Financial incentives for extended weight loss: a randomized, controlled trial

BACKGROUND

Previous efforts to use incentives for weight loss have resulted in substantial weight regain after 16 weeks.

OBJECTIVE

To evaluate a longer term weight loss intervention using financial incentives.

DESIGN

A 32-week, three-arm randomized controlled trial of financial incentives for weight loss consisting of a 24-week weight loss phase during which all participants were given a weight loss goal of 1 pound per week, followed by an 8-week maintenance phase.

PARTICIPANTS

Veterans who were patients at the Philadelphia Veterans Affairs Medical Center with BMIs of 30-40.

INTERVENTION

Participants were randomly assigned to participate in either a weight-monitoring program involving a consultation with a dietician and monthly weigh-ins (control condition), or the same program with one of two financial incentive plans. Both incentive arms used deposit contracts (DC) in which participants put their own money at risk (matched 1:1), which they lost if they failed to lose weight. In one incentive arm participants were told that the period after 24 weeks was for weight-loss maintenance; in the other, no such distinction was made.

MAIN MEASURE

Weight loss after 32 weeks.

KEY RESULTS

Results were analyzed using intention-to-treat. There was no difference in weight loss between the incentive arms (P = 0.80). Incentive participants lost more weight than control participants [mean DC = 8.70 pounds, mean control = 1.17, P = 0.04, 95% CI of the difference in means (0.56, 14.50)]. Follow-up data 36 weeks after the 32-week intervention had ended indicated weight regain; the net weight loss between the incentive and control groups was no longer significant (mean DC = 1.2 pounds, 95% CI, -2.58-5.00; mean control = 0.27, 95% CI, -3.77-4.30, P = 0.76).

CONCLUSIONS

Financial incentives produced significant weight loss over an 8-month intervention; however, participants regained weight post-intervention.

Lottery-based versus fixed incentives to increase clinicians' response to surveys

OBJECTIVE

To compare the effects of lottery-based and fixed incentives on clinicians' response to surveys.

DATA SOURCES

Three randomized trials with fixed payments and actuarially equivalent lotteries.

STUDY DESIGN

Trial 1 compared a low-probability/high-payout lottery, a high-probability/low-payout lottery, and no incentive. Trial 2 compared a moderate-probability/moderate-payout lottery with an unconditional fixed payment (payment sent with questionnaire). Trial 3 compared a moderate-probability/moderate-payout lottery with a conditional fixed payment (payment promised following response).

PRINCIPAL FINDINGS

Neither the low-probability nor high-probability lotteries improved response compared with no incentive. Unconditional fixed payments produced significantly greater response than actuarially equivalent lotteries, but conditional fixed payments did not.

CONCLUSIONS

Lottery-based incentives do not improve clinicians' response rates compared with no incentives, and they are inferior to unconditional fixed payments.

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries

BACKGROUND

A key goal of resident duty hour reform by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 was to improve patient outcomes.

OBJECTIVE

To assess whether the reform led to a change in readmission rates.

DESIGN

Observational study using multiple time series analysis with hospital discharge data from July 1, 2000 to June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of readmission in more versus less teaching-intensive hospitals before and after duty hour reform.

PARTICIPANTS

All unique Medicare patients (n = 8,282,802) admitted to acute-care nonfederal hospitals with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke (combined medical group), or a DRG classification of general, orthopedic, or vascular surgery (combined surgical group).

MAIN MEASURES

Primary outcome was 30-day all-cause readmission. Secondary outcomes were (1) readmission or death within 30 days of discharge, and (2) readmission, death during the index admission, or death within 30 days of discharge.

KEY RESULTS

For the combined medical group, there was no evidence of a change in readmission rates in more versus less teaching-intensive hospitals [OR = 0.99 (95% CI 0.94, 1.03) in post-reform year 1 and OR = 0.99 (95% CI 0.95, 1.04) in post-reform year 2]. There was also no evidence of relative changes in readmission rates for the combined surgical group: OR = 1.03 (95% CI 0.98, 1.08) for post-reform year 1 and OR = 1.02 (95% CI 0.98, 1.07) for post-reform year 2. Findings for the secondary outcomes combining readmission and death were similar.

CONCLUSIONS

Among Medicare beneficiaries, there were no changes in hospital readmission rates associated with resident duty hour reform.

