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Biomedical subjects

John M Welton

Publications and source records attributed to John M Welton.

7 recordsLinked to original sources
PubMed2006

Nursing intensity billing.

UNLABELLED: Hospital nursing care has traditionally been billed using a fixed daily room and board rate. This approach hides the variability of nursing care within and across nursing units and does not align nursing costs with daily charges for actual patient care. Anew nursing intensity billing (NIB) model for assigning hospital daily room charges is proposed, and initial results are reported. METHODS: Two charge methods, one using traditional room and board daily billing and another using an NIB approach, were developed for 12 adult medical or surgical units at the Medical University of South Carolina (MUSC) Medical Center using retrospective data from January 1 to May 31, 2005. The room and board charge was assigned as private room or intermediate care based primarily on patient location. The NIB model added an additional focused care charge between private and intermediate care, and the charge for the 3 levels was based on daily nursing intensity entered as actual hours of nursing care delivered. The mean and sum of charges were compared between the 2 methods. Charge rates were simulated at $700, $950, and $1,200 for the 3 levels, which correlated with the existing proprietary room rates. Nursing cost-to-charge ratios were calculated for room and board and NIB methods. RESULTS: The NIB model resulted in a 32.2% increase in charges or a total sum of $4,870,250 for the 12 nursing units over the 5-month period. The variability of nursing cost-to-charge ratio was reduced from 0.34 to 0.80 for room and board to 0.33 to 0.45 for the NIB method. CONCLUSION: The NIB method of assigning charges based on nursing intensity rather than on patient location increased overall charges and more evenly distributed direct nursing costs to daily charges. Assigning charges based on nursing intensity is appealing as it reflects actual care given in the acute care environment. The NIB provides evidence to support higher charge rates and has the ability to redistribute hospital charges based on nursing care. The relationship between increased daily hospital charges and actual reimbursement is unknown.

Hospital Charges↗
PubMed2006

Nurse staffing, nursing intensity, staff mix, and direct nursing care costs across Massachusetts hospitals.

OBJECTIVE: This study describes the distribution of patient-to-registered nurse (RN) ratios, RN intensity of care, total staff intensity of care, RN to total staff skill mix percent, and RN costs per patient day in 65 acute community hospitals and 9 academic medical centers in Massachusetts. METHODS: We conducted a retrospective secondary analysis of the Patients First database published by the Massachusetts Hospital Association for planned nurse staffing in 601 inpatient nursing units in the state for 2005 using a multivariate linear statistical model controlling for hospital type and unit type. Nursing unit types were identified as adult and pediatric medical/surgical, step down, critical care, neonatal level II, and neonatal level III/IV nurseries. RESULTS: Medical centers had significantly higher case-mix index (1.72 vs 1.20, P < .001), longer lengths of stay (5.18 vs 4.19, P < .001), more beds (574 vs 147, P < .001), discharges (31,597 vs 7,248, P < .001), and patient days (161,440 vs 31,020, P < .001) compared with to community hospitals. Medical centers had significantly lower patient-to-RN ratios (3.22 vs 4.64, P < .001), higher nursing intensity and total nursing staff intensity (9.62 vs 7.43/11.75 vs 9.87, both P < .001), higher percent of RN to all staff mix (79% vs 71%, P < .001), and higher RN costs per patient day ($385 vs $297, P < .001) compared with to community hospitals. There were significant differences in adult med/surg units between community hospitals and medical centers for patient-to-RN staffing ratios (5.25 vs 4.08), nursing intensity (5.1 vs 6.2 hours daily), skill mix (67% vs 73% RN), and RN costs per patient day ($203 vs $248, all P < .001). There were no significant differences between the adult step-down units. CONCLUSION: The significant differences between community hospitals and medical centers, unit type, as well as the high degree of variability in patient-to-RN ratios, nursing intensity, skill mix, and RN costs per patient day suggest that nursing resource expenditure at Massachusetts hospitals is complex and affected by case mix, unit size, and complexity of care.

Academic Medical Centers↗
PubMed2006

Nursing intensity: In the footsteps of John Thompson.

