Department of Medicine, Division of General Internal Medicine, iTEQC Research Program, University of California, Irvine, CA, USA.
UCLA Borun Center at David Geffen School of Medicine, Los Angeles, CA, USA; Veterans Administration GRECC, Los Angeles, CA, USA; RAND Health, Santa Monica, CA, USA.
J Am Med Dir Assoc. 2024 Aug;25(8):105081. doi: 10.1016/j.jamda.2024.105081. Epub 2024 Jun 12.
Nursing homes make staffing decisions in conjunction with choosing quality goals, potentially leading to endogeneity bias between staffing and quality. We use instrumental variables (IVs) to explore it.
Retrospective statistical analysis of 2017-2019 Payroll-Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term Care Focus.
A total of 11,261 nursing homes nationally.
We estimated separate models for each of 6 quality measures as dependent variables, and registered nurses (RNs), certified nurse assistants (CNAs), and licensed practical nurses (LPNs) as independent variables, including other control variables associated with quality. The models were estimated using both ordinary least squares (OLS) and 2-stage least squares (2SLS) methods, the latter accounting for endogeneity. The IVs were defined as the average staffing of competing nursing homes in the same market as the index facility.
Estimated coefficients for the quality measures in the 2SLS models were up to 5 times larger than in the OLS models. The 2SLS estimates for antipsychotic medications use increased with higher RN staffing [0.279 (0.004 to 0.553)] and decreased with higher CNAs [-0.125 (-0.198 to -0.052)]. Hospitalizations decreased with more RNs [-1.328 (-1.673 to -0.983)] and LPN staffing [-0.483 (-0.755 to -0.211])] and increased with CNA [0.201 (0.109 to 0.293)] staffing. Emergency room visits decreased with higher RNs [-1.098 (-1.500 to -0.696)] and increased with CNAs [0.191 (0.084 to 0.298)]. Long-stay activities of daily living [-0.313 (-0.416 to -0.209)] and short-stay functioning [-0.481 (-0.598 to -0.364)] improved only with higher CNA staffing and pressure sores improved only with increased RN staffing [-0.436 (-0.836 to -0.035)].
Our findings demonstrate the importance of accounting for endogeneity in studies of staffing and quality. Endogeneity changes conclusions about significance, direction, and magnitude of the relationship between staffing and specific quality measures. These findings highlight the need to further study and understand the nuanced relationship between different staffing types and different health outcomes such as the difference between the relationship of RN and CNA hours per resident day to antipsychotic quality measures.
养老院在做出人员配置决策的同时选择质量目标，这可能导致人员配置与质量之间存在内生性偏差。我们使用工具变量（instrumental variables，IVs）来对此进行探讨。
2017-2019 年薪酬期刊、最低数据集、养老院护理比较和长期护理焦点的回顾性统计分析。
全国共有 11261 家养老院。
我们分别以 6 项质量指标作为因变量，注册护士（registered nurses，RNs）、认证护士助理（certified nurse assistants，CNAs）和持照实习护士（licensed practical nurses，LPNs）作为自变量，包括与质量相关的其他控制变量，对每个模型进行了估计。使用普通最小二乘法（ordinary least squares，OLS）和两阶段最小二乘法（2-stage least squares，2SLS）对模型进行了估计，后者考虑了内生性。IVs 被定义为与指数机构同市场的竞争养老院的平均人员配置。
2SLS 模型中质量指标的估计系数比 OLS 模型大 5 倍。抗精神病药物使用的 2SLS 估计值随较高的 RN 人员配置增加[0.279（0.004 至 0.553）]，随较高的 CNA 人员配置减少[-0.125（-0.198 至-0.052）]。住院治疗随更多的 RN [−1.328（−1.673 至-0.983）]和 LPN 人员配置[-0.483（-0.755 至-0.211）]减少，随 CNA 人员配置增加[0.201（0.109 至 0.293）]增加。急诊室就诊随较高的 RN [−1.098（-1.500 至-0.696）]减少，随较高的 CNA [0.191（0.084 至 0.298）]增加。长期护理日常生活活动[−0.313（-0.416 至-0.209）]和短期护理功能[−0.481（-0.598 至-0.364）]仅随较高的 CNA 人员配置而改善，压疮仅随 RN 人员配置增加而改善[-0.436（-0.836 至-0.035）]。
我们的研究结果表明，在研究人员配置和质量时，考虑内生性非常重要。内生性改变了人员配置与特定质量指标之间关系的显著性、方向和大小的结论。这些发现强调需要进一步研究和理解不同人员配置类型与不同健康结果之间的细微关系，例如 RN 和 CNA 每居民日工作时间与抗精神病药物质量指标之间的关系。