The law, policy, and ethics of employers' use of financial incentives to improve health

The Patient Protection and Affordable Care Act (ACA) turns to a nontraditional mechanism to improve public health: employer-provided financial incentives for healthy behaviors. Critics raise questions about incentive programs' effectiveness, employer involvement, and potential discrimination. We support incentive program development despite these concerns. The ACA sets the stage for a broad-based research and implementation agenda through which we can learn to structure incentive programs to not only promote public health but also address prevalent concerns.

Residency training at a crossroads: duty-hour standards 2010

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented a single duty-hour standard nationwide. The evidence to date suggests that this neither improved nor worsened patient outcomes. In June 2010, the ACGME proposed a new set of duty-hour standards for implementation in July 2011. The main disadvantage of this approach is that there is no ability to determine whether different standards would have worked better to reduce resident fatigue while improving patient safety. Many unanswered questions remain about how to design duty-hour standards, but relatively little evidence exists. In addition, the same approach may not work in all specialties and all hospitals. A more flexible, dynamic policy that emphasizes ongoing testing and evaluation would be more likely to achieve improvements in clinical and educational outcomes.

Residency training at a crossroads: duty-hour standards 2010

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented a single duty-hour standard nationwide. The evidence to date suggests that this neither improved nor worsened patient outcomes. In June 2010, the ACGME proposed a new set of duty-hour standards for implementation in July 2011. The main disadvantage of this approach is that there is no ability to determine whether different standards would have worked better to reduce resident fatigue while improving patient safety. Many unanswered questions remain about how to design duty-hour standards, but relatively little evidence exists. In addition, the same approach may not work in all specialties and all hospitals. A more flexible, dynamic policy that emphasizes ongoing testing and evaluation would be more likely to achieve improvements in clinical and educational outcomes.

The Hospital Compare mortality model and the volume-outcome relationship

OBJECTIVE

We ask whether Medicare's Hospital Compare random effects model correctly assesses acute myocardial infarction (AMI) hospital mortality rates when there is a volume-outcome relationship.

DATA SOURCES/STUDY SETTING

Medicare claims on 208,157 AMI patients admitted in 3,629 acute care hospitals throughout the United States.

STUDY DESIGN

We compared average-adjusted mortality using logistic regression with average adjusted mortality based on the Hospital Compare random effects model. We then fit random effects models with the same patient variables as in Medicare's Hospital Compare mortality model but also included terms for hospital Medicare AMI volume and another model that additionally included other hospital characteristics.

PRINCIPAL FINDINGS

Hospital Compare's average adjusted mortality significantly underestimates average observed death rates in small volume hospitals. Placing hospital volume in the Hospital Compare model significantly improved predictions.

CONCLUSIONS

The Hospital Compare random effects model underestimates the typically poorer performance of low-volume hospitals. Placing hospital volume in the Hospital Compare model, and possibly other important hospital characteristics, appears indicated when using a random effects model to predict outcomes. Care must be taken to insure the proper method of reporting such models, especially if hospital characteristics are included in the random effects model.

To leave or to lie? Are concerns about a shift-work mentality and eroding professionalism as a result of duty-hour rules justified?

CONTEXT

Medical educators worry that the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty-hour rules (DHR) have encouraged a "shift work" mentality among residents and eroded their professionalism by forcing them either to abandon patients when they have worked for eighty hours or lie about the number of hours worked. In this qualitative study, we explore how medical and surgical residents perceive and respond to DHR by examining the "local" organizational culture in which their work is embedded.

METHODS

In 2008, we conducted three months of ethnographic observation of internal medicine and general surgery residents as they went about their everyday work in two hospitals affiliated with the same training program, as well as in-depth interviews with seventeen residents. Field notes and interview transcripts were analyzed for perceptions and behaviors in regard to beginning and leaving work, reporting duty hours, and expressing opinions about DHR.

FINDINGS

The respondents did not exhibit a "shift work" mentality in relation to their work. We found that residents: (1) occasionally stay in the hospital in order to complete patient care tasks even when, according to the clock, they are required to leave, because the organizational culture stresses performing work thoroughly, (2) do not blindly embrace noncompliance with DHR but are thoughtful about the tradeoffs inherent in the regulations, and (3) express nuanced and complex reasons for erroneously reporting duty hours, suggesting that reporting hours worked is not a simple issue of lying or truth telling.

