BACKGROUND/RATIONALE:
Changes in nurse staffing and management of nursing services have been important components of VA's organizational restructuring to reduce the cost of care per patient, serve more patients and improve the quality of its services. These have resulted in a decrease in inpatient nursing positions and changes in the scope of responsibility and authority of nursing management. However, there has as yet been no evaluation of the association between organizational changes and costs of patient care in VA hospitals.

OBJECTIVE(S):
This study examined the relationships between nurse staffing and nursing service structure and patient care costs in acute medical/surgical units.

METHODS:
This was an observational, cross-sectional study using patient admissions from February through June, 2003. The final sample for the analysis of the relationship between nurse staffing and patient costs included 139,361 admissions of 110,647 patients from 292 units at 125 VAMCs. For the analysis of the relationship between nursing service structure and patient care costs, the final sample included 139,010 admissions from 290 units at 124 VAMCs. Nurse staffing was measured as total nursing hours per patient day (HPPD) and proportion of total nursing hours provided by RNs (RN skill mix). Nursing service structure was measured as whether nurse executives had line authority for nurse staffing under a service line, traditional, or mixed organizational structure. Two-stage multilevel linear regressions were performed to estimate the impact of nurse staffing or nursing service structure on costs above and beyond patient, facility, and market level characteristics. In addition, we conducted simulations to estimate the effect of varying RN skill mix levels on length of stay, in-hospital complication rates, inpatient mortality, and patient care costs, holding total nursing HPPD constant.

FINDINGS/RESULTS:
Patient care costs were not statistically associated with nursing skill mix, but were positively associated with total nursing HPPD among medical admissions (coefficient = 169.35, p<0.001). Simulating effects of RN skill mix by increasing RN skill mix to 75% of total nursing hours for units below this level contributed to a predicted $119 (SE=$24) and $547 (SE=$102) increase in patient care costs per medical and surgical admission, respectively; a 0.33 day (SE=0.02 days) decrease in hospital length of stay, a 0.46% (SE=0.10%) decrease in complication rate among medical admissions, and a 0.51% (SE=0.05%) and 0.25% (SE=0.08%) decrease in mortality for medical and surgical patients, respectively. Nurse executive line authority was not significantly associated with total patient care cost per day (coefficient = 78.9; p=0.486), nursing cost per day (coefficient = -40.64; p=0.417), or non-nursing cost per day (coefficient = 93.49; p=0.494).

IMPACT:
Our simulation results show that although increasing RN skill mix while holding total nursing hours unchanged was associated with a small increase in patient cost per admission, this cost may be off set by shortened length of stay, and decreased mortality and in-hospital complication rates. The effect of increasing RN skill mix on patient care quality and costs is greater for medical admissions than surgical admissions. This study provides no evidence that nurse executive line authority, often associated with changes in organizational structure, offers cost efficiency, nor evidence that there are inefficiencies associated with this organizational change.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Liu CF, Sharp ND, Sales AE, Lowy E, Maciejewski ML, Needleman J, Li YF. Line authority for nurse staffing and costs for acute inpatient care. Inquiry : A Journal of Medical Care Organization, Provision and Financing. 2009 Jan 1; 46(3):339-51. [view]

Conference Presentations

1. Li Y-F, Phibbs CS, Sales AE, Needleman J. Measuring Nurse Staffing Levels: VA and Non-VA Perspectives - Workshop. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD. [view]
2. Liu CF, Li YF, Sharp N, Lowy E, Mackejewski ML, Sales AE, Needleman J. Nurse Staffing and Direct Inpatient Care Costs. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD. [view]
3. Liu CF, Li YF, Sharp N, Maciejewski ML, Sales A, Needleman J. Nurse Staffing and Direct Inpatient Care Costs. Poster session presented at: VA Nursing Leadership Annual Conference; 2008 Apr 12; Seattle, WA. [view]
4. Liu CF, Li YF, Sharp N, Lowy E, Maciejewski M, Sales A. Nurse Staffing and Direct Inpatient Care Costs. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC. [view]
5. Li Y-F, Liu C-F, Lowy E, Sharp ND, Maciejewski M, Sales AE. Patient Care Costs and Nurse Staffing in VA. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA. [view]
6. Li YF, Liu CF, Sharp N, Sales A. The association between costs and nurses' perception of practice environment in acute inpatient care. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 9; Washington, DC. [view]
7. Sales AE, Li YF, Liu CF. The association between costs and nurses' perception of practice environment in acute inpatient nursing. Poster session presented at: American Society of Health Economists Biennial Conference; 2008 Jun 23; Durham, NC. [view]
8. Li YF, Liu CF, Sales A. The association between costs and nurses' perception of practice environment in acute inpatient nursing. Poster session presented at: VA Nursing Leadership Annual Conference; 2008 Apr 12; Seattle, WA. [view]
9. Li YF, Sharp N, Liu CF, Sales A. The associations of nurse, patient and organizational characteristics with nursing workload. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 9; Washington, DC. [view]
10. Sharp N, Liu CF, Li YF, Lowy E, Sales A, Maciejewski M, Needleman J. The Relationship between Line Authority for Nurse Staffing and Patient Care Costs in VA. Poster session presented at: VA Nursing Leadership Annual Conference; 2008 Apr 12; Seattle, WA. [view]

DRA: Health Systems
DRE: none
Keywords: Cost, Research measure, Staffing
MeSH Terms: none