Complex home care: part III--economic impact on family caregiver quality of life and patients' clinical outcomes

Family caregivers perform a significant role in the care of patients with chronic illnesses and prescribed life-long complex home care treatments. Both quantitative and qualitative data from this study suggest the mental health burdens and financial costs of home parenteral nutrition (HPN) caregiving are extensive. In this study, the variability in HPN out-of-pocket expenses and the uncertainty of incurring such extensive costs created additional financial worries within already stressed families. Based on these data, interventions to improve caregivers' sleepiness, depression, and physical health could be hypothesized to improve both patients' and caregivers' quality of life and reduce the frequency of patients' catheter-related infections. These specific nursing interventions also could improve caregiver health and subsequently reduce the costs of caregivers' health care.     

Complex home care: Part I--Utilization and costs to families for health care services each year

As many as 120 persons per million people in the United States are dependent on the lifelong, complex, technology-based care of home parenteral nutrition (HPN) infusions. However, data for costs paid by families for HPN-related health care services and for non-reimbursed expenditures are rarely tabulated and most often underestimated. The goals of this study were to describe health care services used by families to manage HPN, report the frequency of each service used annually, and estimate the average annual non-reimbursed costs to families for these health services. The numerous and varied types of services reported and the time required to coordinate and access HPN services illustrates the challenges faced by patients and their family caregivers. The lack of a coordinated and efficient system for delivering complex chronic care results in poorer outcomes for HPN patients and their families on-reimbursed costs and the extensive amount of time required to coordinate multi-professional services negatively impacts the clinical outcomes and quality of life of complex chronic home care.     

Non-cognitive child outcomes and universal high quality child care

Exploiting a rich panel data child survey merged with administrative records along with a pseudo-experiment generating variation in the take-up of preschool across municipalities, we provide evidence of the effects on non-cognitive child outcomes of participating in large scale publicly provided universal preschool programs and family day care vis-à-vis home care. We find that, compared to home care, being enrolled in preschool at age three does not lead to significant differences in child outcomes at age seven no matter the gender or the mother's level of education. Family day care, on the other hand, seems to significantly deteriorate outcomes for boys whose mothers have a lower level of education. Finally, longer hours in non-parental care lead to poorer child outcomes.     

Expanded role of nursing in ambulatory managed care. Part II: Impact on outcomes of costs, quality, provider and patient satisfaction

This evaluation project used a triangulation of methods and data sources to link the expanded role nurse clinician (NC) to outcomes of costs, quality, and satisfaction in managed care. Results of patient surveys, case studies, cost-benefit analyses, interviews, focus groups, and HMO documents suggest that the impact of the role has benefit far beyond its costs. This article builds on an earlier article (Nursing Economic$, Vol. 17, No. 1). Part I reviewed literature on expanded role nursing in population management, and described the development of the NC role. In Part II, the NC expanded role is linked to organizational outcomes of costs, quality, and satisfaction. Results here could be used by managers and planners to provide rationale for implementing expanded nursing roles in managed care in order to improve ambulatory care processes, recruit and retain nurses, reduce costs, and increase patient and provider satisfaction.     

Cost of health care and quality outcomes of patients at nurse-managed clinics

Lack of health insurance is a critical factor in access to appropriate health services and is directly associated with poor functioning, increased morbidity and mortality, lack of continuity of care, and rising health care costs. Nurse-managed clinics (NMCs) can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations. Indicators of quality of care at NMCs include removing barriers to care, improving health care access, and developing therapeutic relationships with nurse practitioners. Much evidence also exists that nurse-managed clinics improve the use of preventative services, aid in the promotion of health, compliance of treatment and patient satisfaction, and reduce emergency room visits and rehospitalizations. One of the consistent themes in this review is the need for patient volume enhancement and the importance of reimbursement through Medicaid and third-party payers if nurse-managed clinics are to remain viable.     

Nursing unit characteristics and patient outcomes

In this exploratory cross-sectional study, nursing unit organizational characteristics and how they influenced patient outcomes in the form of nurse-sensitive adverse events and failure to rescue were examined. Results showed significant associations between characteristics and adverse events at the unit level. Autonomy/collaboration was associated with pressure ulcer and failure to rescue, practice control with urinary tract infection, and continuity/specialization with death. Unit-level study provided a better understanding of the effect of unit work environment upon nursing practice and outcomes.     