CONCLUSIONS

Concerns about DHR and the erosion of resident professionalism resulting from the development of a "shift work" mentality likely have been overstated. Instead, the influence of DHR on professionalism is more complex than the conventional wisdom suggests and requires additional assessment.

Match rates into higher-income, controllable lifestyle specialties for students from highly ranked, research-based medical schools compared with other applicants

BACKGROUND

Factors impacting medical student specialty career choice are poorly understood, but may include income potential and lifestyle features such as limited and predictable work hours.

METHODS

Data from the National Resident Matching Program and the San Francisco Match were used to examine match rates into higher-income controllable lifestyle (CL), lower-income CL, and noncontrollable lifestyle (NCL) specialties from 2002 to 2007. We studied 3 cohorts: students from highly ranked, research-based medical schools, other US senior medical students, and independent applicants (consisting mostly of graduates from foreign medical schools).

RESULTS

By 2007, 22.5% of students from highly ranked schools matched into a higher-income CL specialty compared with 16.5% of other US seniors and 8.4% of independent applicants. During the study period, students from highly ranked schools increased their match rate in higher-income CL specialties by 7.9%, while all cohorts experienced declines in match rates for NCL specialties. Compared with other US seniors, students from highly ranked schools were more likely to match into higher-income CL specialties (odds ratio [OR], 1.46; 95% confidence interval [CI]: 1.27-1.68), while independent applicants were much less likely to do so (OR, 0.46; 95% CI: 0.42-0.51). Independent applicants had the highest odds (OR, 2.38; 95% CI: 2.25-2.52) of matching into NCL specialties.

CONCLUSIONS

All cohorts had declining match rates into NCL specialties from 2002 to 2007. When compared with other US seniors, students from highly ranked schools had the highest odds of matching in higher-income CL specialties, while independent applicants had the highest odds of matching into NCL specialties. These trends are important to consider in light of recent efforts to better balance the physician workforce.

Informative inducement: study payment as a signal of risk

In research involving human subjects, large participation payments often are deemed undesirable because they may provide 'undue inducement' for potential participants to expose themselves to risk. However, although large incentives may encourage participation, they also may signal the riskiness of a study's procedures. In three experiments, we measured people's interest in participating in potentially risky research studies, and their perception of the risk associated with those studies, as functions of participation payment amounts. All experiments took place 2007-2008 with an on-line nationwide sample or a sample from a northeastern U.S. city. We tested whether people judge studies that offer higher participation payments to be riskier, and, if so, whether this increased perception of risk increases time and effort spent learning about the risks. We found that high participation payments increased willingness to participate, but, consistent with the idea that people infer riskiness from payment amount, high payments also increased perceived risk and time spent viewing risk information. Moreover, when a link between payment amount and risk level was made explicit in Experiment 3, the relationship between high payments and perceived risk strengthened. Research guidelines usually prohibit studies from offering participation incentives that compensate for risks, yet these experiments' results indicate that potential participants naturally assume that the magnitude of risks and incentives are related. This discrepancy between research guidelines and participants' assumptions about those guidelines has implications for informed consent in human subjects research.

Hospital teaching intensity, patient race, and surgical outcomes

OBJECTIVES

To determine if the lower mortality often observed in teaching-intensive hospitals is because of lower complication rates or lower death rates after complications (failure to rescue) and whether the benefits at these hospitals accrue equally to white and black patients, since black patients receive a disproportionate share of their care at teaching-intensive hospitals.

DESIGN

A retrospective study of patient outcomes and teaching intensity using logistic regression models, with and without adjusting for hospital fixed and random effects.

SETTING

Three thousand two hundred seventy acute care hospitals in the United States.

PATIENTS

Medicare claims on general, orthopedic, and vascular surgery admissions in the United States for 2000-2005 (N = 4,658,954 unique patients).

MAIN OUTCOME MEASURES

Thirty-day mortality, in-hospital complications, and failure to rescue (the probability of death following complications).

