A Longitudinal Analysis
(1996-2002) of Rural Hospital
Financial Margins, Nurse
Staffing, and Patient Outcomes
Robin P Newhouse PhD, RN, CNAA, BC
This project was supported by grant number 1 KO8 HS015548 from
1
the Agency for Healthcare Research and Quality (AHRQ)
Co-investigators
Laura Morlock, PhD
Peter Pronovost, MD, PhD
Elizabeth Colantuoni, PhD
Meg Johantgen, RN, PhD
2
Rural Hospitals
Represent 41 % (2,009/4,936) of nonfederal, short-term
general and specialty hospitals1
Provided care for 7.5 million discharges nationally in 2006
(18.9% of all discharges) 2
Patient population is older, portray their health as poor or
fair, more likely to be uninsured, and are more
remote from health care services
Federal legislative efforts to balance the budget have an
impact on rural hospital operational budgets
1 Source:http://www.aha.org/aha/trendwatch/chartbook/07appendix2.pdf
2 Weighted national estimates from HCUP Nationwide Inpatient Sample
(NIS), 2008, AHRQ
3
Purpose
To examine the association among rural
hospitals during 1996 - 2002 between:
-financial margins and nurse staffing per
hospital bed
-nurse staffing per hospital bed and patient
outcomes
-financial margins on patient outcomes
Staffing


Margins  Outcomes
4
Design: Time Series
Hospital-level data during time of BBA
Data Sources:
Medicare Cost Reports (margins)
Hospital Discharge data (mortality, FTR)
American Hospital Association Annual
Survey (RN/LPN FTEs, contextual measures)
5
Study Hospital Types
and Bed Sizes
Rural Hospital Type
Rural Referral Center
(RRC)
Sole Community
Provider (SCP)
Rural
(Not RRC or SCP)
Total
26-49 50-99 >100 Total
0
4
22
26
29
24
9
62
48
30
20
98
77
58
51
186
6
Nurse and Hospital Attributes
Adjusted RN FTE
Mean (SD) FTE/Bed
94 (84)
1.1
Adjusted LPN FTE
18 (22)
0.2
Adjusted Total FTE
112 (95)
1.3
Acute Beds
85 (67)
7
Hospital Attributes
Teaching
System member
Network member
Joint Commission
6%
42%
32%
80%
RUCC Code
6 (1.8)
8
9
11
Regression Analysis
Modeled effects across years of:
-margins on staffing
-margins on outcomes
-staffing on outcomes
1. Tested yearly specific effects
2. Tested overall effect of means (pooled effect)
3. Estimated actual margin & change in margins
(current year-past year)
4. Results presented as % change in mean
12
Effect of Financial Margins on
Nurse FTEs
Nurse FTE (RN, LPN and total) per bed were
not significantly affected by financial
margins or changes in margins during the
study time period.
13
Effect of Financial Margins on
Outcomes
Outcomes were not significantly affected by
financial margins or changes in margins
during the study time period.
14
Effect of RN Staffing on Outcomes
HF mortality - each additional one RN FTE
per bed results in 14% lower mortality
Stroke mortality – each additional one RN
FTE per bed results in 9% lower stroke
mortality
When measuring the change in RNFTE/bed
the following year (lag), adding one RNFTE
per bed results in 15% lower CHF mortality,
13% lower stroke mortality and 17% lower
FTR.
15
Limitations
Exploratory study, secondary data
Representativeness of sample hospitals elimination of hospitals without outcomes
across the 7 years (systematic missing)
Outcomes may not be sensitive to nursing –
need better process and outcome measures
16
Conclusions
Rural hospitals have not reduced nursing staff
(RNs or LPNs) or experienced lower quality
outcomes despite negative financial
margins.
The number of RNs per bed has a significant
effect on patient outcomes in rural hospitals
17
Implications
Policies to promote adequate numbers of
RNs in the rural setting are needed to
achieve better patient outcomes.
18