The Nurse Will See You Now

           

          Articles in medical journals tend to pay scant attention to the role of nurses in treating illness—or for that matter, to the role of social workers, physical therapists, and many other clinicians. Hence, when JAMA, one of the major American general medical journals, published an article in 2002 entitled, “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,” it was a bombshell. The lead author, Linda Aiken, is a nurse researcher at the University of Pennsylvania where she is a Professor of Sociology and the founding director of the Center for Health Outcomes and Policy Research. Looking at survey data from 10,000 nurses and administrative data on nearly 250,000 medical and surgical patients hospitalized in Pennsylvania in 1998-1999, she drew some dramatic conclusions: each additional patient per nurse was associated with a 7 percent increase in the likelihood of dying within 30 days of hospitalization, and each additional patient per nurse was associated with a 23 percent increase in the odds of “burnout” and a 15 percent increase in nursing job dissatisfaction. 

          Aiken's analysis, along with other smaller studies, have led to calls for an increase in the nurse to patient staffing ratios in hospitals. In light of general hospital administrative reluctance to make such increases, many nurses have demanded and some state legislatures have proposed mandatory increases in nurse to patient ratios. Massachusetts voters are being asked to vote this November on a referendum that would establish mandatory staffing ratios. To date, the only state to have instituted such a requirement is California—which passed legislation in 1999, before Aiken’s landmark study. California’s experience offers an unparalleled opportunity to ask whether mandatory ratios result in the desired improvements in quality of care and whether they produce a variety of unintended consequences. In principle, it could also shed light on whether nurse to patient ratios are particularly important for older people.

            California’s law specifies different nurse to patient ratios for intensive care units, surgical units, and medical units. Compliance was at first uneven, but gradually hospitals conformed to the requirements. Several studies have attempted to assess the outcomes. They are limited because California did not conduct a randomized, controlled experiment before passing its legislation—it did not impose mandatory minimum ratios on some hospitals and not on others. Moreover, nursing staff ratios are hardly the only factor affecting outcomes that changed in the early years of the mandate: many other federal quality improvement initiatives were undertaken to encourage hospitals to prevent pressure ulcers, falls, catheter-related infections and other major hazards of hospitalization. Hospitals have also experienced major financial pressures: the cost of hiring nurses was only one of many economic challenges. Determining cause and effect is not easy. Nearly twenty years later, what do we know?

            First and foremost, did the mandatory ratios result in improved quality of care? One of the most carefully performed studies was undertaken by the California Health Care Foundation, part of UCSF, in 2009. This report looked at pressure ulcers, pneumonia deaths, and deaths from sepsis (blood-borne infection) and were unable to find any statistically significant change after the law was implemented in 2004 (following a multi-year study period to design the regulations). Another study that focused exclusively on pressure ulcers and falls used data from CalNOC, a large nursing database for the entire state, to conclude there was no change in fall rates. They did note a paradoxical increase in pressure ulcers in patients admitted to “step-down” units, units between an ICU and a general medical or surgical floor in the acuity of their patients, after the requirement of more nurses per patient was introduced (presumably a reflection of sicker patients). A systematic review of the literature, published in the Annals of Internal Medicine in 2013, failed to find any statistically significant effect on a variety of safety measures. Of note, none of the studies I identified looked at either patient or nursing satisfaction.

            If mandatory nurse to patient ratios did result in more face-time with patients but no demonstrable improvement in overall quality of care, might older patients nonetheless be one subgroup that did benefit?  All we can say is that many of the quality measures that were examined—pressure ulcers and falls, for example—are particularly relevant to older people. 

            What about the feared adverse consequences of imposing rigid nursing staff ratios? An analysis in Health Affairs in 2011 found no evidence that hospitals were substituting less well-qualified staff (who still meet the legal requirements) such as LPNs for registered nurses. The California Health Care Foundation did conclude that hospitals were increasingly relying on “travel nurses,” (nurses from out of state or from other countries, hired for short periods of time) and on “float nurses” to move from floor to floor to compensate for lunch breaks by the regular staff. Such changes may result in less continuity of nursing care for patients. They also showed that hospitals across the state experienced shrinking operating margins beginning in 2002, especially in the hospitals that were initially fiscally strongest. However, they emphasize that many other factors could account for this phenomenon. Hospitals of all types did comply with the law, resulting in more hours of nursing care for each patient every day:

          On balance, regulating nurse to patient staff ratios in isolation is not likely to make much of a difference in patient outcomes, nor is it likely to devastate hospitals' finances. Hospitals are complex institutions with many interrelated parts. Just because hospitals with low nurse to patient staffing ratios tend to have poorer outcomes than other hospitals does not mean that if we "fix" the ratio, care will necessarily improve. Assuring that there are enough nurses to provide good care is essential, but that step alone is unlikely to dramatically improve the hospital experience.

