Effects of Nurse Staffing on Resident Outcomes in Nursing Homes: A Systematic Review

ObjectivesTo evaluate the evidence on effects of nurse staffing in nursing homes on resident outcomes.DesignSystematic review.Setting and ParticipantsStudies evaluating the effects of nurse staffing levels, total staffing, or skill mix on pressure ulcers, nursing home associated infections, and pain outcomes for adult residents in US nursing homes.MethodsWe searched MEDLINE, Embase, CINAHL, and the Cochrane Database for English-language articles published between January 2000 and May 2021. We also searched for gray literature and sought expert referrals. Two reviewers participated in determination of eligibility, assessment of methodological quality, and abstraction of data. Abstracted data included study design; setting and population characteristics; and resident outcomes. We rated overall certainty of evidence (very low, low, moderate, and high) for each outcome using GRADE.ResultsOf 9152 unique citations, 378 articles underwent full-text review. We identified 22 eligible studies that addressed pressure ulcers (k = 15), COVID-19 cases and/or mortality (k = 4), other infections (k = 8), and moderate-severe pain among residents (k = 7); some examined multiple outcomes. Most studies (k = 17) were rated moderate or high quality. All studies were observational. Overall, registered nurse (RN) staffing was probably associated with fewer pressure ulcers (moderate certainty) and possibly fewer COVID-19 infections/mortality (low certainty), other infections (low certainty) and lower rates of moderate-severe pain (low certainty). Higher skill mix was probably associated with fewer pressure ulcers, higher resident COVID-19 infections, fewer other infections, and lower rates of moderate-severe pain (low certainty for all outcomes).Conclusions and ImplicationsHigher RN staffing and skill mix may be associated with better nursing home resident outcomes, while results were mixed for total staffing. Increasing RN staffing levels and skill mix are one of a variety of approaches to improve nursing home care.     

Safe nurse staffing policies for hospitals in England,Ireland, California,Victoria and Queensland: A discussion paper

ObjectiveThe association between higher registered nurses (RN) staffing (educational level and number) and better patient and nurse outcomes is well-documented. This discussion paper aims to provide an overview of safe staffing policies in various high-income countries to identify reform trends in response to recurring nurse workforce challenges.MethodsBased on a scan of the literature five cases were selected: England (UK), Ireland, California (USA), Victoria and Queensland (Australia). Information was gathered via a review of the grey and peer-reviewed literature. Country experts were consulted for additional information and to review country reports.ResultsThe focus of safe staffing policies varies: increasing transparency about staffing decisions (England), matching actual and required staffing levels based on patient acuity measurement (Ireland), mandated patient-to-nurse ratios at the level of the nurse (California) or the ward (Victoria, Queensland). Calibration of the number of patients by the number of nurses varies across cases. Nevertheless, positive effects on the nursing workforce (increased bedside staffing) and staff well-being (increased job satisfaction) have been consistently documented. The impact on patient outcomes is promising but less well evidenced.ConclusionCountries will have to set safe staffing policies to tackle challenges such as the ageing population and workforce shortages. Various approaches may prove effective, but need to be accompanied by a comprehensive policy that enhances bedside nurse staffing in an evidence-based, objective and transparent way.     

The relationship between nurse staffing levels and nursing-sensitive outcomes in hospitals: Assessing heterogeneity among unit and outcome types

ObjectiveTo identify which unit types are most sensitive to nurse staffing levels.Data sources/study settingCollection of secondary data took place from March to July 2016. For our study, we analyzed administrative hospital claims data and self-reported structural data from hospitals in Germany. We used 26,502,579 admissions nested in 13,089 units in 3,680 hospitals from 2012 to 2014.Study designWe used regression analysis to examine the relationship between 11 established nursing-sensitive outcomes (NSOs) and nurse-to-patient ratios on a unit level. Nurse-to-patient ratios were our key explanatory variable. We conducted separate OLS regressions for each NSO in each unit type using linear and non-linear terms.Data collection/extraction methodsWe linked hospital claims data with self-reported structural data from hospitals from 2012 to 2014.Principal findingsWe identified 15 unit types with at least one significant NSO. The effect of potential understaffing on NSOs depends on the unit type.ConclusionsOur study indicates that the relationship between nurse staffing levels and NSOs varies greatly depending on the unit type concerning both significance and magnitude. Future research might consider performing analyses on unit level instead of hospital level.     

