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Research Roundup
September 22, 2009, Volume 56, No. 04

Nurse Satisfaction Influences Patient Satisfaction

Researchers at the Center for Health Policy Outcomes at the University of Pennsylvania have found that patients report higher satisfaction in hospitals where nurses practice in better work environments or with lower patient-to-nurse ratios.

The Centers for Medicare and Medicaid Services require hospitals to demonstrate patient satisfaction through a national survey in order to qualify for full payment, demonstrating the financial incentive for hospitals to enhance patient satisfaction. 

“Improving nurse work environments, including nurse staffing, may improve patients’ experiences and their quality of care,” said Dr. Linda Aiken, the study’s lead author and professor of nursing and sociology at Penn’s School of Nursing. The national study involving 98,000 nurses in 430 hospitals was published in the policy journal Health Affairs.   

The study found:

• The percentage of patients who would definitely recommend a hospital was over eight percent higher in hospitals that offered better nurse work environments than ones with poor work environments and over four percent higher in better nurse work environments than average ones.

• Hospitals that improved their nurse work environments from poor to better and reduced nurses’ workloads by one patient would expect to move from the 16th percentile to the 50th percentile, in terms of percentage of patients who would recommend their hospital.

The Institute of Medicine has highlighted patient-centered care as one of six priority areas for improvement in the US health care system.

Foreclosures Causing Health Problems

The nation’s home foreclosure epidemic may be taking its toll on Americans’ health as well as their wallets. Nearly half of the people studied while undergoing foreclosure reported depressive symptoms, and 37 percent met screening criteria for major depression, according to the School of Medicine’s research published online in the American Journal of Public Health. Many also reported an inability to afford prescription drugs, and skipping meals. The authors say their findings should serve as a call for policy makers to tie health interventions into their response to the nation’s ongoing housing crisis.

“The foreclosure crisis is also a health crisis,” said lead author Dr. Craig E. Pollack, who conducted the research while working as an internist and Robert Wood Johnson Foundation Clinical Scholar at Penn. “We need to do more to ensure that if people lose their homes, they don’t also lose their health.”

In addition to the high number of participants reporting depression symptoms, the study of 250 Philadelphia homeowners undergoing foreclosure also shed light on other health care problems that may be spurred by difficulties keeping up with housing costs. The study participants were recruited with the Consumer Credit Counseling Service of Delaware Valley, a non-profit, US Housing and Urban Development-approved mortgage counselor. The authors found that compared to a sample of residents in the general public, those in foreclosure were more likely to be uninsured (22 percent compared to 8 percent), though similar health problems were seen among both the insured and uninsured. Nearly 60 percent reported that they had skipped or delayed meals because they couldn’t afford food, and people undergoing foreclosure were also more likely to have forgone filling a prescription because of the expense during the preceding year (48 percent vs. 15 percent). The study also revealed that for nine percent of respondents, a medical condition in their family was the primary reason for the home foreclosure, and more than a quarter of those surveyed said they had significant unpaid medical bills.

Because the financial hardships of foreclosure may lead homeowners to cut back on health care spending that they consider “discretionary”—preventive care visits, healthy foods or drugs for chronic conditions like hypertension. In addition, the stress of undergoing foreclosure may exacerbate health-undermining behaviors.

“When people purchase homes, they are buying a piece of the American Dream,” says co-author Dr. Julia Lynch, the Janice and Julian Bers Assistant Professor in the Social Sciences in Penn’s department of political science. “Losing a home can be especially devastating because it means the loss of this dream. When this happens, there is reason to worry not only about the health of the homeowner but also that of family members and the broader community they live in.”

To combat the health problems revealed in the study, Drs. Pollack and Lynch suggest that health care workers and mortgage counseling agencies coordinate their efforts to help people at risk of foreclosure access both medical and housing help. Doctors, they suggest, should ask their patients about their housing situation and steer them towards mortgage relief resources. Mortgage counselors, meanwhile, can provide information about how to access safety net health care, enroll in public insurance programs like SCHIP or Medicaid, or apply for nutritional assistance programs for pregnant and nursing mothers and their children.

