagem , Acesso aos Serviços de Saúde/legislação & jurisprudência , Humanos , Recursos Humanos de Enfermagem no Hospital/estatística & dados numéricos , Assistentes Médicos/legislação & jurisprudência , Padrões de Prática em Enfermagem/legislação & jurisprudência , Serviços de Saúde Rural/organização & administração
6.
Artigo em Inglês | MEDLINE | ID: mdl-33007842

RESUMO

BACKGROUND: All states in the USA have established Workers' Compensation (WC) insurance systems/programs. WC systems address key occupational safety and health concerns. This effort uses data from a large insurance provider for the years 2011-2018 to provide estimates for WC payments, stratified by the claim severity, i.e., medical only, and indemnity. METHODS: Besides providing descriptive statistics, we used generalized estimating equations to analyze the association between the key injury characteristics (nature, source, and body part injured) and total WC payments made. We also provide the overall cost burden for the former. RESULTS: Out of the total 151,959 closed claims, 83% were medical only. The mean overall WC payment per claim for the claims that resulted in a payment was $1477 (SD: $7221). Adjusted models showed that mean payments vary by claim severity. For example, among medical only claims, the mean payment was the highest for amputations ($3849; CI: $1396, $10,608), and among disability and death related claims, ruptures cost the most ($14,285; $7772, $26,255). With frequencies taken into account, the overall cost burden was however the highest for strains. CONCLUSIONS: Workplace interventions should prioritize both the costs of claims on average and the frequency.


Assuntos
Seguradoras , Saúde do Trabalhador , Indenização aos Trabalhadores , Humanos , Local de Trabalho
7.
J Rural Health ; 36(4): 577-583, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32603017

RESUMO

BACKGROUND: Telehealth is likely to play a crucial role in treating COVID-19 patients. However, not all US hospitals possess telehealth capabilities. This brief report was designed to explore US hospitals' readiness with respect to telehealth availability. We hope to gain deeper insight into the factors affecting possession of these valuable capabilities, and how this varies between rural and urban areas. METHODS: Based on 2017 data from the American Hospital Association survey, Area Health Resource Files and Medicare cost reports, we used logistic regression models to identify predictors of telehealth and eICU capabilities in US hospitals. RESULTS: We found that larger hospitals (OR(telehealth) = 1.013; P < .01) and system members (OR(telehealth) = 1.55; P < .01) (OR(eICU) = 1.65; P < .01) had higher odds of possessing telehealth and eICU capabilities. We also found evidence suggesting that telehealth and eICU capabilities are concentrated in particular regions; the West North Central region was the most likely to possess capabilities, given that these hospitals had higher odds of possessing telehealth (OR = 1.49; P < .10) and eICU capabilities (OR = 2.15; P < .05). Rural hospitals had higher odds of possessing telehealth capabilities as compared to their urban counterparts, although this relationship was marginally significant (OR = 1.34, P < .10). CONCLUSIONS: US hospitals vary in their preparation to use telehealth to aid in the COVID-19 battle, among other issues. Hospitals' odds of possessing the capability to provide such services vary largely by region; overall, rural hospitals have more widespread telehealth capabilities than urban hospitals. There is still great potential to expand these capabilities further, especially in areas that have been hard hit by COVID-19.


Assuntos
Infecções por Coronavirus/terapia , Acesso aos Serviços de Saúde/organização & administração , Hospitais Rurais/organização & administração , Pneumonia Viral/terapia , População Rural/estatística & dados numéricos , Telemedicina/estatística & dados numéricos , Atitude do Pessoal de Saúde , Betacoronavirus , COVID-19 , Infecções por Coronavirus/epidemiologia , Registros Eletrônicos de Saúde/organização & administração , Humanos , Pandemias , Pneumonia Viral/epidemiologia , Serviços de Saúde Rural/organização & administração , SARS-CoV-2 , Estados Unidos
8.
J Healthc Qual ; 42(3): 127-135, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31821178

RESUMO

BACKGROUND: Clostridioides difficile infections (CDIs) have been identified as a major health concern due to the high morbidity, mortality, and cost of treatment. The aim of this study was to review the extant literature and identify the various patient-related, medication-related, and organizational risk factors associated with developing hospital-acquired CDIs in adult patients in the United States. METHODS: A systematic review of four (4) online databases, including Scopus, PubMed, CINAHL, and Cochrane Library, was conducted to identify empirical studies published from 2007 to 2017 pertaining to risk factors of developing hospital-acquired CDIs. FINDINGS: Thirty-eight studies (38) were included in the review. Various patient-level and medication-related risk factors were identified including advanced patient age, comorbidities, length of hospital stay, previous hospitalizations, use of probiotic medications and proton pump inhibitors. The review also identified organizational factors such as room size, academic affiliation, and geographic location to be significantly associated with hospital-acquired CDIs. CONCLUSION: Validation of the factors associated with high risk of developing hospital-acquired CDIs identified in this review can aid in the development of risk prediction models to identify patients who are at a higher risk of developing CDIs and developing quality improvement interventions that might improve patient outcomes by minimizing risk of infection.


Assuntos
Clostridioides difficile/isolamento & purificação , Infecções por Clostridium/epidemiologia , Infecções por Clostridium/prevenção & controle , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/prevenção & controle , Valor Preditivo dos Testes , Medição de Risco/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Estados Unidos/epidemiologia
9.
Perspect Health Inf Manag ; 16(Fall): 1c, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31908626

RESUMO

Technology is intended to assist with diagnosing, treating, and monitoring patients remotely. Little is known of its impact on health outcomes or how it is used for obesity management. This study reviewed the literature to identify the different types of technologies used for obesity management and their outcomes. A literature search strategy using PubMed, CINAHL, Scopus, Embase, and ABI/Inform was developed and then was vetted by two pairs of researchers. Twenty-three studies from 2010 to 2017 were identified as relevant. Mobile health, eHealth, and telehealth/telemedicine are among the most popular technologies used. Study outcome measurements include association between technology use and weight loss, changes in body mass index, dietary habits, physical activities, self-efficacy, and engagement. All studies reported positive findings between technology use and weight loss; 60 percent of the studies found statistically significant relationships. Knowledge gaps persist regarding opportunities for technology use in obesity management. Future research needs to include patient-level outcomes, cost-effectiveness, and user engagement to fully evaluate the feasibility of continued and expanded use of technology in obesity management.


Assuntos
Obesidade/terapia , Telemedicina/métodos , Índice de Massa Corporal , Aconselhamento/métodos , Dieta , Exercício Físico , Humanos , Aplicativos Móveis , Autoeficácia , Smartphone , Dispositivos Eletrônicos Vestíveis , Perda de Peso
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