Alzheimer’s Disease Services,Staffing, and Outcomes in Adult Day Health Centers

ObjectivesIncreasing rates of Alzheimer disease and related dementia (ADRD) has resulted in greater reliance on adult day health centers (ADHCs) and their skilled workforce. Little is known about staffing in ADHCs that provide ADRD services compared with ADHCs that do not. This study examines whether there are differences in staffing between ADHCs that offer ADRD services versus those that do not, and whether the percentage of ADHC participants with ADRD is associated with staffing levels. It also examines whether staffing levels and provision of ADRD services are associated with participant outcomes.DesignCross-sectional analysis of secondary survey data.Setting and ParticipantsWe used facility-level data from the 2014 National Post-acute and Long-term Care Study Adult Day Services Center module. This survey is completed by administrators of ADHCs, who provide information about their ADHC’s organization, services, participants, sources of payment, staffing, and participant outcomes.MethodsBivariate comparisons and multivariate regressions were used to compare scope of services, staffing, and participant outcomes for ADHCs that offered ADRD programs compared with those that did not.ResultsADHCs with ADRD programs had similar average daily attendance, less revenue from Medicaid and self-payment, and greater proportions of Black and female participants. ADHCs with ADRD programs had similar staff hours per participant day for all staff categories; licensed nurse staffing increased and social worker staffing decreased with the proportion of participants with ADRD. Staffing had significant associations with participant outcomes.Conclusions and ImplicationsADHCs that have more participants with ADRD have greater staffing of licensed nurses but fewer social workers. Participant outcomes are associated with staffing, but the results suggest that there are unmeasured dimensions of participant risk that confound the relationship.     

Electronic Medical Records, Nurse Staffing, and Nurse-Sensitive Patient Outcomes: Evidence from California Hospitals, 1998�C2007

Objective

To estimate the effects of electronic medical records (EMR) implementation on medical-surgical acute unit costs, length of stay, nurse staffing levels, nursing skill mix, nurse cost per hour, and nurse-sensitive patient outcomes.

Data Sources

Data on EMR implementation came from the 1998–2007 HIMSS Analytics Databases. Data on nurse staffing and patient outcomes came from the 1998–2007 Annual Financial Disclosure Reports and Patient Discharge Databases of the California Office of Statewide Health Planning and Development (OSHPD).

Methods

Longitudinal analysis of an unbalanced panel of 326 short-term, general acute care hospitals in California. Marginal effects estimated using fixed effects (within-hospital) OLS regression.

Principal Findings

EMR implementation was associated with 6–10 percent higher cost per discharge in medical-surgical acute units. EMR stage 2 increased registered nurse hours per patient day by 15–26 percent and reduced licensed vocational nurse cost per hour by 2–4 percent. EMR stage 3 was associated with 3–4 percent lower rates of in-hospital mortality for conditions.

Conclusions

Our results suggest that advanced EMR applications may increase hospital costs and nurse staffing levels, as well as increase complications and decrease mortality for some conditions. Contrary to expectation, we found no support for the proposition that EMR reduced length of stay or decreased the demand for nurses.     

