Health Policy

Geographic Variations in Health Care Workforce Training in the US: The Case of Registered Nurses (RNs)

Geographic Variations in Health Care Workforce Training in the US: The Case of Registered Nurses (RNs)
Med Care. 2011 Aug;49(8):769-74.

Blustein, Jan.
08/01/2011

Background: In the United States, registered nurses [RNs] are trained through one of three educational pathways: a diploma course; an associate's degree, or a baccalaureate degree in nursing (the BSN). A national consensus has emerged that the proportion of RNs that are baccalaureate-trained should be substantially increased. Yet achieving that goal may be difficult in areas where college graduates are unlikely to reside.


Objectives: To determine whether the level of training of the hospital registered nurse [RN] workforce varies geographically, along with the education of the local general workforce.


Research design: Cross sectional, ecological study.


Subjects: Hospital nurses who participated in the National Sample Survey of Registered Nurses [NSSRN] in 2004 (n = 16,567).


Measures. Registered Nurse training was measured as Diploma, Associates degree, or Baccalaureate degree or above. County-level general workforce quality was assessed as the adult college graduation rate. Counties were divided into US population quartiles, with the highest quartile (Q4) having more than 29.3% college graduates, and the lowest quartile (Q1) having fewer than 16.93% college graduates.


Results: Hospital RNs have a higher level of training in counties where the general population is better
educated. For example, in Q4, 55.2% of hospital RNs are baccalaureate-trained, in Q3, 50.2%; in Q2,45.2%; and in Q1, 34.9% (p < .001 for all pairwise comparisons). The association between RN training and general workforce education is found in cities, towns and rural areas.

Conclusions: Nationwide, there are substantial geographic variations in the training of hospital RNs. Educational segregation (the tendency for educated people to cluster geographically) may make it more difficult to achieve a BSN-rich nursing workforce in some areas of the US. Further work is needed to assess whether educational segregation similarly influences the distribution of other health care professionals, and whether it leads to variations in the local quality of care.

Resetting our priorities in environmental health: An example from the south-north partnership in Lake Chapala, Mexico

Resetting our priorities in environmental health: An example from the south-north partnership in Lake Chapala, Mexico
Environ Res. 2011 Aug;111(6):877-80.

Cifuentes E, Lozano Kasten F, Trasande L, Goldman RH.
08/01/2011

Lake Chapala is a major source of water for crop irrigation and subsistence fishing for a population of 300,000 people in central Mexico. Economic activities have created increasing pollution and pressure on the whole watershed resources. Previous reports of mercury concentrations detected in fish caught in Lake Chapala have raised concerns about health risks to local families who rely on fish for both their livelihood and traditional diet. Our own data has indicated that 27% of women of childbearing age have elevated hair mercury levels, and multivariable analysis indicated that frequent consumption of carp (i.e., once a week or more) was associated with significantly higher hair mercury concentrations. In this paper we describe a range of environmental health research projects. Our main priorities are to build the necessary capacities to identify sources of water pollution, enhance early detection of environmental hazardous exposures, and deliver feasible health protection measures targeting children and pregnant women. Our projects are led by the Children's Environmental Health Specialty Unit nested in the University of Guadalajara, in collaboration with the Department of Environmental Health of Harvard School of Public Health and Department of Pediatrics of the New York School of Medicine. Our partnership focuses on translation of knowledge, building capacity, advocacy and accountability. Communication will be enhanced among women's advocacy coalitions and the Ministries of Environment and Health. We see this initiative as an important pilot program with potential to be strengthened and replicated regionally and internationally.

We All Want It, but We Don't Know What It Is: Toward a Standard of Affordability for Health Insurance Premiums

We All Want It, but We Don't Know What It Is: Toward a Standard of Affordability for Health Insurance Premiums
Journal of Health Politics, Policy and Law, 2011. Volume 36 / Issue 05 / July 2011, pp 829-853, Published online

Peter Muennig, Bhaven Sampat, Nicholas Tilipman, Lawrence D. Brown and Sherry A. Glied
07/22/2011

The 2010 Patient Protection and Affordable Care Act (P.L. 111-148), or ACA, requires that U.S. citizens either purchase health insurance or pay a fine. To offset the financial burden for lower-income households, it also provides subsidies to ensure that health insurance premiums are affordable. However, relatively little work has been done on how such affordability standards should be set. The existing literature on affordability is not grounded in social norms and has methodological and theoretical flaws. To address these issues, we developed a series of hypothetical vignettes in which individual and household sociodemographic characteristics were varied. We then convened a panel of eighteen experts with extensive experience in affordability standards to evaluate the extent to which each vignette character could afford to pay for one of two health insurance plans. The panel varied with respect to political ideology and discipline. We find that there was considerable disagreement about how affordability is defined. There was also disagreement about what might be included in an affordability standard, with substantive debate surrounding whether savings, debt, education, or single parenthood is relevant. There was also substantial variation in experts' assessed affordability scores. Nevertheless, median expert affordability assessments were not far from those of ACA.