Advances in Development Reverse Fertility Declines

A team of researchers at Penn and the Università Bocconi in Milan released a study that challenges one of the most established and accepted standards in the social sciences: human fertility levels tend to decline as countries advance towards high levels of social and economic development.

The researchers questioned the conventional wisdom by documenting new findings, potentially relevant to discussions of economic and social policy, of a reversal of fertility declines in highly developed countries once they reach a certain level of wealth.

The study, “Advances in Development Reverse Fertility Declines,” by Drs. Hans-Peter Kohler and Mikko Myrskylä of Penn’s Populations Studies Center and Francesco C. Billari of the Università Bocconi, was published in the journal Nature.

Researchers looked at total fertility rate and the human development index, HDI, in 24 developed countries during a 30-year period. The data demonstrated that the well-established negative relationship between fertility and development has been reversing as the global population entered the 21st century. While social and economic development continues to promote fertility decline at low and medium levels of HDI, at advanced HDI levels further development can reverse the declining trend in fertility.

Now, HDI is positively associated with fertility among highly developed countries. This reversal of fertility decline as a result of continued economic and social development has the potential to slow the rates of population aging, thereby ameliorating the social and economic problems that have been associated with the emergence and persistence of very low fertility.

“This study provides some ‘light at the end of the tunnel’ for countries that were concerned about population aging and population decline as a result of very low fertility rates,” said Dr. Kohler, a professor of sociology in Penn’s School of Arts and Sciences. “This is a surprising new empirical finding that will almost certainly generate additional research to better understand the underlying mechanisms of fertility change and possible policy responses to low fertility.”

Clues of Aging Glass

A Penn-led study, published in the September 11 issue of the journal Physical Review Letters, set out to determine why glasses become more viscous and rigid over time without major changes to their molecular structure, a phenomenon known as aging. The researchers introduced a new technique to permit observation of particle rearrangements in an aging glass just after its formation. The findings provide experimental input for modern theories of glasses and provide insight about dynamic arrest in systems ranging from traditional molecular glasses to traffic jams.

The physicists created soft colloidal glasses by suspending microgel spheres in water. The microgel particles were special in that their diameters vary with changes in temperature. Using a mercury lamp to focus energy into the colloidal suspension, the team rapidly heated the spheres, causing them to shrink, move freely and rearrange in an experimentally-induced liquid state. The team then removed the light, thus quenching the entire system using a rapid temperature drop and returning the liquid to a glass state in about a tenth of a second.

In the following tenths of seconds, the team used a microscope to observe what they believe to be the reason why the dynamics of glass get slower and more sluggish as they age. Researchers observed a special class of rearrangement event in which the particles composing the glass dramatically change their local environments, losing neighboring particles never to regain them. The number of these so-called irreversible rearrangement events decreased as the glass continued to age, and the number of particles required to move as part of these irreversible rearrangements increased. Thus, as glass ages, the motion of more and more particles is required to accompany irreversible arrangements, thereby slowing glass dynamics.

“The nature of the glass phase is a deep and long-standing unsolved problem in science, and insights about how these materials age hold potential for applications ranging from improved vehicles for drug delivery to novel coatings based on polymer, ceramic, and metallic glasses,” said Peter Yunker, a doctoral student in the department of physics and astronomy.

The Penn researchers employed state-of-the-art digital imaging technology and computer image analysis for their microscopy experiments. “We used microscopy to visualize the structure and dynamics of ‘big slow-moving atoms’ in the colloidal glass,” said Dr. Arjun Yodh, professor in the department of physics and astronomy at Penn. “We discovered that only a very select class of fast-moving clusters of particles play a role in helping the glass to find its low energy configurations.”

Almanac - September 22, 2009, Volume 56, No. 04