RESULTS

Combining all surgeries, compared with nonteaching hospitals, patients at very major teaching hospitals demonstrated a 15% lower odds of death (P < .001), no difference in complications, and a 15% lower odds of death after complications (failure to rescue) (P < .001). These relative benefits associated with higher resident-to-bed ratio were not experienced by black patients, for whom the odds of mortality and failure to rescue were similar at teaching and nonteaching hospitals, a pattern that is significantly different from that of white patients (P < .001).

CONCLUSIONS

Survival after surgery is higher at hospitals with higher teaching intensity. Improved survival is because of lower mortality after complications (better failure to rescue) and generally not because of fewer complications. However, this better survival and failure to rescue at teaching-intensive hospitals is seen for white patients, not for black patients.

A randomized, controlled trial of financial incentives for smoking cessation

BACKGROUND

Smoking is the leading preventable cause of premature death in the United States. Previous studies of financial incentives for smoking cessation in work settings have not shown that such incentives have significant effects on cessation rates, but these studies have had limited power, and the incentives used may have been insufficient.

METHODS

We randomly assigned 878 employees of a multinational company based in the United States to receive information about smoking-cessation programs (442 employees) or to receive information about programs plus financial incentives (436 employees). The financial incentives were $100 for completion of a smoking-cessation program, $250 for cessation of smoking within 6 months after study enrollment, as confirmed by a biochemical test, and $400 for abstinence for an additional 6 months after the initial cessation, as confirmed by a biochemical test. Individual participants were stratified according to work site, heavy or nonheavy smoking, and income. The primary end point was smoking cessation 9 or 12 months after enrollment, depending on whether initial cessation was reported at 3 or 6 months. Secondary end points were smoking cessation within the first 6 months after enrollment and rates of participation in and completion of smoking-cessation programs.

RESULTS

The incentive group had significantly higher rates of smoking cessation than did the information-only group 9 or 12 months after enrollment (14.7% vs. 5.0%, P<0.001) and 15 or 18 months after enrollment (9.4% vs. 3.6%, P<0.001). Incentive-group participants also had significantly higher rates of enrollment in a smoking-cessation program (15.4% vs. 5.4%, P<0.001), completion of a smoking-cessation program (10.8% vs. 2.5%, P<0.001), and smoking cessation within the first 6 months after enrollment (20.9% vs. 11.8%, P<0.001).

CONCLUSIONS

In this study of employees of one large company, financial incentives for smoking cessation significantly increased the rates of smoking cessation. (ClinicalTrials.gov number, NCT00128375.)

Paying people to lose weight and stop smoking

Unhealthy behaviors, such as smoking, poor diet, and sedentary lifestyles, account for as much as 40% of premature deaths in the U.S. Although behavioral interventions have the potential to improve health, behavior change is difficult, especially over the long term. Many people have difficulty changing health behaviors because it requires trade-offs between immediate consumption and delayed and often intangible health benefits. Incentives can provide people with immediate and tangible feedback that helps make it easier for them to do in the short term what is in their long-term best interest. This Issue Brief explores the use of financial incentives to motivate and sustain smoking cessation and weight loss.

Impact of a prescription copayment increase on lipid-lowering medication adherence in veterans

BACKGROUND

In February 2002, the Department of Veterans Affairs (VA) increased copayments from $2 to $7 per 30-day drug supply of each medication for many veterans. We examined the impact of the copayment increase on lipid-lowering medication adherence.

METHODS AND RESULTS

This quasiexperimental study used electronic records of 5604 veterans receiving care at the Philadelphia VA Medical Center from November 1999 to April 2004. The all copayment group included veterans subject to copayments for all drugs with no annual cap. Veterans subject to copayments for drugs only if indicated for a non-service-connected condition with an annual cap of $840 for out-of-pocket costs made up the some copayment group. Veterans who remained copayment exempt formed a natural control group (no copayment group). Patients were identified as adherent if the proportion of days covered with lipid-lowering medications was > or =80%. Patients were identified as having a continuous gap if they had at least 1 continuous episode with no lipid-lowering medications for > or =90 days. A difference-in-difference approach compared changes in lipid-lowering medication adherence during the 24 months before and after copayment increase among veterans subject to the copayment change with those who were not. Adherence declined in all 3 groups after the copayment increase. However, the percentage of patients who were adherent (proportion of days covered > or =80%) declined significantly more in the all copayment (-19.2%) and some copayment (-19.3%) groups relative to the exempt group (-11.9%). The incidence of a continuous gap increased significantly at twice the rate in both copayment groups (all copayment group, 24.6%; some copayment group, 24.1%) as the exempt group (11.7%). Compared with the exempt group, the odds of having a continuous gap in the after relative to the before period were significantly higher in both the all copayment group (odds ratio, 3.04; 95% confidence interval, 2.29 to 4.03) and the some copayment group (odds ratio, 1.85; 95% confidence interval, 1.43 to 2.40). Similar results were seen in subgroups of patients at high risk for coronary heart disease, high medication users, and elderly veterans.