             

            

  

Vavavoom--the Vital VA

The Veterans Health Administration, as its website reminds us, is the largest integrated health care system in the US, where “integrated” is a contemporary buzzword in health care. It denotes coordination across many sites and implies a focus on populations, not just individuals, both of which are generally viewed as essential features of a good health care system—and which are widely lacking in the US. The VA, as it is known, provides care to 9 million people at 170 medical centers and over 1,000 outpatient sites. It is also the only form of socialized medicine in the United States: the federal government does not just provide health insurance (as is the case with Medicare); it employs the physicians, nurses, administrators, and others who actually provide medical care. Not surprisingly, the VA is under threat from the current administration, despite its popularity with veterans and the organizations that represent them.

The goal of the current administration is to privatize the VA, and arguably the real reason the Secretary of Veterans Affairs was summarily fired is that he wasn’t moving rapidly enough in that direction. At issue may not be money—Trump’s proposed 2019 budget for the VA would be nearly $200 billion, or a 12 percent increase over the current year. Rather, the main concern is ideological—getting government out of health care. My question is: what would that mean for older people, many of whom receive VA benefits?

In many respects, the VA provides excellent care for older veterans. It has a long history of innovation in the geriatric realm: it has for years had a network of Geriatric Research and Clinical Education Centers (GRECC) that carry out research and provide clinical care to older people. Its Geriatric Evaluation and Management Units (GEMU) that offer inpatient geriatric assessment have been shown to slow the rate of functional decline compared to standard care. The VA has a model Extended Care program that provides room, board, and medical care to veterans needing long term care. And in recent years, it has developed an innovative home visit program for its neediest members. Are all these programs a fluke?

To understand, we need a little perspective. The VA health system was created by Congress in the immediate aftermath of World War II. It had several missions including: improving the health and function of US veterans, providing education and training to medical students and residents, and conducting research. But for many years, it was the poor stepchild of the federal government. The Secretary of Veterans Affairs did not become a cabinet level position until 1989. The system became known for inefficiency and mediocrity. But then in 1994, then Under Secretary for Health in the VA John Kizer initiated a radical transformation of the VA system. He created a new system of regional integrated service networks. He developed and implemented a system of quality indicators to drive improved performance.

The transformation worked. A 2007 study published in the Milbank Quarterly looked at performance over the 1998-2005 period and found that the VA outperformed traditional Medicare, Medicaid, and the private sector on a variety of indices.  

A RAND study published in 2016 examined the period from 2005 to 2015 and again found that the VA performance was comparable to or superior to standard American health care in most domains.

But there were cracks in the system. By 2014, those cracks split wide open, and a scandal over long wait times—and a cover-up to conceal the problem—erupted. As Kizer himself, the mover and shaker of the earlier reforms, argued in a New England Journal of Medicine essay in 2014 written with health policy expert Ashish Jha, the reforms have become unfocused and the bureaucracy bloated. The original idea of using quality indicators had mushroomed until there were so many indicators that both administrators and physicians were paralyzed; the earlier regionalization and centralization of the VA system, while effective managerially, had led to excess insularity of the entire system from new developments in the private sector (many of which may have taken their inspiration from the VA in the first place!) 

The solution they proposed was to fix those problems, not to outsource VA care to the private sector. Firing Secretary Shulkin, who by all accounts was a very competent and visionary leader, and replacing him with the president’s personal physician, Ronny Jackson who has no experience managing a large organization (let alone one as complex and needy of reform as the VA), is a classic case of throwing out the baby with the bathwater.

What We Pay

The Princeton health economist, Uwe Reinhardt, first said it in 2004. The private think tank, the McKinsey Global Institute, persuasively demonstrated it was true in 2008. But maybe now that the Wall Street Journal is saying the same thing, policy makers will listen. The elephant in the room, the main factor accounting for the high cost of health care in the US, is prices.

The spending gap between the US and other developed countries remains huge. We spend 17 percent of GDP on health care (that’s all spending, public and private combined); our closest competitor, Switzerland, manages to spend 11 percent. Other OECD countries, such as New Zealand and Norway, spend closer to 9 percent. And despite all the excess spending, we don’t have better outcomes across a broad range of measures, from infant mortality to life-expectancy.

