Posts Tagged ‘University of Pennsylvania’

Burnout Affects 30 Percent of Nurses

Wednesday, August 29th, 2012

With hospitals slashing costs to cope with growing financial pressures, nurses believe that the resulting insufficient staffing is detrimental to patients.  A team from the University of Pennsylvania has identified a key reason for this: Hospitals where relative fewer caregivers work typically provide inferior care.  If hospitals reduced their proportion of burned-out nurses to 10 percent from the prevailing 30 percent, they would prevent 4,160 cases a year of the two most-common hospital-acquired infections and save $41 million in Pennsylvania alone.  “It is costing hospitals more money not to spend money on nursing,” said Linda H. Aiken, one of the study’s authors and director of the Penn Nursing School’s Center for Health Outcomes and Policy Research.

The researchers determined that the nurses studied averaged 5.7 patients on a typical shift, said Rutgers University professor Jeannie Cimiotti.  “Maybe they are staffed a little bit above what they should, but if they (hospitals) can provide an organizational climate that’s conducive to nursing, I think they’d be fine,” Cimiotti said. “That doesn’t mean you can overburden them because workload is one of those factors that does contribute to burnout.”

“Most burnout is related to high workload,” said Patricia Eakin, an ER nurse who is president of the Pennsylvania Association of Staff Nurses and Allied Professionals.  Patients nowadays need a whole lot of care. There’s a lot of equipment, a whole lot of fancy things. A lot of things that take a lot of time and a lot of attention.”

Historically, the number of nurses per patient was low following World War I.  At what would ultimately become Baylor University Medical Center, the hospital in 1919 accommodated 225 patients who were cared for by a nursing staff of 12 graduates and 100 students.  As recently as the 1980s, nurses often cared for eight or nine patients (Insert Nurse Together link here.)  The night shift could see a single nurse caring for as many as a dozen patients, often without a Certified Nursing Assistant (CNA) to assist.

The shift in the United States from Florence Nightingale’s concept of multi-bed wards (which often contained 30 or more beds and were typically staffed by one or two nurses) to private and semi-private rooms started in the years following World War II and was mostly complete by the 1970s.  Private hospital rooms at this time were primarily reserved for patients whose families could afford to pay extra to keep their relative out of a ward and hire a private duty nurse to provide one-on-one care.  According to Jean C. Whelan, PhD, RN, “Private-duty nursing was the employment of nurses by individual patients for the delivery of care.  Patients hired their own nurse, who cared for them either in their homes or in the hospital.  Patients paid the nurse for her services with cash, based on a predetermined fee.  The nurse, generally employed for the duration of an illness, cared for only one patient at a time.  In essence, the private-duty nurse delivered highly individualized care to paying patients for as long as a patient needed and could pay for the nurse’s services.”

According to a U.S. National Library of Medicine of the National Institutes of Health Study, thousands of nurses – the vast majority of them women — migrate each year in search of better pay and working conditions, career mobility, professional development, a better quality of life, personal safety, or sometimes just novelty and adventure.  The percentage of foreign-educated physicians working in Australia, Canada, the United Kingdom, and the United States is currently reported to be between 21 and 33 percent, while foreign-educated nurses represent five to 10 percent of these countries’ nurse workforce.”

In 1994, nine percent of total registered nurses were foreign-born RNs; by 2008 that percentage had risen to 16.3 percent, or about 400,000 RNs.  Of those, approximately 10 percent had immigrated to the U.S. during the previous five years. About one-third of growth in RNs between 2001 and 2008 was fueled by foreign-born RNs.  The news is not all positive, though.  According to Newsweek, “While pay has risen in some regions to attract more nurses, in recent years it has flattened at the national level.  That’s why up to 500,000 registered nurses are choosing not to practice their profession — fully one-fifth of the current RN workforce of 2.5 million.”

Bringing those badly needed nurses from overseas is not always easy, said William R. Moore of El Centro Regional Medical Center in California, who has been waiting two years for 20 nurses from the Philippines he recruited to obtain visas.  In the meantime, Moore can’t find talent in the area.  “We’re in the poorest and least literate county in California, right in the middle of the desert,” says Moore. “We’re not a destination for (American) nurses.”

As the role of registered nurses has evolved over the years to encompass increased responsibility, so too, have the educational requirements.  A two-year associate degree (AND) or a four years bachelor’s degree — typically a Bachelor of Science in Nursing (BSN) — are the two primary degrees required in the 21st century.  Many nurses opt to pursue their Master of Science in Nursing (MSN) degree, which requires a minimal commitment of two years to complete the course work.  Others go even further in their educations, studying for a Doctor of Philosophy (PhD) or a Doctor of Nursing Practice (DNP).

