Purpose:The relationship between job satisfaction of nurse aides and intent to leave and actual turnover after 1 year is examined. Design and Methods: Data came from a random sample of 72 nursing homes from 5 states (Colorado, Florida, Michigan, New York, and Oregon). From these nursing homes, we collected 1,779 surveys from nurse aides (a response rate of 62%). We used a job satisfaction instrument specifically developed for use with nurse aides, as well as previously validated measures of intent to leave and turnover. We used ordered logistic regression and logistic regression to examine the data. Results: High overall job satisfaction was associated with low scores on thinking about leaving, thinking about a job search, searching for a job, and turnover. In examining the association between the job satisfaction subscales and intent to leave and turnover, we found that high Work Schedule subscale scores, high Training subscale scores, and high Rewards subscale scores were associated with low scores on thinking about leaving, thinking about a job search, searching for a job, and turnover. High scores on the Quality of Care subscale were associated with low turnover after 1 year. Implications: These results are important in clearly showing the relationship between job satisfaction and intent to leave and turnover of nurse aides. Training, rewards, and workload are particularly important aspects of nurse aides' jobs.

Purpose: We used data from a large sample of nursing homes to examine the association between staff turnover and quality. Design and Methods: The staff turnover measures came from primary data collected from 2,840 nursing homes in 2004 (representing a 71% response rate). Data collection included measures for nurse aides, licensed practical nurses, and registered nurses. We examined 14 indicators of care quality that came from the Nursing Home Compare Web site. Results: We found that reducing turnover from high to medium levels was associated with increased quality, but the evidence was mixed regarding the quality improvements from further lowering turnover to low levels. Implications: Our investigation shows that the relationship between turnover and quality might not be linear. Nevertheless, in general, high turnover is associated with poor quality.

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Objective To determine the 12-month cost-effectiveness of a collaborative care (CC) program for treating depression following coronary artery bypass graft (CABG) surgery versus physicians’ usual care (UC). Methods We obtained 12 continuous months of Medicare and private medical insurance claims data on 189 patients who screened positive for depression following CABG surgery, met criteria for depression when reassessed by telephone two-weeks following hospitalization (9-item Patient Health Questionnaire ≥10), and were randomized to either an 8-month centralized, nurse-provided, and telephone-delivered collaborative care (CC) intervention for depression or to their physicians’ usual care (UC). Results At 12-months following randomization, CC patients had $2,068 lower but statistically similar estimated median costs compared to UC (P=0.30) and a variety of sensitivity analyses produced no significant changes. The incremental cost effectiveness ratio of CC was −$9,889 (−$11,940 to −$7,838) per additional quality-adjusted life-year (QALY), and there was 90% probability it would be cost-effective at the willingness to pay threshold of $20,000 per additional QALY. A bootstrapped cost-effectiveness plane also demonstrated a 68% probability of CC “dominating” UC (more QALYs at lower cost). Conclusions Centralized, nurse-provided, and telephone-delivered CC for post-CABG depression is a quality-improving and cost-effective treatment that meets generally accepted criteria for high-value care.

Data from a large sample of nursing homes are used to examine the association between use of nurse aide agency staff and quality. Agency use data come from a survey conducted in 2005 (N = 2,840), and the quality indicators come from the Nursing Home Compare Web site. The authors found a nonlinear relationship between nurse aide agency levels and quality; however, in general, higher nurse aide agency levels were associated with low quality. The results have policy and practice implications, the most significant of which is that use of nurse aide agency staff of less than 14 full-time equivalents per 100 beds has little influence on quality, whereas nurse aide agency staff of more than 25 full-time equivalents per 100 beds has a substantial influence on quality.

Background Adherence to pharmacotherapy for heart failure is poor among older adults due, in part, to high prescription drug costs. We examined the impact of improvements in drug coverage under Medicare Part D on utilization of, and adherence to, medications for heart failure in older adults. Methods We used a quasi-experimental approach to analyze pharmacy claims for 6,950 individuals age≥65 years with heart failure enrolled in a Medicare managed care organization two years before and after Part D’s implementation. We compared prescription fill patterns among individuals who moved from limited (quarterly benefits caps of $150 or $350) or no drug coverage to Part D in 2006 to those who had generous employer-sponsored coverage throughout the study period. Results Individuals who previously lacked drug coverage filled approximately 6 more heart failure prescriptions annually after Part D (Adjusted Ratio of Prescription Counts = 1.36, 95% Confidence Interval=CI=1.29-1.44; p<0.0001 relative to the comparison group). Those previously lacking drug coverage were more likely to fill prescriptions for an angiotensin converting enzyme inhibitor/angiotensin II receptor blocker plus a beta blocker after Part D (adjusted ratio of odds ratios=AROR=1.73; 95% CI=1.42-2.10; p<0.0001), and more likely to be adherent to such pharmacotherapy (AROR=2.95; 95% CI=1.85-4.69; p<0.0001) relative to the comparison group. Conclusions Medicare Part D was associated with improved access to medications and adherence to pharmacotherapy in older adults with heart failure.

Objectives-Depression in older adults is often undertreated due, in part, to medication costs. We examined the impact of improved prescription drug coverage under Medicare Part D on use of antidepressants, medication choice and adherence.Design, Setting and Participants-Observational claims-based study of older adults with depression 296.3, 311, 300.4) Disclosure of competing interestsDrs Lave and Zhang are investigators for a project in part funded by Highmark Inc (a Medicare-Advantage plan) to evaluate the economic impact of high-deductible health plan on medical care spending. Dr. Reynolds receives pharmaceutical supplies for his NIH-sponsored research from Pfizer, Forest, BMS, Wyeth, and Lilly NIH Public Access Author ManuscriptAm J Geriatr Psychiatry. Author manuscript; available in PMC 2012 March 1. Depression affects 6% to 10% of older adults in primary care settings, and 20% to 40% of those with chronic medical conditions such as diabetes and cardiovascular disease.(1) Depression leads to substantial morbidity, functional impairment and increased risk of suicide in older adults.(2,3) It also can undermine adherence to treatment for coexisting medical disorders and is associated with significantly higher health care utilization, and mortality.(4-7)Antidepressant medication prescribed in primary care settings is the mainstay of depression treatment in older adults. However, approximately half of depressed older adults receive no treatment and those who are treated are often non-adherent and/or receive poor quality care (e.g., use of highly anti-cholinergic tricyclic antidepressants).(8) A major barrier to access and adherence to antidepressant therapy is out-of-pocket prescription drug costs.(9) The Medicare drug benefit (Part D) was intended to improve medication access for older adults who previously lacked (18%) or had limited (27%) drug coverage. (10) Studies indicate that Part D successfully expanded drug coverage(11), reduced out-of-pocket costs and increased overall medication utilization among beneficiaries.(12-17) Given that the response to drug costs varies by medication class depending, for instance, on whether medications are used to treat symptomatic or asymptomatic conditions(18), it is important to study the effects of Part D on treatment of specific conditions. One study using Medicare Current Beneficiary Survey data reported that cost-related non-adherence (i.e., skipping or reducing medication doses and/or not filling prescriptions due to cost) is high among older adults with depression and that the rate of cost-related non-adherence among depressed elders did not change after Part D.(19) However, this study did not stratify by level of prior coverage.Our objective was to examine the impact of Part D on the likelihood of antidepressant treatment, medication choice, and refill adherence among older adults with depression who transitioned from no or limited drug coverage to Medicare drug coverage. We hypothesized that Part D would lead to increased rates of treatment, choice of ...