The main culprit, the WSJ reports, is higher prices in the US. The average price of most prescription drugs is higher here—by a lot. Avastin (an expensive medication but not the most expensive medication there is) costs $4000 for a 400 mg vial in America and less than $2000 in western Europe. Ditto for procedures: the cost of coronary artery bypass surgery in the US is $80,000, compared to half that in other OECD countries. And so on, down the line.  Elsewhere in the world, the WSJ explains, state run health systems set limits on prices or refuse to pay a supplier if the cost is regarded as excessive. Our free market system, far from keeping costs down, drives them up.

The McKinsey Report, though a few years old now, makes further adjustments based on a country’s wealth. It argues that richer countries may want to spend a larger proportion of their income on health care. But even adjusting for greater GDP per capita, the US spent $650 billion more than “expected” in 2006. The fastest growing part of the excess, the study showed, was due to outpatient care, both office visits and ambulatory surgery. And what was driving up costs in these domains wasn’t the frequency of visits—Europeans tend to go to the doctor at least as often as their American counterparts—it was the cost per visit. Other major contributors to the high cost of American health care are drug pricing (McKinsey found, as did the WSJ, that we pay more in the US for a given drug than we would in other OECD countries) and the cost of health administration (all the spending on marketing and administration of multiple private health plans boosts costs way over what they would be with a single payer).

I think it’s fair to conclude that the high cost of American medicine isn’t solely—or even mainly—due to waste. Targeting the use of less-than-optimal therapies in outpatient practice, as the Choosing Wisely campaign does won’t solve the cost problem. Nor will targeting expensive, burdensome, and unwanted treatment near the end of life. These are important efforts to improve quality of care. But if we want to do something about cost, we need to have an impact on prices. That means cutting payments made by insurers (both Medicare and private insurance companies) to pricey specialists. It means allowing the biggest and most influential insurer of all, Medicare, to negotiate with drug companies about price. It means allowing insurers such as Medicare to pay for devices based on their cost-effectiveness, not based on what the manufacturer charges. 

Introducing single payer health insurance would help, too. It happens to be the only other way to cover all Americans and make health insurance affordable and get rid of pre-existing conditions riders without use of the “mandate” that Republicans find so very unpalatable. But that’s a topic for another day.

The Emperor Has No Clothes

I’ve been studying Medicare’s new Hospital Compare website. Lots of people have complained about this particular ranking, which gives only 102 hospitals in the country five stars, some of them fairly obscure institutions. I’ve argued in the past that rankings are often misleading, that institutions try to game the system, and that they are often based on measuring the wrong things. But I was curious about how Boston area hospitals, hospitals that I’m familiar with, actually performed. I was particularly interested in how they compared to other hospitals in the country in those domains that Medicare chose to examine. The bottom line is that they didn’t do very well.

Not a single hospital earned five stars. The only major teaching hospital to earn four stars was Massachusetts General Hospital (MGH). And I was curious about its weaknesses: CMS reports two, in readmissions rates and in the timeliness of care. Now I’ve suggested that there may be an irreducible minimum readmission rate—the frailest, sickest patients are going to get sick again, no matter what kind of care they get either in the hospital or after they return home. The only way they aren’t going to be readmitted is if they are offered, and agree to, care exclusively at home (for example, home hospice). And unless we provide more ways that the frailest and sickest can get care at home (aside from hospice, for which not all will be eligible and not all those who are eligible will elect), and unless we discuss their goals of care and how best to achieve them, they are going to return to the hospital when they get sick again. Which they will. But it’s nonetheless striking that MGH—and every single other major teaching hospital in Boston—did worse than the national average in readmissions. That's not a problem with hitting an irreducible minimum. That's a problem achieving the achievable.

MGH’s other Achilles heel, timeliness of care, was also a problem for all the other leading Boston hospitals. Both these deficiencies suggest that the hospitals are not doing a good job of working with primary care doctors and community agencies to coordinate care, to make sure that whatever needs to get done is in fact done. That's a problem for geriatric care.

The other two principal teaching hospitals of Harvard Medical School, the Beth Israel Deaconess Medical Center (BIDMC) and the Brigham and Women’s Hospital (BWH), only managed to get three stars each. In addition to problems with readmissions and timeliness of care, they had assorted other difficulties. BIDMC’s “effectiveness” was on par with the national average, but no better. It did not demonstrate the efficient use of medical imaging. And BWH was below the national average in effectiveness and in safety. That’s disturbing.

The major teaching hospital of Boston University, the Boston Medical Center, also got three stars. It was the only large hospital that did worse than the national average in the domain of the "patient's experience," or how patients rated their stay. The principal teaching hospital of Tufts University, New England Medical Center, only got two stars, with problems in safety, readmissions, timeliness of care, and the efficient use of imaging. Not very impressive.