Nurse Staffing Impact on Quality of Care in Nursing Homes: A Systematic Review of Longitudinal Studies

BackgroundThe relationship between nurse staffing and quality of care (QoC) in nursing homes continues to receive major attention. The evidence supporting this relationship, however, is weak because most studies employ a cross-sectional design. This review summarizes the findings from recent longitudinal studies.MethodsIn April 2013, the databases PubMed, CINAHL, EMBASE, and PsycINFO were systematically searched. Studies were eligible if they (1) examined the relationship between nurse staffing and QoC outcomes, (2) included only nursing home data, (3) were original research articles describing quantitative, longitudinal studies, and (4) were written in English, Dutch, or German. The methodological quality of 20 studies was assessed using the Newcastle-Ottawa scale, excluding 2 low-quality articles for the analysis.ResultsNo consistent relationship was found between nurse staffing and QoC. Higher staffing levels were associated with better as well as lower QoC indicators. For example, for restraint use both positive (ie, less restraint use) and negative outcomes (ie, more restraint use) were found. With regard to pressure ulcers, we found that more staff led to fewer pressure ulcers and, therefore, better results, no matter who (registered nurse, licensed practical nurse/ licensed vocational nurse, or nurse assistant) delivered care.ConclusionsNo consistent evidence was found for a positive relationship between staffing and QoC. Although some positive indications were suggested, major methodological and theoretical weaknesses (eg, timing of data collection, assumed linear relationship between staffing and QoC) limit interpretation of results. Our findings demonstrate the necessity for well-designed longitudinal studies to gain a better insight into the relationship between nurse staffing and QoC in nursing homes.     

Nursing Home Staffing Requirements and Input Substitution: Effects on Housekeeping,Food Service,and Activities Staff

Objective

To study the effect of minimum nurse staffing requirements on the subsequent employment of nursing home support staff.

Data Sources

Nursing home data from the Online Survey Certification and Reporting (OSCAR) System merged with state nurse staffing requirements.

Study Design

Facility-level housekeeping, food service, and activities staff levels are regressed on nurse staffing requirements and other controls using fixed effect panel regression.

Data Extraction Method

OSCAR surveys from 1999 to 2004.

Principal Findings

Increases in state direct care and licensed nurse staffing requirements are associated with decreases in the staffing levels of all types of support staff.

Conclusions

Increased nursing home nurse staffing requirements lead to input substitution in the form of reduced support staffing levels.     

Staffing ratios and quality: an analysis of minimum direct care staffing requirements for nursing homes

Objective. To study the impact of minimum direct care staffing (MDCS) requirements on nurse staffing levels, nurse skill mix, and quality. Data Sources. U.S. nursing home facility data from the Online Survey Certification and Reporting (OSCAR) System merged with MDCS requirements. Study Design. Facility‐level outcomes of nurse staffing levels, nurse skill mix, and quality measures are regressed on the level of nurse staffing required by MDCS requirements in the prior year and other controls using fixed effect panel regression. Quality measures are care practices, resident outcomes, and regulatory deficiencies. Data Extraction Method. Analysis used all OSCAR surveys from 1999 to 2004, resulting in 17,552 unique facilities with a total of 94,371 survey observations. Principle Findings. The effect of MDCS requirements varied with reliance of the nursing home on Medicaid. Higher MDCS requirements increase nurse staffing levels, while their effect on nurse skill mix depends on the reliance of the nursing home on Medicaid. MDCS have mixed effects on care practices but are generally associated with improved resident outcomes and meeting regulatory standards. Conclusions. MDCS requirements change staffing levels and skill mix, improve certain aspects of quality, but can also lead to use of care practices associated with lower quality.     

Evidence on the Effects of the Federal COVID-19 Vaccine Mandate on Nursing Home Staffing Levels

