Cost-Benefit Analysis of Nursing Home
Registered Nurse Staffing Times
Presented by
Susan D. Horn, Ph.D.
Senior Scientist
Institute for Clinical Outcomes Research
Salt Lake City, Utah
Lead author: David Dorr, MD, University of Utah
Co-author: Randall Smout, MS, ICOR
Background

Adequate nurse staffing in hospitals,
ICUs, ambulatory clinics, and nursing
homes has been shown to be critical for
quality care.

Cost-benefit of better resident outcomes
versus additional wages for nurses is
largely unknown.
2
Research Objective
•
To perform a cost-benefit analysis of
societal benefits of decreased adverse
resident outcomes versus additional wages
of registered nurses to achieve adequate
staffing in nursing homes.
•
Perform cost-benefit analysis from
institutional perspective.
3
Study Design
•
Retrospective chart review was used to
collect data on over 500 resident, treatment,
facility, and outcome variables including
Comprehensive Severity Index (CSI).
4
CPI Study Design
Process to Develop Decidable and Executable Dynamic Protocols
Improve/Standardize:
Process Factors
•Management Strategies
•Interventions
•Medications
Control for:
Patient Factors
•Disease
•Severity of Disease
Measure:
Outcomes
•Clinical
•Health Status
•Cost/LOS/Encounters
› physiologic signs and symptoms
› complexity/psychosocial factors
•Multiple Points in Time
5
National Pressure Ulcer Long-term Care Study
(NPULS) 1996-1997
• 6 long-term care provider organizations
• 82 facilities
• 1,376 residents studied
• Inclusion criteria:
LOS > 14 days,
 at risk of developing pressure ulcers with Braden Scale score < 17
no pressure ulcer on study entry
• Outcomes: Develop Pressure Ulcer (PU), hospitalization,
urinary tract infection (UTI)
Funded by Ross Products Division, Abbott Laboratories
6
Event Rates and Cost Estimates
•
Event rates for from National Pressure Ulcer LongTerm Care Study (NPULS).
•
Hospital costs estimated from age and gender-specific
charges from Health Care Cost and Utilization Project
(HCUP) with Medicare discount applied (48.9%).
•
UTI and PU costs from cost-identification studies.
7
DEVELOP PRESSURE ULCER by RN Time
40%
35%
38.1%
30%
31.8%
25%
25.1%
20%
15%
10%
9.4%
5%
0%
<10 min
10 - <20 min
20 - <30 min
30 - <40 min
RN Time Per Resident Per Day
Chi-Square (6 df) = 50.86, p<.0001, n=1,376
8
DEVELOP PRESSURE ULCER by RN Time
Logistic Regression: DEVELOP PU -- RN/LPN/CNA Time and Other Effects
Parameter
ADLs_78
CSI Severity
MDS PU_hx
Wt loss
Oral_eat prob
Catheter
Entcalpr
Ent_dis
Fluid order
RN 10-20m
RN 20-30m
RN 30-40m
CNA >2.25h
LPN >=45m
Estimate
0.28
0.01
0.75
0.34
0.39
0.78
-0.55
-0.98
-0.43
-0.41
-0.62
-1.86
-0.64
-0.64
Chi-Square
Pr > ChiSq
4.68
18.19
15.00
6.04
9.33
16.98
6.77
6.00
8.43
0.0305
<.0001
0.0001
0.0140
0.0023
<.0001
0.0093
0.0143
0.0037
7.84
13.12
42.82
5.76
8.74
0.0051
0.0003
<.0001
0.0164
0.0031
C = 0.727
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HOSPITALIZATION by RN Time
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
18.4%
11.1%
9.6%
6.1%
<10 min
10 - <20 min
20 - <30 min
30 - <40 min
RN Time Per Resident Per Day
Chi-Square (4 df) = 35.17, p<.0001, n=1,542
10
Effects of RN Time
RN time of 30-40 min/resident/day
is associated with




