Better Nursing Environments Linked to Greater Surgical Value

Ricki Lewis, PhD

January 21, 2016

Hospitals with excellent nursing environments are associated with lower mortality in surgical patients for similar costs than hospitals with worse nursing environments, according to study results published online January 20 in JAMA Surgery.

"This is especially true for higher-risk patients, where the value of a better nursing environment appears to be greatest," Jeffrey H. Silber, MD, PhD, from the Perelman School of Medicine at the University of Pennsylvania, and colleagues write.

The results of previous studies suggest that better nursing environments are associated with better quality of care; in the current study, the researchers set out to look at the value of care, defined as cost vs quality.

Dr Silber and colleagues compared two groups of hospitals with very different nursing environments but similar patients, not considering other hospital characteristics. Hospitals with good nursing environments, called "focal hospitals," were identified on the basis of 2007 results of a national accreditation program for nursing environment excellence and on above-average nurse-to-bed ratios. Control hospitals did not have this distinction and had nurse-to-bed ratios less than 1. In addition, focal hospitals were larger, more teaching-intensive, and had better technology (defined as a burn unit, coronary artery bypass graft surgery, or transplants) than control hospitals.

The study included 35 focal hospitals and 293 control hospitals. The study included 25,752 patients treated at focal hospitals and 62,882 patients treated at control hospitals between 2004 and 2006 in Illinois, New York, or Texas. All patients were elderly, on Medicare, and undergoing general surgery. Outcomes were 30-day mortality and cost, which included in-hospital expenses; emergency, outpatient, or office visits; and rehospitalization costs even if they extended beyond the 30 days. An algorithm matched patients for one of 130 surgical procedures.

The focal hospitals had a mean nurse-to-bed ratio of 1.51, and the control hospitals had a ratio of 0.69. The 30-day mortality at focal hospitals was lower than at control hospitals (4.8% vs 5.8%; odds ratio [OR], 0.79; 95% confidence interval [CI], 0.73 - 0.86; P < .001; clustered P value = .005).

Surgical patients at the focal hospitals had lower 30-day failure-to-rescue rates compared with patients at control hospitals (7.5% vs 8.9%; OR, 0.83; 95% CI, 0.76 - 0.90; P < .001) and were in the intensive care unit less often (32.9% vs 42.9%; OR, 0.55; 95% CI, 0.52 - 0.57; P < .001) and stayed in the hospital for shorter times than patients at control hospitals (8.4 vs 8.6 days; paired difference, −0.1; 95% CI, −0.3 to −0.0; P =. 01).

In-hospital and 30-day costs were similar for the two patient groups. The 30-day cost per patient at a focal hospital was $27,131 compared with $27,292 for the matched controls, generating a $163 difference per patient pair (95% CI, −$542 to $215; P = .40). However, subtracting the nurse-to-bed ratio gives a focal–control difference of −$2038 per patient pair (P < .001; clustered P value < .001).

Mortality benefit was greater for the sickest patients (in the highest-risk quintile) at the focal hospitals (17.3% vs 19.9%; P < .001), with a cost difference of $941 per patient ($53,701 vs $52,760; P = .25), which is not statistically significant. The second-highest risk quintile demonstrated the biggest difference in value between focal and control hospitals, with mortality of 4.2% vs 5.8% (P < .001) and a cost difference of $862 ($33,513 vs $34,375; P = .12).

The researchers acknowledge that a limitation of the study was the use of a voluntary program of accreditation for good nursing environments, but say that using nurse-to-bed ratios added information.

"While better outcomes and value may be owing to other features of hospitals with good nursing, excellent nursing environments appear to provide a strong signal to patients and referring physicians for better quality, lower cost, and higher value," they conclude.

In an invited commentary, Amir A. Ghaferi, MD, and Christopher R. Friese, PhD, RN, from the University of Michigan, Ann Arbor, point out that each year, 100,000 patients die in the United States after elective surgery, and mortality rates vary from two- to 10-fold across hospitals. Failure to rescue after a postsurgical complication is an obvious contributory factor, and superior nursing environments might make that less likely.

"While we do not fully understand how hospitals rescue surgical patients, successful rescue likely requires teamwork, communication, and leadership skills from front-line nurses," they write, adding that these attributes are difficult to assess.

As well, improvements in nurse-to-bed ratio and recognition of better nursing environments may be difficult to attain; therefore, Dr Ghaferi and Dr Friese call for continuing identification of "actionable targets" to improve rescue from postsurgical complications.

The researchers and commentators have disclosed no relevant financial relationships.

JAMA Surg. Published online January 20, 2016. Abstract


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