The Brazilian Health System: History, Advances, and Challenges

The Brazilian Health System: History, Advances, and Challenges
The Lancet, Vol. 377, no. 9779, pp. 1778-1797. 10.1016/S0140-6736(11)60054-8

Paim, J., C. Travassos, C. Almeida, L. Bahia, and J. Macinko
05/21/2011

Brazil is a country of continental dimensions with widespread regional and social inequalities. In this report, we examine the historical development and components of the Brazilian health system, focusing on the reform process during the past 40 years, including the creation of the Unified Health System. A defining characteristic of the contemporary health sector reform in Brazil is that it was driven by civil society rather than by governments, political parties, or international organisations. The advent of the Unified Health System increased access to health care for a substantial proportion of the Brazilian population, at a time when the system was becoming increasingly privatised. Much is still to be done if universal health care is to be achieved. Over the past 20 years, there have been other advances, including investments in human resources, science and technology, and primary care, and a substantial decentralisation process, widespread social participation, and growing public awareness of a right to health care. If the Brazilian health system is to overcome the challenges with which it is presently faced, strengthened political support is needed so that financing can be restructured and the roles of both the public and private sector can be redefined.

Robotic Surgery Claims on United States Hospital Websites

Robotic Surgery Claims on United States Hospital Websites
Journal for Healthcare Quality, Vol. 33, no. 6, pp. 48-52. DOI: 10.1111/j.1945-1474.2011.00148.x

Jin, L.X., A.M. Ibrahim, N.A. Newman, D.V. Makarov, P.J. Pronovost, and M.A. Makary
05/17/2011

To examine the prevalence and content of robotic surgery information presented on websites of U.S. hospitals. We completed a systematic analysis of 400 randomly selected U.S. hospital websites in June of 2010. Data were collected on the presence and location of robotic surgery information on a hospital's website; use of images or text provided by the manufacturer; use of direct link to manufacturer website; statements of clinical superiority; statements of improved cancer outcome; mention of a comparison group for a statement; citation of supporting data and mention of specific risks. Forty-one percent of hospital websites described robotic surgery. Among these, 37% percent presented robotic surgery on their homepage, 73% used manufacturer-provided stock images or text, and 33% linked to a manufacturer website. Statements of clinical superiority were made on 86% of websites, with 32% describing improved cancer control, and 2% described a reference group. No hospital website mentioned risks. Materials provided by hospitals regarding the surgical robot overestimate benefits, largely ignore risks and are strongly influenced by the manufacturer.

Prediction of patient-specific risk and percentile cohort risk of pathological stage outcome using continuous prostate-specific antigen measurement, clinical stage and biopsy Gleason score

Prediction of patient-specific risk and percentile cohort risk of pathological stage outcome using continuous prostate-specific antigen measurement, clinical stage and biopsy Gleason score
BJU International, Vol. 107, no. 10, pp. 1562-1569. DOI: 10.1111/j.1464-410X.2010.09692.x

Huang, Y., S. Isharwal, A. Haese, F.K.H. Chun,D.V. Makarov, Z. Feng, M. Han, E. Humphreys, J.I. Epstein, A.W. Partin, and R.W. Veltri
05/01/2011

Objectives: To develop a ‘2010 Partin Nomogram’ with total prostate-specific antigen (tPSA) as a continuous biomarker, in light of the fact that the current 2007 Partin Tables restrict the application of tPSA as a non-continuous biomarker by creating ‘groups’ for risk stratification with tPSA levels (ng/mL) of 0–2.5, 2.6–4.0, 4.1–6.0, 6.1–10.0 and >10.0. • To use a ‘predictiveness curve’ to calculate the percentile risk of a patient among the cohort.

Patients and Methods: In all, 5730 and 1646 patients were treated with radical prostatectomy (without neoadjuvant therapy) between 2000 and 2005 at the Johns Hopkins Hospital (JHH) and University Clinic Hamburg-Eppendorf (UCHE), respectively. • Multinomial logistic regression analysis was performed to create a model for predicting the risk of the four non-ordered pathological stages, i.e. organ-confined disease (OC), extraprostatic extension (EPE), and seminal vesicle (SV+) and lymph node (LN+) involvement. • Patient-specific risk was modelled as a function of the B-spline basis of tPSA (with knots at the first, second and third quartiles), clinical stage (T1c, T2a, and T2b/T2c) and biopsy Gleason score (5–6, 3 + 4 = 7, 4 + 3 = 7, 8–10).