Two community hospitals, Faulkner and Newton Wellesley (both in the Partners orbit, the hospital system that owns MGH and BWH) got four stars. This result is a bit perplexing as Newton Wellesley, for example, was actually at (not above) the national average in safety, readmission, effectiveness of care and efficient use of imaging, and below the national average in timeliness. Evidently a bunch of B’s and only one C is deemed worse than a bunch of A’s and two C’s. The process of lumping all these measures together to get one final grade seems to me to lead to a misleading conclusion.

So I still don’t think it’s reasonable to conclude very much from the conglomeration that goes into coming up with a single rating. But I do think that observing that every single hospital in the Boston area was below the national average in at least one area and most of them, including the most prestigious institutions, were below the national average in several, is sobering. The areas Medicare chose to focus on are important for quality. There is no good reason for Boston institutions to have more difficulty with any of these measures than the national average. Boston, shape up!

Sense, Common Sense, and Nonsense

Massachusetts has a problem with nursing home quality. A recent report by the Boston Globe found that a number of the state’s for-profit nursing homes provide substandard care—and pay their chief executives million dollar salaries. Earlier investigative journalism revealed that in several facilities, the trouble started when an out-of-state private equity firm bought the nursing homes. Previously high performing homes suddenly were cited for a variety of deficiencies, such as lax infection control and a rise in pressure ulcers (bed sores), which seemed to be directly linked to a corporate decision to cut the nursing staff. Then came a couple of disturbing deaths of residents, such as the case of an aide who accidentally dropped a resident, resulting in her death a few days later. The state Department of Public Health investigated. Fines were levied. And now the Massachusetts legislature is considering tougher laws to deal with the situation: higher fines, more draconian penalties for unsafe conditions in area nursing homes. Who could disagree with a strategy to promote basic health and safety standards in nursing homes—a standard we thought we had achieved after exposes in the 1980s led to sweeping federal regulation of nursing facilities (OBRA-87, the so-called “Nursing Home Reform Act”)? The goal is indisputable; the strategy is questionable.

The proposed legislative changes are billed as “common sense regulations.” Everyone seems to talk about common sense regulations these days, except the most extreme politicians such as Ted Cruz who want to get rid of all regulations. Republican presidential hopeful John Kasich touted as a model that he would emulate at the federal level the “Common Sense Initiative Office.” As governor of Ohio, he created this pro-business group which reviewed 2476 rules and rescinded or amended 1398. President Obama talks about common sense gun safety reform. Massachusetts governor Charlie Baker has recommended reforming the disaster-ridden Department of Children and Families by imposing common sense regulations. The list goes on and on. But the problem is that our intuitions about how the world works, our common sense solutions to how to make it better, are often mistaken.

If modern science has shown us one profound truth, it’s that behavior, whether of man or of molecules, is often entirely unexpected. Common sense told us that some illnesses were divine punishment for immoral behavior—after all, poor people living in crowded urban areas were more prone to various outbreaks than wealthier people living in sparsely populated rural areas. Common sense told us that some diseases were due to particulate matter, to something floating around in the “miasma,” and surely not to invisible, live microorganisms. Common sense told us that time has nothing to do with the speed at which you travel. Common sense told us that light is either a particle or a wave but not both. Common sense was plain wrong.

Health policy is similarly full of surprises. In the policy arena, we talk about “unintended consequences” of our actions. Now the fact that things don’t always turn out the way we planned doesn’t mean we shouldn’t plan. In the case of nursing homes, it doesn’t mean we shouldn’t have any regulations. But it does mean we need to evaluate whether our interventions have the desired effect. And in the case of substandard nursing homes, I strongly suspect, based on studies documenting the relationship between staffing ratios and quality of care, that better surveillance and tougher penalties are only a small part of the solution. What we really need is more staff and better paid staff. And that means higher levels of Medicaid reimbursement to nursing homes (the majority of long-stay residents are on Medicaid), which means that the states have to increase what they pay nursing homes.

Between 2009 and 2012, 40 states froze or cut Medicaid reimbursement to nursing homes, though these trends are gradually reversing. Massachusetts is considering, as part of the 2016-2017 budget, increasing its payments to nursing homes. How this provision will fare in the final budget remains unclear. It’s easier to use the stick than the carrot. But only careful study of whatever policies are instituted will reveal whether they’re working. So far, the evidence favors more and better staff as the best way to improve nursing home quality.