ObjectiveTo assess the federal COVID-19 vaccine mandate's effects on nursing homes' nurse aide and licensed nurse staffing levels in states both with and without state-level vaccine mandates.DesignCross-sectional study using data from Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, and Economic Innovation Group. Including nursing home facility fixed effects provides evidence on the intertemporal effects of the federal vaccine mandate within nursing homes.Setting and ParticipantsThe sample contains 15,031 nursing homes, representing all US nursing homes with available data.MethodsOn January 13, 2022, the US Supreme Court upheld the federal COVID-19 vaccine mandate for health care workers in Medicare- and Medicaid-eligible facilities, with workers generally required to be vaccinated by March 20, 2022 (ie, the compliance date). We examined actual nursing home staffing levels in 3 time periods: (1) pre-Court decision; (2) precompliance date; and (3) postcompliance date. We separately examined staffing levels for nurse aides and licensed nursing staff. Because 28% of nursing homes were in states with state-imposed vaccine mandates that predated the Supreme Court's ruling, we divided the sample into 2 groups (nursing homes in mandate states vs nonmandate states) and performed all analyses separately.ResultsStaff vaccination rates and staffing levels were higher in mandate states than nonmandate states in all 3 time periods. After the Court's decision, staff vaccination rates increased 5% in nonmandate states and 1% in mandate states (on average). We find little evidence that the Court's vaccine mandate ruling materially affected nurse aide and licensed nurse staffing levels, or that nursing homes in mandate states and nonmandate states were differentially affected by the Court's ruling. Staffing levels over time were generally flat, with some evidence of a modestly greater increase for nurse aide staffing in mandate states than nonmandate states, and a modestly smaller decrease for licensed nurse staffing in mandate states than nonmandate states. Finally, regression results suggest that for both nurse aides and licensed nurses, staffing levels were lower in rural and for-profit nursing homes, and higher in Medicare-only, higher quality, and hospital-based nursing homes.Conclusions and ImplicationsResults suggest the federal COVID-19 vaccine mandate has not caused clinically material changes in nursing home's nurse aide and licensed nurse staffing levels, which continue to be primarily associated with factors that are well-known to researchers and practitioners.     

Hospital nurse practice environments and outcomes for surgical oncology patients

Objective. To examine the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery.
Data Sources. Secondary analysis of cancer registry, inpatient claims, administrative and nurse survey data collected in Pennsylvania for 1998–1999.
Study Design. Nurse staffing (patient to nurse ratio), educational preparation (proportion of nurses holding at least a bachelor's degree), and the practice environment (Practice Environment Scale of the Nursing Work Index) were calculated from a survey of nurses and aggregated to the hospital level. Logistic regression models predicted the odds of 30-day mortality, complications, and failure to rescue (death following a complication).
Principal Findings. Unadjusted death, complication, and failure to rescue rates were 3.4, 35.7, and 9.3 percent, respectively. Nurse staffing and educational preparation of registered nurses were significantly associated with patient outcomes. After adjusting for patient and hospital characteristics, patients in hospitals with poor nurse practice environments had significantly increased odds of death (odds ratio, 1.37; 95 percent confidence interval, 1.07–1.76) and of failure to rescue (odds ratio, 1.48; 95 percent confidence interval, 1.07–2.03). Receipt of care in National Cancer Institute-designated cancer centers significantly decreased the odds of death, which can be explained partly by better nurse practice environments.
Conclusions. This study is one of the first to examine the predictive validity of the National Quality Forum's endorsed measure of the nurse practice environment. Improvements in the quality of nurse practice environments could reduce adverse outcomes for hospitalized surgical oncology patients.     

Health outcomes of interest for evaluation in the Post-Licensure Rapid Immunization Safety Monitoring Program

Active vaccine safety surveillance systems commonly use computerized diagnostic codes to identify potential health outcomes of interest. Evidence concerning the accuracy of these codes is variable, and few systematic reviews are available. This project's aim was to select a list of health outcomes of interest most suitable for evaluation in the Food and Drug Administration's Post-Licensure Rapid Immunization Safety Monitoring (PRISM) program. We conducted an expert elicitation process to develop the list. A comprehensive list of potential health outcomes of interest was formed based on input from a wide variety of vaccine safety experts. We then selected five panelists with senior leadership roles in vaccine safety from both within and outside the FDA. We elicited the experts' recommendations via a structured, iterative process that included an Internet-assisted telephone conference call and formal voting procedures. The expert panelists identified several criteria as important in their choices, including clinical severity, public health importance, rare or uncommon incidence, relevance to two or more vaccines, and historical association with vaccines. The list of 24 outcomes chosen by the experts and refined by the FDA included ten neurologic outcomes, two circulatory system outcomes, and two musculoskeletal outcomes. The PRISM program plans to conduct a set of evidence reviews on the positive predictive value and other characteristics of existing computerized codes and algorithms to identify these health outcomes of interest.     