Results: The ‘2010 Partin Nomogram’ calculates patient-specific absolute risk for all four pathological outcomes (OC, EPE, SV+, LN+) given a patient’s preoperative clinical stage, tPSA and biopsy Gleason score. • While having similar performance in terms of calibration and discriminatory power, this new model provides a more accurate prediction of patients’ pathological stage than the 2007 Partin Tables model. • The use of ‘predictiveness curves’ has also made it possible to obtain the percentile risk of a patient among the cohort and to gauge the impact of risk thresholds for making decisions regarding radical prostatectomy.

Conclusion: The ‘2010 Partin Nomogram’ using tPSA as a continuous biomarker together with the corresponding ‘predictiveness curve’ will help clinicians and patients to make improved treatment decisions.

A New Formula for Prostate Cancer Lymph Node Risk

A New Formula for Prostate Cancer Lymph Node Risk
International Journal of Radiation Oncology Biology Physics, Vol. 80, no. 1, pp. 69-75. DOI: 10.1016/j.ijrobp.2010.01.068

Yu, J.B. D.V. Makarov, and C. Gross
05/01/2011

Introduction: The successful treatment of prostate cancer depends on the accurate estimation of the risk of regional lymph node (LN) involvement. The Roach formula (RF) has been criticized as overestimating LN risk. A modification of the RF has been attempted by other investigators using simplified adjustment ratios: the Nguyen formula (NF).

Methods and Materials: The National Cancer Institute Surveillance, Epidemiology, and End Results database was investigated for patients treated in 2004 through 2006 for whom at least 10 LN were examined at radical prostatectomy, cT1c or cT2 disease, and prostate-specific antigen (PSA) <26 ng/ml (N = 2,930). The Yale formula (YF) was derived from half of the sample (n = 1,460), and validated in the other half (n = 1,470).

Results: We identified 2,930 patients. Only 4.6% of patients had LN+, and 72.6% had cT1c disease. Gleason (GS) 8–10 histology was found in 14.4% of patients. The YF for prediction of %LN+ risk is [GS – 5] × [PSA/3 + 1.5 × T], where T = 0, 1, and 2 for cT1c, cT2a, and cT2b/cT2c. Within each strata of predicted %LN+ risk, the actual %LN+ was closest to the YF. Using a >15% risk as an indicator of high-risk disease, the YF had increased sensitivity (39.0% vs. 13.6%) compared with the NF, without a significant reduction in specificity (94.9% vs. 98.8%). The NF was overly restrictive of the high-risk group, with only 2% of patients having a >15% risk of LN+ by that formula.

Conclusion: The YF performed better than the RF and NF and was best at differentiating patients at high risk for LN+ disease.

Fine particulate matter pollution linked to respiratory illness in infants and increased hospital costs

Fine particulate matter pollution linked to respiratory illness in infants and increased hospital costs
Health Aff (Millwood). 2011 May;30(5):871-8.

Sheffield P, Roy A, Wong K, Trasande L.
05/01/2011

There has been little research to date on the linkages between air pollution and infectious respiratory illness in children, and the resulting health care costs. In this study we used data on air pollutants and national hospitalizations to study the relationship between fine particulate air pollution and health care charges and costs for the treatment of bronchiolitis, an acute viral infection of the lungs. We found that as the average exposure to fine particulate matter over the lifetime of an infant increased, so did costs for the child's health care. If the United States were to reduce levels of fine particulate matter to 7 percent below the current annual standard, the nation could save $15 million annually in reduced health care costs from hospitalizations of children with bronchiolitis living in urban areas. These findings reinforce the need for ongoing efforts to reduce levels of air pollutants. They should trigger additional investigation to determine if the current standards for fine-particulate matter are sufficiently protective of children's health.

The Oxford Handbook of Health Economics

The Oxford Handbook of Health Economics
Oxford University Press.

Glied, Sherry and Peter C. Smith
04/07/2011

The Oxford Handbook of Health Economics provides an accessible and authoritative guide to health economics, intended for scholars and students in the field, as well as those in adjacent disciplines including health policy and clinical medicine. The chapters stress the direct impact of health economics reasoning on policy and practice, offering readers an introduction to the potential reach of the discipline. Contributions come from internationally-recognized leaders in health economics and reflect the worldwide reach of the discipline. Authoritative, but non-technical, the chapters place great emphasis on the connections between theory and policy-making, and develop the contributions of health economics to problems arising in a variety of institutional contexts, from primary care to the operations of health insurers. The volume addresses policy concerns relevant to health systems in both developed and developing countries. It takes a broad perspective, with relevance to systems with single or multi-payer health insurance arrangements, and to those relying predominantly on user charges; contributions are also included that focus both on medical care and on non-medical factors that affect health. Each chapter provides a succinct summary of the current state of economic thinking in a given area, as well as the author's unique perspective on issues that remain open to debate. The volume presents a view of health economics as a vibrant and continually advancing field, highlighting ongoing challenges and pointing to new directions for further progress.

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