Studying for a BSN degree – like all college educations – doesn’t come cheaply.  According to the Registered Nurse Education Requirements website, “Tuition and clinical fees together make up the total cost of nursing education while the tuition fee for a two-year nursing course in a community college is just $1,400, the clinical fees can are considerably higher at $4,000 plus per semester.  For a bachelors course the students end up paying almost $7,000 to $8,000 in clinical fees while the tuition is still lower at just $2,000 to $3,000 per semester.  Apart from this, students will also have to incur the cost of books, parking, basic living expenses and housing in case of out-of-town colleges. The cost of training at hospital affiliated nursing schools can be higher at $55,000 for resident student and over $100,000 for non-residents.”

Brain Scans a Tool In Early Alzheimer’s Detection

Tuesday, January 3rd, 2012

Researchers believe they can see revealing brain shrinkage years before a person develops memory loss or other symptoms of Alzheimer’s disease. The new finding may ultimately let physicians detect the disease and treat patients earlier with the goal of keeping them functional longer.

Massachusetts General Hospital and the University of Pennsylvania researchers used magnetic resonance imaging (MRI) scans to measure how thick the brain’s outer layer is in 159 people who did not suffer from memory loss.  Earlier studies have linked Alzheimer’s disease with distinctive shrinkage in nine regions of the brain’s gray matter, or cerebral cortex.  This is what physicians call the “Alzheimer’s signature.”

According to researchers, the brain shrinks as it loses nerve cells – more commonly known as neurons.  They aren’t entirely sure what causes this.  One theory is that the cells die after they become choked by excess amounts of two kinds of protein — beta amyloid and tau.  “The neurons degenerating over time are really what we think causes the shrinkage,” said researcher Brad Dickerson, M.D., an associate professor of neurology at Harvard Medical School and director of the frontotemporal disorders unit at Massachusetts General Hospital.  “And that shrinkage in their size is something you can measure with an MRI scan.”

Alzheimer’s is the sixth leading cause of death in the United States, according to the Alzheimer’s Association.  The number of deaths has increased in recent years, and there is no cure.  In the new study, researchers focused on how thick the edges of the brain are.  “We’re looking at the parts of the cortex that are particularly vulnerable to Alzheimer’s disease, parts that are important for memory, problem-solving skills and higher-language functions,” Dickerson said.

The 15 percent of participants – who averaged 76 years old –who had the thinnest brain areas performed poorly on the tests: About one in five of them were experiencing cognitive decline, as well as increases in signs of abnormal spinal fluid, a possible sign of developing Alzheimer’s disease.  “That suggests they may be developing symptoms,” according to Dickerson.

Susan Resnick, PhD, who works at the National Institute of Aging, wrote:  “The ability to identify people who are not showing memory problems and other symptoms but may be at a higher risk for cognitive decline is a very important step toward developing new ways for doctors to detect Alzheimer’s disease.”

Dr. Simon Ridley, from the charity Alzheimer’s Research UK, said, “The ability to predict who will develop Alzheimer’s disease is a key target for dementia research, as it would allow new treatments to be tried early, when they are more likely to be effective.  These findings add weight to existing evidence that Alzheimer’s begins long before symptoms appear, although it’s important to note that the study did not assess who went on to develop the disease.  This research provides a potential new avenue to follow, but we need to see larger and longer-term studies before we can know whether this type of brain scan could accurately predict Alzheimer’s.”

Writing in Time, Alice Park notes that “Alzheimer’s disease has always been difficult to diagnose — the only way to identify it definitively is by autopsying the brain after death — but scientists may now have an easier way to spot the degenerative brain disease long before that, even before symptoms appear, using brain scans.  By studying people’s brain scans over time, they were able to see that these nine brain regions appear to be thinner in people who eventually go on to develop Alzheimer’s — but that it takes many years for this structural difference to show up as symptoms of memory loss or cognitive problems.  Using this brain-size signature as a yardstick, the researchers decided to confirm the correlation by testing the patients’ cognitive abilities three years after a baseline brain scan.  Indeed, they found that 21 percent of participants, who had the thinnest Alzheimer’s-related brain regions but showed no signs of memory problems or other cognitive deficits at the start of the study did show signs of cognitive decline three years later, compared with none of the subjects who did not have the same brain thinning and seven percent who showed moderately thinner brain areas.”

The Affordable Care Act: A Tale of Two Studies

Monday, May 23rd, 2011

A study of medical bills under the Patient Protection and Affordable Care Act (ACA) determined that most households will be able to afford premiums and related expenses after paying bills for food, child care, transportation and other necessities, according to the Commonwealth Fund. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.