Lower Mortality for Abdominal Aortic Aneurysm Repair in High‐Volume Hospitals Is Contingent upon Nurse Staffing

Objective

To determine whether and to what extent the lower mortality rates for patients undergoing abdominal aortic aneurysm (AAA) repair in high-volume hospitals is explained by better nursing.

Data Sources

State hospital discharge data, Multi-State Nursing Care and Patient Safety Survey, and hospital characteristics from the AHA Annual Survey.

Study Design

Cross-sectional analysis of linked patient outcomes for individuals undergoing AAA repair in four states.

Data Collection

Secondary data sources.

Principal Findings

Favorable nursing practice environments and higher hospital volumes of AAA repair are associated with lower mortality and fewer failures-to-rescue in main-effects models. Furthermore, nurse staffing interacts with volume such that there is no mortality advantage observed in high-volume hospitals with poor nurse staffing. When hospitals have good nurse staffing, patients in low-volume hospitals are 3.4 times as likely to die and 2.6 times as likely to die from complications as patients in high-volume hospitals (p < .001).

Conclusions

Nursing is part of the explanation for lower mortality after AAA repair in high-volume hospitals. Importantly, lower mortality is not found in high-volume hospitals if nurse staffing is poor.     

Hospital Use of Agency‐Employed Supplemental Nurses and Patient Mortality and Failure to Rescue

Objective

To determine the association between the use of agency-employed supplemental registered nurses (SRNs) to staff hospitals and patient mortality and failure to rescue (FTR).

Data Sources

Primary survey data from 40,356 registered nurses in 665 hospitals in four states in 2006 were linked with American Hospital Association and inpatient mortality data from state agencies for approximately 1.3 million patients.

Study Design

Logistic regression models were used to examine the association between SRN use and 30-day in-hospital mortality and FTR, controlling for patient and hospital characteristics, nurse staffing, the proportion of nurses with bachelor''s degrees, and quality of the work environment.

Principal Findings

Before controlling for multiple nurse characteristics of hospitals, higher proportions of agency-employed SRNs in hospitals appeared to be associated with higher mortality (OR = 1.06) and FTR (OR = 1.05). Hospitals with higher proportions of SRNs have poorer work environments, however, and the significant relationships between SRNs and mortality outcomes were rendered insignificant when work environments were taken into account.

Conclusions

Higher use of SRNs does not appear to have deleterious consequences for patient mortality and may alleviate nurse staffing problems that could produce higher mortality.     

Does Public Reporting of Staffing Ratios and Nursing Home Compare Ratings Matter?

ObjectivePublic reporting is a policy to improve quality and increase data transparency. The objective was to examine the association between publicly available staffing ratios and the Five-Star Quality Ratings from Nursing Home Compare over time.DesignPanel data analysis.Setting and ParticipantsAbout 146 nursing homes with complete quarterly data in New Jersey between January 1, 2012, and December 31, 2019.MethodsUsing data from the State of New Jersey Department of Health and Nursing Home Compare, staff-to-resident ratios were trended for registered nurses, licensed practical nurses, and certified nursing assistants by shift and over time. Panel data analysis was used to test the association between the ratios and the ratings.ResultsCompared to 2012, staffing ratios improved slightly for licensed practical nurses but not for registered nurses or certified nursing assistants in 2019 (P < .001). The number of residents assigned doubled at night for all personnel. During the day and evening shifts, registered nurse staffing was significantly associated with the Nursing Home Compare staffing rating (P < .01) but not the overall rating.Conclusions and ImplicationsDecreasing the number of residents assigned to a registered nurse in NHs results in an increase in staffing ratings. Mandatory public reporting holds nursing homes accountable for quality outcomes but does not improve staffing ratios. Quality resident care is the cumulative result of multiple measures inclusive of staffing; therefore, administrators should continue to focus on improving quality in NHs, which may improve staffing ratios across shifts.     

