1. Measuring Outcomes: a methodological challenge M9205 October 24, 2000

2. Columbia University School of NursingM6920, Fall, 2000 Dummy variable l variable in a regression equation with a finite number of values so that different categories of a nominal variable can be identified. l also called an indicator variable l Examples 1=treatment 0=no treatment 1=female 2=male 1=female 2=male 1=residence in West 0=residence is Central -1=residence is East

3. Columbia University School of NursingM6920, Fall, 2000 Identification of the time frame l Immediately following the intervention l 3-6 months post intervention l 5 years l Lifetime

4. Columbia University School of NursingM6920, Fall, 2000 Selection of objective measures l Use of services l Return to work l Life expectancy

5. Columbia University School of NursingM6920, Fall, 2000 Selection of subjective measures l Provider assessment l Quality of life or other patient reports l Observer reports

6. Columbia University School of NursingM6920, Fall, 2000 Development of data l Access to multiple sources l Developing a cohort l Retrospective cohort identification

7. Columbia University School of NursingM6920, Fall, 2000 HEDIS as an example of the issues l A set of 75 performance measures for comparison of HMOs l Designed for purchasers of care plans

8. Columbia University School of NursingM6920, Fall, 2000 Measures should be l relevant l scientifically sound l feasible

9. Columbia University School of NursingM6920, Fall, 2000 Sample HEDIS Measures l Effectiveness of care beta blocker treatments after heart attack childhood immunization status l Access to care availability of primary care providers annual dental visit l Cost of Care rate trends

10. Columbia University School of NursingM6920, Fall, 2000 Measures, cont. l Informed care choices language/transla tion services l Descriptive information provider compensation pediatric mental health network family planing

11. Columbia University School of NursingM6920, Fall, 2000 A nursing perspective on the challenges* l increasing nursing involvement in quality initiatives l identifying strategies that are effective l changing the clinical framework l demonstrating nursing’s contributions *Jones KR et al 1997 Policy Issues Associated with analyzing outcomes of care Image 29:3 (261-7)

12. Columbia University School of NursingM6920, Fall, 2000 ANA Report Card Goals l Test relationships between nurse staffing and specific outcome indicators l Assess the feasibility of capturing information necessary to develop measures with acceptable reliability and validity

13. Columbia University School of NursingM6920, Fall, 2000 ANA Methodology l quantify nurse staffing at a sample of hospitals l quantify patient incidents and length of stay at same hospitals l measure relationship between these two sets of variables

14. Columbia University School of NursingM6920, Fall, 2000 ANA Data challenges l For two states, had to allocate total numbers of hours worked to cost centers l California proportion of hours per cost center used as base of NY and Mass allocations

15. Columbia University School of NursingM6920, Fall, 2000 ANA Data challenges, cont. l Nursing intensity weights used as developed in NY l dimensions include assessment, planing, physical needs, medical needs, socioemotional support, teaching

16. Columbia University School of NursingM6920, Fall, 2000 ANA Quality indicators for acute care settings l Outcomes Patient satisfaction with nursing care, pain management, patient education Patient injury rate Nosocomial infection rate l Process maintenance of skin integrity nursing staff satisfaction l Structure mix of RN, LPN, unlicensed staff total care hours per patient

17. Columbia University School of NursingM6920, Fall, 2000 Blegan, Goode, Reed Nurse Staffing l Objective: describe at the level of the nursing care unit the relationships among total hours of care, RN skill mix and adverse outcomes l Methods: corellational and multivariate analyses controlling for patient acuity

18. Columbia University School of NursingM6920, Fall, 2000 Measures selected included rates of l medication errors (from incident reports) l patient falls (from incident reports) l skin breakdown l patient and family complaints l infections l deaths

19. Columbia University School of NursingM6920, Fall, 2000 Nurse staffing variables l hours of care per patient day from all nursing personnel l hours of care provided by RNs

20. Columbia University School of NursingM6920, Fall, 2000 Key analysis l “total hours of patient care...was associated with higher rates of decubiti, complaints and death....Given the high correlation between acuity and total nursing care hours, the interpretation of these coefficients must be done with care” (p. 49)

21. Columbia University School of NursingM6920, Fall, 2000 Key analysis l “Most of the previous research in this area was multiinstitutional and generalizeable but suffered from an accompanying lack of detail. The results of this project are more detailed and specific but less generalizable.” (p. 49)

22. Columbia University School of NursingM6920, Fall, 2000 Chen Top 100 Hospitals l Issue: do Medicare patients with acute MI admitted to a “top 100” hospital receive better care or have better outcomes than patients treated in other hospitals?

23. Columbia University School of NursingM6920, Fall, 2000 Quality of care measures l use of aspirin during hospitalization l reperfusion therapy l in-hospital use of beta blockers

24. Columbia University School of NursingM6920, Fall, 2000 Findings l top 100 hospitals more likely to have higher AMI volume, be private for-profit, have on-site facilities for procedures l major differences were in length of stay and cost per AMI admission ($1,014 to $1,855 lower per admission; highly correlated with LOS)

25. Columbia University School of NursingM6920, Fall, 2000 Comment l goal of ‘top 100’ was to identify superior financial management, operations and clinical practices. l it may, instead, identify lower LOS and cost for same outcomes

26. Columbia University School of NursingM6920, Fall, 2000 Frank et al, Treating Depression l Why care? 1/2 of private insurance for MH is on depression l Defining value and benefits l Critical of either traditional cost effectiveness analysis or supply-demand analysis

27. Columbia University School of NursingM6920, Fall, 2000 Frank: Definitions l system effectiveness: sum of all effects produced by health care in a system, including those persons treated by various methods and those not treated at all l system cost: sum of all direct treatment costs l Systems cost effectiveness is the ration of system effects to system costs

28. Columbia University School of NursingM6920, Fall, 2000 Data identification l identifying persons and episodes: claims data l treatment effects: clinical research on efficacy and effectiveness

29. Columbia University School of NursingM6920, Fall, 2000 Findings l cost for highest expected outcomes was $1,059/case l 20% of all spending was in the range expected to equal no treatment.

30. Columbia University School of NursingM6920, Fall, 2000 Kelleher l Concurrent, prospective study l Consecutive admissions l Resident assessment of variables l Outcome of interest: length of stay l Scales created for the study

31. Columbia University School of NursingM6920, Fall, 2000 Kelleher l Regression analysis to identify explanatory power l Severity has been common indicator and does help l adding difficulty increases explanatory power l peak values and fluctuation strongly predictive

32. Columbia University School of NursingM6920, Fall, 2000 Borzekowski l Outcome of interest: response to anti-violence PSA’s l Interest, understanding, credibility, effect l Sample size? location? l Low but suggestive significance

33. Columbia University School of NursingM6920, Fall, 2000 Sochalski et al l Research review l Proposal of an agenda l Focus on nursing staff patterns