Fewer UTIs
Fewer catheterizations
Less weight loss
Less decline in ADLs
 More nutrition supplements
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Measurements
•
Differences in rates of PU, UTI, and
hospitalizations per resident per day were
calculated from low staffing (<10 min/res/day)
and adequate staffing (30-40 min/res/day)
nursing homes.
•
Time horizon: single year
•
Inflation adjustment: Medical Care Price Index
12
Benefits and Costs
•
•
Benefits per event prevented (FY 2001
dollars) (95% CI)
• Per pressure ulcer: $1,727 ($1,654, $1,800)
• Per UTI: $691 ($495, $887)
• Per hospitalization: $8,523 ($7,514, $9,533)
Cost of additional nurse staffing (adding 30
min/pt):
• $25.91 ($25.70, $26,11).
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Principal Findings
•
Analysis shows net societal benefit of $319,000
per year for 100-bed high-risk nursing home unit
with sufficient nurses to achieve 30-40 minutes
direct RN care/res/day versus nursing homes with
direct RN care <10 min/res/day
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Societal Perspective
Economic Value of Nurses
Cost/Benefit Analysis of More RN Time
$ Per 100 at-risk residents per year (FY2001 dollars)
Savings in avoided PU treatment cost
Cost of additional 30 min
RN care per resident day
$242,426
Savings in avoided hospitalizations
$518,627
$472,814
Savings in avoided UTI costs
30,882
Net Savings $319,121
Assumptions: $1,727 wtd avg to treat PU across stages,
$8,523 avg for Medicare hospitalization, $53,900K RN salary & FB/yr
15
Institutional Perspective
Economic Value of Nurses
Institutional Analysis of More RN Time
$ Per 100 at-risk residents per year (FY2001 dollars)
Savings in avoided PU treatment cost
Cost of additional 30 min
RN care per resident day
$242,426
Savings in avoided hospitalizations
$518,627
$472,814
Savings in avoided UTI costs
30,882
Net Cost $199,507
Assumptions: $1,727 wtd avg to treat PU across stages,
$691 per UTI, hospitalization not counted, $53,900K RN salary & FB/yr
16
Sensitivity Analyses
•
Sensitivity analyses revealed a robust
set of estimates with no single or
paired elements reaching cost/benefit
equality threshold.
17
Sensitivity
Event Rate sensitivities per 100 bed Nursing Home
$400,000.00
$350,000.00
Benefit (cost), $, per NH
$300,000.00
$250,000.00
$200,000.00
+10%
$150,000.00
-10%
Estimate
$100,000.00
$50,000.00
$0.00
UTI
Hospitalizations
Pressure Ulcers
Event rate categories
Wages
18
Conclusions
•
Adequate nurse staffing in nursing homes
can have significant societal quality of care
and cost benefits, but cost benefits may not
accrue to nursing homes under current
reimbursement systems.
19
Implications for Policy and Practice
•
Incentives for improvement must
allow some (or most) of the savings to
be returned to nursing homes that
voluntarily improve or maintain
appropriate registered nurse staffing.
20
Implications for Policy and Practice
•
Altering reimbursement to more accurately reflect
cost-effectiveness of care has support in the
literature, can be implemented relatively quickly,
and may improve outcomes.
•
Effective nursing care to prevent adverse
outcomes must be reflected in these alterations.
21
Funding Sources
•
Partial support from National Library of
Medicine Training Grant (David Dorr).
•
NPULS that created database used in analyses
originally funded by Ross Products Division of
Abbott Laboratories
•
Portions of analyses funded by Institute for
Clinical Outcomes Research (Randall Smout
and Susan Horn).
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Long Term Care CPI Results
Outcome: Develop Pressure Ulcer
General Care
General
Assessment
+ Age  85
+ Male
+ Severity of Illness
+ History of PU
+ Dependency in  7
ADLs
+ Diabetes
+ History of tobacco use
Incontinence
Interventions
Pressure Relief
Interventions
Staffing
Interventions
+ Mechanical devices for
the containment of urine
(catheters) (treatment
time  14 days)
+ Static pressure
reduction: protective
device (treatment time 
14 days)
- RN hours per resident
per day  0 .25
- Disposable briefs
(treatment time  14 days)
- Toileting Program
(treatment time  21days)
+ Positioning: protective
device (treatment time 
14 days) (p=.07)
- CNA hours per
resident per day  2
- LPN hours per resident
per day  0.75
Medications
- Antidepressant
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Long Term Care CPI Results
Outcome: Develop Pressure Ulcer
Nutritional Care
Nutritional
Assessment
+ Dehydration signs and
symptoms: low systolic blood
pressure, high temperature,
dysphagia, high BUN, diarrhea,
dehydration
+ Weight Loss: >=5% in last 30
days or >=10% in last 180 days
Horn et al, J. Amer Geriatr Soc March 2004
Nutritional
Interventions
- Fluid Order
- Nutritional Supplements
• standard medical
- Enteral Supplements
• disease-specific
• high calorie/high
protein
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