Approximately 8.5 to nine percent of American families living closest to the poverty line could not afford basic necessities and typical medical bills proposed by the health reform law.  The ACA requires individuals to purchase insurance by 2014, although with occasional exceptions.  The ACA restricts household out-of-pocket costs and subsidizes plans available through insurance exchanges to people with low-incomes.  Fewer households in high cost-of-living states could afford healthcare expenses, according to the Commonwealth Fund study.  The report included projections of spending on necessities, premiums and out-of-pocket costs for households between the federal poverty line and 500 percent of the threshold.  Those insured by safety net or state run insurance exchanges were not factored into the study.

Even with implementation of the ACA, some families across all income levels would continue to struggle to afford coverage because of steep out-of-pocket costs.  According to the report, 17 percent of families of four earning up to $44,700; approximately 25 percent of families earning between $44,700 and $67,050, would struggle with healthcare costs.  The data examines costs in 2014, the first year the ACA will be fully implemented and the start of state-based health insurance exchanges.  The law provides federal subsidies for the lowest-income people to buy insurance.  Americans with incomes between 133 and 399 percent of the poverty level are eligible for income-based tax credits.  Some low-income people will be eligible for subsidies to make up for out-of-pocket costs.  Americans who make less than 133 percent of the poverty level are eligible for Medicaid.

“The Affordable Care Act is very good news for millions of Americans who are struggling to afford health care, going without health insurance, or skipping the care they need because they can’t afford it,” said Commonwealth Fund President Karen Davis. “The new law makes health insurance and health care affordable for nearly all families, and introduces delivery system reforms that have the potential to greatly improve quality and efficiency.  If implemented well, new entities like accountable care organizations may bring even greater savings and affordability than this report predicts.”

Although the Commonwealth report is positive about the likelihood that more families will be able to afford health insurance, Craig Pollack, M.D., M.H.S., assistant professor of medicine at Johns Hopkins, and Katrina Armstrong, M.D., from the University of Pennsylvania, are not as upbeat about the ACA.  The physicians warn that as a result of certain provisions in the ACA, wealthy hospitals and physician practices might “cherry-pick” similar institutions and create Accountable Care Organizations (ACOs).  In this way, they can avoid poor and minority-heavy patient populations who will be treated elsewhere to cut costs.  ACOs encourage patients to seek care within their own network, which highlights the disparities between networks.

According to Pollack, hospitals and physician practices that treat too many minorities may be unable to join ACOs and will fall further behind in the cost and quality of care that is likely to occur in such networks.  “There is ample evidence of racial and ethnic disparities in healthcare,” Pollack said.  “Hospitals and private practices that care for greater numbers of minorities tend to have larger populations of Medicaid and uninsured patients.  These patients have less access to specialists, and their hospitals and practices tend to have fewer institutional resources than their counterparts.”

Lower-Income Families Often Defer Healthcare Because of Cost

Tuesday, December 7th, 2010

Lower-income families covered by health plans with high deductibles are more likely to defer care than their counterparts who earn more money and have similar coverage.  A survey of 141 families whose income levels were less than 300 percent of the U.S. poverty rate and 273 families with high incomes found that 51 percent of the poorer families deferred healthcare because of the cost, compared with 35 percent of the better off families.  The study, which was led by Jeffrey Kullgren, a clinical scholar at the Robert Wood Johnson Foundation, which is affiliated with the Philadelphia VA Medical Center and the University of Pennsylvania, was published in a recent edition of the Archives of Internal Medicine.  A 22-item questionnaire collected data about health plan characteristics, attitudes towards use, cost and sought information about behavior and demographics.

One way in which a growing number of families are facing higher levels of cost-shariing for healthcare is enrollment in high-deductible health plans.   These plans, which feature annual deductibles of at least $1,000 per individual and at least $2,000 per family before more services are covered, seek to encourage patients to become more cost-effective consumers of healthcare and frequently offer lower premiums than other types of health insurance.”

Those surveyed were asked how they might respond to three hypothetical scenarios involving services that their plans did not cover – a $100 blood test; a $1,000 colonoscopy; or a $2,000 MRI.  The majority of participants – no matter their income level – would talk with their physician about deferring or making other plans in all three scenarios.  Rather surprisingly, though, the lower-income families were more likely to discuss the $100 blood test of $1,000 colonoscopy than were the higher-income families.

“These findings suggest that physicians have a central role to play in helping their patients navigate the challenges of decision making in high-deductible health plans,” according to the authors.  “Beyond the implications for clinicians, our findings have important implications for federal health reform.  Reform legislation that establishes an individual health insurance mandate could lead more families to enroll in plans with high levels of cost-sharing, as has been seen following the implementation of coverage mandates in Massachusetts.  If more families do enroll in high-deductible health plans, policymakers should consider strategies to support patients facing high levels of cost sharing.”