Valuing hospital investments in nursing: multistate matched-cohort study of surgical patients

Abstract

BackgroundThere are known clinical benefits associated with investments in nursing. Less is known about their value.AimsTo compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks.MethodsRetrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital’s size category, teaching and technology status, and were closely matched on comorbidities and other risk factors.ResultsPatients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (p<0.001), lower failure-to-rescue: 5.4% vs 6.2% (p<0.001), lower readmissions: 12.6% vs 13.5% (p<0.001), shorter lengths of stay: 4.70 days vs 4.76 days (p<0.001), more intensive care unit admissions: 17.2% vs 15.4% (p<0.001) and marginally higher nurse-adjusted costs (which account for the costs of better nursing resources): $20 096 vs $19 358 (p<0.001), as compared with patients in worse nursing resourced hospitals. The nurse-adjusted cost associated with a 1% improvement in mortality at better nursing hospitals was $2035. Patients with the highest mortality risk realised the greatest value from nursing resources.ConclusionHospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.

Evaluating the Costs and Outcomes of Hospital Nursing Resources: a Matched Cohort Study of Patients with Common Medical Conditions

“…Economic performance was evaluated using a measure of 30-day resource utilizationbased costs, which were inflation-adjusted and computed from the costs of resources used during the in-hospital admission as well as any costs accrued 30-days post-admission (Appendix 4). 5,6,13,14 If a patient was readmitted within 30 days of the index admission date, all costs accrued during the readmission (including in-patient costs beyond 30 days) were included. Inhospital costs are a function of length of stay, level of care (i.e., ICU vs. general unit), 15 and total relative value units from bills.…”

“…We defined study hospitals as having either better or worse nursing resources using a coherence rank score based on four aspects of nursing (i.e., staffing, skill mix, education, work environment) (Appendix 5). 6,17 The four aspects of nursing within each of the 512 study hospitals were compared to all other hospitals to compute a score for every hospital using coherence methods. 18 In brief, each hospital was assigned a score between 1 and 512 and rank-ordered.…”

“…An analysis of surgical Medicare patients similarly found lower mortality, failure-to-rescue, shorter lengths of stay and marginally higher costs among patients in better nursing resourced hospitals. 6 Other studies of medical patients have linked nursing resources with better outcomes including lower mortality, 27 lower readmissions, 28 and fewer complications. 29,30 A study examining costs of care among medical patients in Veteran's Administration facilities and its association with nurse hours per patient day and skill mix found that greater time RNs spend with patients is associated with cost offsets derived from shorter lengths of stay.…”

“…[2][3][4] More favorable nursing environments have been associated with greater value among surgical cohorts, especially for the sickest patients. 5,6 Increasing the proportion of nurses educated at the baccalaureate level is linked to shorter lengths of stay, fewer readmissions, and consequently lower costs. 7,8 In this study, we compare clinically and demographically similar patients admitted to comparable hospitals with respect to size, teaching status, and technology capabilities, but that are otherwise dissimilar with respect to their nursing resources.…”

Care complexity individual factors associated with adverse events and in-hospital mortality

“…Several studies have demonstrated the association between acute status and other patient and organizational measures, and nurse-sensitive outcomes such as mortality and the AE studied here. Nevertheless, further studies are required that combine acuity and complexity measures, as well as organizational variables such as nurse staffing or missed care, to gain a better understanding of their role in patient outcomes [56][57][58].…”