Agency for Healthcare Research and Quality Evidence-based Practice Center methods for systematically reviewing complex multicomponent health care interventions

ObjectivesThe purpose of this Agency for Healthcare Research and Quality Evidence-based Practice Center methods white paper was to outline approaches to conducting systematic reviews of complex multicomponent health care interventions.Study Design and SettingWe performed a literature scan and conducted semistructured interviews with international experts who conduct research or systematic reviews of complex multicomponent interventions (CMCIs) or organizational leaders who implement CMCIs in health care.ResultsChallenges identified include lack of consistent terminology for such interventions (eg, complex, multicomponent, multidimensional, multifactorial); a wide range of approaches used to frame the review, from grouping interventions by common features to using more theoretical approaches; decisions regarding whether and how to quantitatively analyze the interventions, from holistic to individual component analytic approaches; and incomplete and inconsistent reporting of elements critical to understanding the success and impact of multicomponent interventions, such as methods used for implementation the context in which interventions are implemented.ConclusionWe provide a framework for the spectrum of conceptual and analytic approaches to synthesizing studies of multicomponent interventions and an initial list of critical reporting elements for such studies. This information is intended to help systematic reviewers understand the options and tradeoffs available for such reviews.     

Associations Between Daily Nurse Staffing Levels and Daily Hospitalizations and ED Visits in Nursing Homes

ObjectivesAlthough many prior studies have shown that high average levels of nurse staffing in nursing homes are associated with fewer hospitalizations, some studies have not, suggesting that the average nursing level may mask a more complex relationship. This study examines this issue by investigating the associations of daily staffing patterns and daily hospitalizations and emergency department (ED) visits.DesignRetrospective analyses of national Payroll Based Journal (PBJ) staffing data merged with the Minimum Data Set.Setting and ParticipantsA total of 15,718 nursing homes nationally reporting PBJ data during 2017–2019, their staff, and residents.MethodsWe estimated facility-day-level models as conditional facility fixed-effect Poisson regressions with robust standard errors. The dependent variables were daily numbers of hospitalization and ED visits and the independent variables of interest were the number of registered nurse (RN), licensed practical nurse (LPN), and certified nurse assistant (CNA) hours on the same and prior days.ResultsThe daily number of hospital transfers averaged 0.28 (SD 0.21). Daily total direct-care staffing hours averaged 288.7 (SD 188.2), with RNs accounting for 35.0, LPNs for 68.7, and CNAs for 185.0. Higher staffing was associated with more hospitalizations on the concurrent day. Higher staffing on the day prior was associated with fewer hospitalizations. The effect size was larger for RNs and LPNs (same day = ～2%; prior day = approximately ?0.7% to ?0.9%) than for CNAs (same day <1%; prior day < ?0.5%). ED visits not leading to hospitalizations, and analyses for subsamples exhibited similar findings.Conclusions and ImplicationsOur findings suggest that staff can address developing problems and prevent admissions the next day and identify emergent problems and hospitalize the same day. They also underscore the complex array of nursing home factors involved in hospitalization and ED visits, including the influence of daily staffing variation, suggesting the need for further research to better understand the associations between staffing and appropriate resident transfers to the hospital or the ED, and the potential implications for quality metrics in these domains.     

Nursing Home Compare Star Rating and Daily Direct-Care Nurse Staffing During Hurricane Irma

ObjectivesNursing homes (NHs) are affected by major hurricanes and other natural disasters. To mitigate adverse effects of a major hurricane, NHs often increase their direct-care nurse staffing levels to meet the needs of their residents. However, the quality rating of the NH may affect the resources available to obtain and retain staff. This data brief provides estimates of direct-care nurse staffing levels by quality star rating during Hurricane Irma.DesignRetrospective cohort study from September 3, 2017, to September 10, 2017.Setting and Participants570 Florida NHs that sheltered in place during Hurricane Irma.MethodsWe stratified NHs by their NH Compare overall quality star rating and then measured change in direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants.ResultsWe found that the NH Compare overall star rating was positively associated with a greater staffing level response during Hurricane Irma among registered nurses, licensed practical nurses, and certified nursing assistants. This change was largest for 5-star facilities and smallest for 1-star facilities.Conclusions and ImplicationsHigher-quality NHs may be more responsive and have the resources to be more responsive, to increased needs during a natural disaster. Our findings may serve as a platform for ongoing discussion on the role of the federal, state, and local governments in ensuring minimum staffing standards during natural disasters.     