CONCLUSIONS

The copayment increase adversely affected lipid-lowering medication adherence among veterans, including those at high coronary heart disease risk.

P4P4P: an agenda for research on pay-for-performance for patients

Unhealthy behavior is a major cause of poor health outcomes and high health care costs. In this paper we describe an agenda for research to guide broader use of patient-targeted financial incentives, either in conjunction with provider-targeted financial incentives (pay-for-performance, or P4P) or in clinical contexts where provider-targeted approaches are unlikely to be effective. We discuss evidence of proven effectiveness and limitations of the existing evidence, reasons for underuse of these approaches, and options for achieving wider use. Patient-targeted incentives have great potential, and systematic testing will help determine how they can best be used to improve population health.

A test of financial incentives to improve warfarin adherence

Background

Sub-optimal adherence to warfarin places millions of patients at risk for stroke and bleeding complications each year. Novel methods are needed to improve adherence for warfarin. We conducted two pilot studies to determine whether a lottery-based daily financial incentive is feasible and improves warfarin adherence and anticoagulation control.

Methods

Volunteers from the University of Pennsylvania Anticoagulation Management Center who had taken warfarin for at least 3 months participated in either a pilot study with a lottery with a daily expected value of $5 (N = 10) or a daily expected value of $3 (N = 10). All subjects received use of an Informedix Med-eMonitor™ System with a daily reminder feature. If subjects opened up their pill compartments appropriately, they were entered into a daily lottery with a 1 in 5 chance of winning $10 and a 1 in 100 chance of winning $100 (pilot 1) or a 1 in 10 chance of winning $10 and a 1 in 100 chance of winning $100 (pilot 2). The primary study outcome was proportion of incorrect warfarin doses. The secondary outcome was proportion of INR measurements not within therapeutic range. Within-subject pre-post comparisons were done of INR measurements with comparisons with either historic means or within-subject comparisons of incorrect warfarin doses.

Results

In the first pilot, the percent of out-of-range INRs decreased from 35.0% to 12.2% during the intervention, before increasing to 42% post-intervention. The mean proportion of incorrect pills taken during the intervention was 2.3% incorrect pills, compared with a historic mean of 22% incorrect pill taking in this clinic population. Among the five subjects who also had MEMS cap adherence data from warfarin use in our prior study, mean incorrect pill taking decreased from 26% pre-pilot to 2.8% in the pilot. In the second pilot, the time out of INR range decreased from 65.0% to 40.4%, with the proportion of mean incorrect pill taking dropping to 1.6%.

Conclusion

A daily lottery-based financial incentive demonstrated the potential for significant improvements in missed doses of warfarin and time out of INR range. Further testing should be done of this approach to determine its effectiveness and potential application to both warfarin and other chronic medications.

Financial incentive-based approaches for weight loss: a randomized trial

CONTEXT

Identifying effective obesity treatment is both a clinical challenge and a public health priority due to the health consequences of obesity.

OBJECTIVE

To determine whether common decision errors identified by behavioral economists such as prospect theory, loss aversion, and regret could be used to design an effective weight loss intervention.

DESIGN, SETTING, AND PARTICIPANTS

Fifty-seven healthy participants aged 30-70 years with a body mass index of 30-40 were randomized to 3 weight loss plans: monthly weigh-ins, a lottery incentive program, or a deposit contract that allowed for participant matching, with a weight loss goal of 1 lb (0.45 kg) a week for 16 weeks. Participants were recruited May-August 2007 at the Philadelphia VA Medical Center in Pennsylvania and were followed up through June 2008.

MAIN OUTCOME MEASURES

Weight loss after 16 weeks.

