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Patient Care Costs and Nurse Staffing in VA

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.

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Objectives: VA has implemented extensive organizational changes to improve cost-effectiveness of inpatient care. A cost reduction strategy in nursing has included replacing professional nursing staff with unlicensed assistive personnel. While the effectiveness of these strategies for cost saving is unclear, the consequence of lowered nursing skill mix has drawn attention to issues of nurse staffing and patient outcomes. This study examines the relationship between patient care costs and nurse staffing in acute medical/surgical units, controlling for patient outcomes. Methods: This cross-sectional study includes all admissions to 292 acute medical/surgical units in 125 VAMCs between 2/03-6/03. Data sources were DSS inpatient and ALB extracts, VA administrative databases, and national databases on market/health service area characteristics. Nurse staffing measures included RN hours per patient day (HPPD), non-RN HPPD, total nursing HPPD, and RN skill mix (proportion of RN to total nursing hours). We used a three-stage least squares, where 1st stage predicts the complication rate at the patient level; 2nd stage predicts nurse staffing at unit level, based on complication rate, and facility and market characteristics; and 3rd stage evaluates the association between patient care costs and nurse staffing at the unit level. Results: Patient care costs ranged from $740 to $4,183/day, with an average of $1,729/day. Average total nursing HPPD, RN HPPD, and non-RN HPPD were 7.3, 4.4, and 2.9 hours, respectively. Average RN skill mix was 61%. In-hospital complication rate was 12.8% on average. Occurrence of in-hospital complications was associated with patient demographic, source of admission, and comorbid conditions. Unit level nurse staffing was associated with facility complexity grouping, but not with in-hospital complication rate. Patient care costs/day was positively associated with total nursing HPPD, RN skill mix, and RN HPPD. Implications: Nurse staffing might be a relatively stable measure that reflects the demand to provide care based on the complexity of patient population served and is less responsive to short-term changes of patient conditions. Patient care costs were higher on units providing higher overall or RN nurse staffing. Impacts: Understanding the cost-effectiveness of nurse staffing structures, and the impact of resource allocation on patient care costs, is critical for informed decision making about nurse staffing.

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