Association between non‐profit hospital community benefit spending and health outcomes

ObjectiveTo determine if greater non‐profit hospital spending for community benefits is associated with better health outcomes in the county where they are located.Data Sources and Study SettingCommunity benefit data from IRS Form 990/Schedule H was linked to health outcome data from Area Health Resource Files, Map the Meal Gap, and Medicare claims from the Center for Medicare and Medicaid Services at the county level. Counties with at least one non‐profit hospital in the United States from 2015 to 2019 (N = 5469 across the 5 years) were included.Study DesignWe ran multiple regressions on community benefit expenditures linked with the number of health professionals, food insecurity, and adherence to diabetes and hypertension medication for each county.Data CollectionThe three outcomes were chosen based on prior studies of community benefit and a recent survey sent to 12 health care executives across four regions of the U.S. Data on community benefit expenditures and health outcomes were aggregated at the county level.Principal FindingsAverage hospital community benefit spending in 2019 was $63.6 million per county ($255 per capita). Multivariable regression results did not demonstrate significant associations of total community benefit spending with food insecurity or medication adherence for diabetes. Statistically significant associations with the number of health professionals per 1000 (coefficient, 12.10; SE, 0.32; p < 0.001) and medication adherence for hypertension (marginal effect, 0.27; SE, 0.09; p = 0.003) were identified, but both would require very large increases in community benefit spending to meaningfully improve outcomes.ConclusionsDespite varying levels of non‐profit hospital community benefit investment across counties, higher community benefit expenditures are not associated with an improvement in the selected health outcomes at the county level. Hospitals can use this information to reassess community benefit strategies, while federal, state, and local governments can use these findings to redefine the measures of community benefit they use to monitor and grant tax exemption.     

The impact of candidate influenza virus and egg-based manufacture on vaccine effectiveness: Literature review and expert consensus

IntroductionInfluenza is associated with significant morbidity and mortality worldwide. Whilst vaccination is key for the prevention of influenza infection, there are many factors which may contribute to reduced vaccine effectiveness, including antigenic evolution via both antigenic drift and egg-adaptations. Due to the currently dissociated and indirect evidence supporting both the occurrence of these two phenomena in the egg-based manufacturing process and their effects on vaccine effectiveness, this topic remains a subject of debate.ObjectiveTo review the evidence and level of agreement in expert opinion supporting a mechanistic basis for reduced vaccine effectiveness due to egg-based manufacturing, using an expert consensus-based methodology and literature reviews.MethodsTen European influenza specialists were recruited to the expert panel. The overall research question was deconstructed into four component principles, which were examined in series using a novel, online, two-stage assessment of proportional group awareness and consensus. The first stage independently generated a list of supporting references for each component principle via literature searches and expert assessments. In the second stage, a summary of each reference was circulated amongst the experts, who rated their agreement that each reference supported the component principle on a 5-point Likert scale. Finally, the panel were asked if they agreed that, as a whole, the evidence supported a mechanistic basis for reduced vaccine effectiveness due to egg-based manufacturing.ResultsAll component principles were reported to have a majority of strong or very strong supporting evidence (70–90%).ConclusionsOn reviewing the evidence for all component principles, experts unanimously agreed that there is a mechanistic basis for reduced vaccine effectiveness resulting from candidate influenza virus variation due to egg-based manufacturing, particularly in the influenza A/H3N2 strain. Experts pointed to surveillance, candidate vaccine virus selection and manufacturing stages involving eggs as the most likely to impact vaccine effectiveness.