RESULTS

The incentive groups lost significantly more weight than the control group (mean, 3.9 lb). Compared with the control group, the lottery group lost a mean of 13.1 lb (95% confidence interval [CI] of the difference in means, 1.95-16.40; P = .02) and the deposit contract group lost a mean of 14.0 lb (95% CI of the difference in means, 3.69-16.43; P = .006). About half of those in both incentive groups met the 16-lb target weight loss: 47.4% (95% CI, 24.5%-71.1%) in the deposit contract group and 52.6% (95% CI, 28.9%-75.6%) in the lottery group, whereas 10.5% (95% CI, 1.3%-33.1%; P = .01) in the control group met the 16-lb target. Although the net weight loss between enrollment in the study and at the end of 7 months was larger in the incentive groups (9.2 lb; t = 1.21; 95% CI, -3.20 to 12.66; P = .23, in the lottery group and 6.2 lb; t = 0.52; 95% CI, -5.17 to 8.75; P = .61 in the deposit contract group) than in the control group (4.4 lb), these differences were not statistically significant. However, incentive participants weighed significantly less at 7 months than at the study start (P = .01 for the lottery group; P = .03 for the deposit contract group) whereas controls did not.

CONCLUSIONS

The use of economic incentives produced significant weight loss during the 16 weeks of intervention that was not fully sustained. The longer-term use of incentives should be evaluated.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00520611.

Patient opinions regarding 'pay for performance for patients'

BACKGROUND

Pay for performance (P4P) programs have shown only modest improvements in outcomes and do not target patient behaviors. Many large employers and payers are turning to pay for performance for patients (P4P4P) to reduce health costs and improve the health of their covered populations. How these programs may be perceived by patients is unknown.

OBJECTIVE

To assess patients' opinion of the acceptability of P4P4P.

DESIGN

Cross-sectional self-administered survey.

PARTICIPANTS

Patients in waiting rooms in two university-based primary care clinics.

MEASUREMENTS

Participants were asked their opinions about paying people to quit smoking, lose weight, control their blood pressure, or control their diabetes.

RESULTS

Respondents were split on whether P4P4P is desirable. Thirty-six to 42% thought it was a good/excellent idea to pay smokers to quit smoking, obese people to lose weight, people with hypertension to control their blood pressure, or people with diabetes to control their blood sugar, while 41-44% of the sample thought it was a bad/very bad idea. Smokers and patients who were obese endorsed P4P4P more favorably as a means to achieving tobacco cessation and weight loss than their non-smoking and non-obese counterparts.

CONCLUSIONS

Acceptance of paying patients for performance by the general population is equivocal. Establishing the efficacy of paying patients for performance may help it gain wider acceptance.

Nurse staffing ratios: trends and policy implications for hospitalists and the safety net

BACKGROUND

Mandated minimum nurse-to-patient staffing ratio legislation was passed in California in 1999 and implemented January 1, 2004. Nurse staffing legislation is being considered in at least 25 other states.

OBJECTIVES

The objectives of this study were: (1) to evaluate nurse staffing trends in California from 1993 to 2004, (2) to identify types of hospitals below minimum staffing ratios and staffing changes in 2004, the first year post-implementation; and (3) to discuss possible implications of nurse staffing on hospitalists and their hospital-based initiatives.

DESIGN, SETTING, PATIENTS

We analyzed data from the medical-surgical units of all short-term acute-care general hospitals in California from 1993 to 2004. The annual hospital staffing ratio is composed of the combined hours of registered nurses and licensed vocational nurses and total number of patient days on medical-surgical units.

RESULTS

Nurse staffing ratios were relatively unchanged from 1993 to 1999 and then increased significantly from 1999 to 2004, with the largest increase in 2004, the year the nurse staffing ratio was implemented. Types of hospitals more likely to be below minimum ratios had a high Medicaid/uninsured patient population and were government owned, nonteaching, urban, and in more competitive markets. Most hospitals below ratios were considered part of the health care "safety net."

CONCLUSIONS

Nurse staffing legislation may increase nurse staffing. However, mandated nurse staffing ratios without mechanisms to help achieve ratios may force hospitals, especially safety-net hospitals, to make tradeoffs in other services or investments with unintended negative consequences for patients. Nurse staffing likely influences the outcomes of hospitalist-led quality initiatives, but these effects need to be explored further.