• Karen B Lasater, Matthew D McHugh, Paul R Rosenbaum, Linda H Aiken, Herbert L Smith, Joseph G Reiter, Bijan A Niknam, Alexander S Hill, Lauren L Hochman, Siddharth Jain, and Jeffrey H Silber.
• Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA. karenbl@nursing.upenn.edu.
• J Gen Intern Med. 2021 Jan 1; 36 (1): 84-91.

BackgroundNursing resources, such as staffing ratios and skill mix, vary across hospitals. Better nursing resources have been linked to better patient outcomes but are assumed to increase costs. The value of investments in nursing resources, in terms of clinical benefits relative to costs, is unclear.ObjectiveTo determine whether there are differential clinical outcomes, costs, and value among medical patients at hospitals characterized by better or worse nursing resources.DesignMatched cohort study of patients in 306 acute care hospitals.PatientsA total of 74,045 matched pairs of fee-for-service Medicare beneficiaries admitted for common medical conditions (25,446 sepsis pairs; 16,332 congestive heart failure pairs; 12,811 pneumonia pairs; 10,598 stroke pairs; 8858 acute myocardial infarction pairs). Patients were also matched on hospital size, technology, and teaching status.Main MeasuresBetter (n = 76) and worse (n = 230) nursing resourced hospitals were defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses, and nurse work environments. Outcomes included 30-day mortality, readmission, and resource utilization-based costs.Key ResultsPatients in hospitals with better nursing resources had significantly lower 30-day mortality (16.1% vs 17.1%, p < 0.0001) and fewer readmissions (32.3% vs 33.6%, p < 0.0001) yet costs were not significantly different ($18,848 vs 18,671, p = 0.133). The greatest outcomes and cost advantage of better nursing resourced hospitals were in patients with sepsis who had lower mortality (25.3% vs 27.6%, p < 0.0001). Overall, patients with the highest risk of mortality on admission experienced the greatest reductions in mortality and readmission from better nursing at no difference in cost.ConclusionsMedicare beneficiaries with common medical conditions admitted to hospitals with better nursing resources experienced more favorable outcomes at almost no difference in cost.

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