Markups,quality, and transport costs

This paper provides new evidence on trade prices based on firm-level data from France. It shows that firms charge higher free-on-board (net of transportation costs, hereafter noted as fob) unit values on exports to more distant countries. This finding holds within firms and products, and across destinations. The price premium paid by distant consumers is due to firms charging higher fob prices, and to higher transportation costs. A simple decomposition of the elasticity of import prices to distance shows that, after a fall in transport costs, almost 80% of the decline in import prices enjoyed by consumers is due to firms charging lower fob prices. This suggests a new channel through which changes in transport costs may affect welfare.     

The costs of behavioral health care coverage

Psychiatric and chemical dependency conditions can have significant financial implication for plan sponsors, but a variety of mechanisms are available to control these costs. The application of appropriately designed and implemented benefit designs in combination with managed behavioral health care protocols can have a significant return on investment for the plan sponsor.     

Trade costs,quality and the skill premium

We develop a monopolistic competition model with non‐homothetic factor input bundles where increasing quality requires increasing use of skilled workers. As a result more skill abundant countries export higher quality, higher priced goods. Using a multi‐country dataset, we test and confirm the findings in Schott ( 2004 ) of a positive effect of skill abundance on unit values identified with US data. We extend the core model with per unit trade costs leading to the Washington apples effect that goods shipped over larger distance are of higher quality. The combination of high‐quality goods being relatively skill intensive with the Washington apples effect implies that countries at a larger distance from their trading partners display a higher skill premium. Simulating our model, we find that a doubling of distance of a country relative to all its trading partners raises the skill premium in a country by about 1.6%.     

University quality and labour market outcomes

This paper uses proxies for university quality derived from the Research Assessment Exercise and the Teaching Quality Assurance Agency to assess the impact of university quality on the labour market outcomes of a cohort of UK graduates. The impacts on job quality and earnings were mainly limited to graduates in particular disciplines or those obtaining ‘poor’ degrees from ‘good’ universities. The results suggest that, after controlling for pre-entry qualifications, labour market outcomes for most graduates depended more on the subject studied and degree classification awarded than on the university attended.     

Evaluation of a client care delivery model, Part 2: Variability in client outcomes in community home nursing

Using similar variables, Part II explores variation in client outcomes such as OMAHA knowledge, behavior, and SF-36 scores. Medical and nursing diagnoses explained large variations in client outcomes. Clients cared for by degree-prepared nurses improved knowledge and behavior scores. Unanticipated case complexity was negatively associated with client outcome even with nursing intervention. The study revealed that "for every unit increase in assignment of baccalaureate-prepared nurses, clients will on average demonstrate an 80% greater likelihood of improvement in knowledge scores and a 120% greater likelihood of improvement in behavior scores in relation to their health condition at discharge." This two-part study has offered insight into the controllable variables influencing the cost and quality of home care services.     

Informal home care and labor-force participation of household members

In Germany, informal home care is preferred to professional care services in the public discussion as well as in legal care regulations. However, only minor importance is ascribed to the opportunity costs caregivers face. Therefore, this article explores the influence home care has on the labor supply of caregivers who cohabitate with the care recipient. I use data from the German Socio-Economic Panel from 2001 to 2007, which allows researchers to merge the characteristics of both groups for the first time. Owing to diverging gender roles, I examine female and male caregivers separately. The results show that having an individual in need of care in the household does not decrease labor supply to an economically relevant quantity. As providing care might be endogenous to the labor-supply decision, I test for endogeneity by using characteristics of care recipients as instruments and I additionally test for sample attrition. Moreover, the panel structure allows me to control for unobserved heterogeneity.     

Specific taxation,asymmetric costs,and endogenous quality

This paper shows how a specific tax—in contrast to an ad valorem tax—alters industry structure and firm-level performance in a monopolistic competition framework, where firms chose product quality endogenously and differ exogenously in productivity (i.e., marginal production efficiency). Industry equilibrium mechanisms and selection based on productivity play a significant role: A specific tax shifts market shares and profits toward firms with costs and prices above the industry average at the expense of low-cost firms. This reallocation of market shares releases a novel scale effect such that low-cost firms may quality downgrade, while high-cost firms always quality upgrade. There exists a parameter subspace, where this combines to a decrease on average quality for the industry. In comparison: An ad valorem tax only reduces the number of firms/varieties in the industry due to demand absorption, but affects neither firm-level performance nor industry structure.