The Nursing Minimum Data Set (NMDS) provides a way to incorporate nursing data into the hospital discharge abstract to potentially compare nursing care across institutions. An extension of this framework is to use these data for directly billing and reimbursing hospital nursing care. We provide a review of the existing literature and new empirical evidence to support hospital nurse billing. Two existing large data sets are compared, one using nursing diagnosis and the other a nursing intensity based tool to collect daily nursing times. These NMDS data sources are compared to diagnostic related groups (DRG) and hospital outcomes from the UB92 discharge abstract using multivariate regression and logistic regression. Either NMDS approach provides additional explanatory power (improvements in R2) over DRG alone. The findings strengthen the argument to use primary nursing data such as nursing intensity as a basis for direct costing, billing, and reimbursement of hospital nursing care.

Diagnosis-Related Groups↗
PubMed2005

Nursing diagnoses, diagnosis-related group, and hospital outcomes.

BACKGROUND AND OBJECTIVE: There are no nursing centric data in the hospital discharge abstract. This study investigates whether adding nursing data in the form of nursing diagnoses to medical diagnostic data in the discharge abstract can improve overall explanation of variance in commonly studied hospital outcomes. METHOD: A retrospective analyses of 123,241 sequential patient admissions to a university hospital in a Midwestern city was performed. Two data sets were combined: (1) a daily collection of patient assessments by nurses using nursing diagnosis terminology (NDX); and (2) the summary discharge information from the hospital discharge abstract including diagnosis-related group (DRG) and all payer refined DRG (APR-DRG). Each of 61 daily NDX observations were collapsed as frequency of occurrence for the hospital stay and inserted into the discharge abstract. NDX was then compared to both DRG and APR-DRG across 5 hospital outcome variables using multivariate regression or logistic regression. RESULTS AND CONCLUSIONS: In all statistical models, DRG, APR-DRG, and NDX were significantly associated with the 5 hospital outcome variables (P <.0001). When NDX was added to models containing either the DRG or the APR-DRG, explanatory power (R2) and model discrimination (c statistic) improved by 30% to 146% across the outcome variables of hospital length of stay, ICU length of stay, total charges, probably of death, and discharge to a nursing home (P <.0001). The findings support the contention that nursing care is an independent predictor of patient hospital outcomes. These nursing data are not redundant with the medical diagnosis, in particular, the DRG. The findings support the argument for including nursing care data in the hospital discharge abstract. Further study is needed to clarify which nursing data are the best fit for the current hospital discharge abstract data collection scheme.

Diagnosis-Related Groups↗
PubMed2002

Outcomes of and resource consumption by high-cost patients in the intensive care unit.

BACKGROUND: Care of patients in an intensive care unit is among the most costly in hospitals. Little is known about high-cost patients within the intensive care unit or their outcomes of care. OBJECTIVES: To examine outcomes of and resource consumption by high-cost adult patients who received care in an intensive care unit at an academic medical center. METHODS: Data on patients admitted during the period January 1, 1995, through June 30, 1999, were analyzed retrospectively. An intensive care unit database, the hospital discharge data set, and a cost-accounting data set were used to determine the total intensive care unit cost for the hospitalization. Patients were then stratified into cost deciles. Hospital and intensive care unit outcomes for patients in the top decile were compared with those of patients in the other deciles. RESULTS: Cost data were available on 10,606 of the 11,244 patients who received care in an intensive care unit. Patients in the top decile accounted for 48.7% of all intensive care unit costs, and 67.6% of this group survived to discharge despite prolonged care. Patients transferred from an outside hospital were more likely to be in the top decile, have a longer stay in the intensive care unit, or die than were the other patients. CONCLUSIONS: A small group of patients accounts for a disproportionately higher amount of intensive care unit resources but has a relatively high survival rate. This cohort should be treated as an intact group that is not amenable to traditional cost-cutting measures.

Academic Medical Centers↗
PubMedDate not supplied

Hospital nursing costs, billing, and reimbursement.

Nursing intensity, estimated direct nursing costs, and daily billing were compared for 12 adult medical or surgical units at an academic medical center from January 1 to May 31, 2005 (22,649 patient days). Two main findings, nursing intensity and direct nursing costs, were highly variable within and across each of the study nursing units (mean 429 dollars, SD 160 dollars); direct costs of nursing care were significantly higher for private room rates compared to intermediate room per diem charges billed at a higher rate (441 dollars vs. 426 dollars, F 37.77, p < 0.001). The results demonstrate that the direct costs of nursing care are not aligned with current billing practices at this university hospital. The use of fixed room and board charges to account for nursing care in U.S. hospitals may be obsolete and an alternative nurse-centric costing, billing, and reimbursement model is proposed.

Academic Medical Centers↗