Cost-Benefit Analysis of Nursing Home Registered Nurse Staffing Times

Presented bySusan D. Horn, Ph.D.

Senior ScientistInstitute for Clinical Outcomes ResearchInstitute for Clinical Outcomes Research

Salt Lake City, Utah Salt Lake City, Utah

Lead author: David Dorr, MD, University of UtahCo-author: Randall Smout, MS, ICOR

2

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.

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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.

4

Study Design

• Retrospective chart review was used to

collect data on over 500 resident, treatment,

facility, and outcome variables including

Comprehensive Severity Index (CSI).

5

CPI Study DesignCPI Study DesignProcess to Develop Decidable and Executable Dynamic ProtocolsProcess to Develop Decidable and Executable Dynamic Protocols

Process FactorsProcess Factors•Management StrategiesManagement Strategies•InterventionsInterventions•MedicationsMedications

Patient FactorsPatient Factors•DiseaseDisease•Severity of DiseaseSeverity of Disease

› physiologic signs and symptomsphysiologic signs and symptoms› complexity/psychosocial factorscomplexity/psychosocial factors

•Multiple Points in TimeMultiple Points in Time

OutcomesOutcomes•ClinicalClinical•Health StatusHealth Status•Cost/LOS/EncountersCost/LOS/Encounters

Improve/Standardize:Improve/Standardize:

Control for:Control for:

Measure:Measure:

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National Pressure Ulcer Long-term Care Study (NPULS) 1996-1997

• 6 long-term care provider organizations6 long-term care provider organizations

• 82 facilities82 facilities

• 1,376 residents studied1,376 residents studied

• Inclusion criteria: Inclusion criteria: LOS > 14 days, LOS > 14 days, at risk of developing pressure ulcers with Braden Scale score < 17at risk of developing pressure ulcers with Braden Scale score < 17 no pressure ulcer on study entryno pressure ulcer on study entry

• Outcomes: Develop Pressure Ulcer (PU), hospitalization, Outcomes: Develop Pressure Ulcer (PU), hospitalization, urinary tract infectionurinary tract infection (UTI) (UTI)

Funded by Ross Products Division, Abbott LaboratoriesFunded by Ross Products Division, Abbott Laboratories

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Event Rates and Cost Estimates

• Event rates for from National Pressure Ulcer Long-

Term 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.

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DEVELOP PRESSURE ULCER by RNDEVELOP PRESSURE ULCER by RN TimeTime

38.1%

31.8%

25.1%

9.4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

<10 min 10 - <20 min 20 - <30 min 30 - <40 min

Chi-Square (6 df) = 50.86, p<.0001, n=1,376Chi-Square (6 df) = 50.86, p<.0001, n=1,376

% P

ress

ure

Ulc

ers

RN Time Per Resident Per Day

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DEVELOP PRESSURE ULCER by RNDEVELOP PRESSURE ULCER by RN TimeTime

Parameter Estimate Chi-Square Pr > ChiSq

ADLs_78 0.28 4.68 0.0305 CSI Severity 0.01 18.19 <.0001 MDS PU_hx 0.75 15.00 0.0001 Wt loss 0.34 6.04 0.0140Oral_eat prob 0.39 9.33 0.0023 Catheter 0.78 16.98 <.0001Entcalpr -0.55 6.77 0.0093 Ent_dis -0.98 6.00 0.0143 Fluid order -0.43 8.43 0.0037 RN 10-20m -0.41 7.84 0.0051 RN 20-30m -0.62 13.12 0.0003 RN 30-40m -1.86 42.82 <.0001 CNA >2.25h -0.64 5.76 0.0164 LPN >=45m -0.64 8.74 0.0031  

C = 0.727

Logistic Regression: Logistic Regression: DEVELOP PU -- RN/LPN/CNA Time and Other EffectsDEVELOP PU -- RN/LPN/CNA Time and Other Effects

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HOSPITALIZATION by RN TimeHOSPITALIZATION by RN Time

18.4%

11.1%9.6%

6.1%

0%

2%

4%6%

8%

10%

12%14%

16%

18%

20%

<10 min 10 - <20 min 20 - <30 min 30 - <40 min

Chi-Square (4 df) = 35.17, p<.0001, n=1,542Chi-Square (4 df) = 35.17, p<.0001, n=1,542

% H

osp

ital

izat

ion

RN Time Per Resident Per Day

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Effects of RN TimeEffects of RN Time

RN time of 30-40 min/resident/dayRN time of 30-40 min/resident/day

is associated withis associated with

Fewer UTIs Fewer UTIs Fewer catheterizationsFewer catheterizations Less weight lossLess weight loss Less decline in ADLsLess decline in ADLs More nutrition supplementsMore 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

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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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Cost of additional 30 min

RN care per resident day

$472,814

Societal PerspectiveEconomic Value of Nurses

Savings in avoided PU treatment costSavings in avoided PU treatment cost

$242,426$242,426Savings in avoided hospitalizationsSavings in avoided hospitalizations

$518,627$518,627

Savings in avoided UTI costsSavings in avoided UTI costs

30,88230,882

Cost/Benefit Analysis of More RN TimeCost/Benefit Analysis of More RN Time$ Per 100 at-risk residents per year (FY2001 dollars)$ Per 100 at-risk residents per year (FY2001 dollars)

Assumptions: $1,727 wtd avg to treat PU across stages, Assumptions: $1,727 wtd avg to treat PU across stages,

$8,523 avg for Medicare hospitalization, $53,900K RN salary & FB/yr$8,523 avg for Medicare hospitalization, $53,900K RN salary & FB/yr

Net Savings $319,121Net Savings $319,121

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Cost of additional 30 min

RN care per resident day

$472,814

Institutional PerspectiveEconomic Value of Nurses

Savings in avoided PU treatment costSavings in avoided PU treatment cost

$242,426$242,426Savings in avoided hospitalizationsSavings in avoided hospitalizations

$518,627$518,627

Savings in avoided UTI costsSavings in avoided UTI costs

30,88230,882

Institutional Analysis of More RN TimeInstitutional Analysis of More RN Time$ Per 100 at-risk residents per year (FY2001 dollars)$ Per 100 at-risk residents per year (FY2001 dollars)

Assumptions: $1,727 wtd avg to treat PU across stages, Assumptions: $1,727 wtd avg to treat PU across stages,

$691 per UTI, hospitalization not counted, $53,900K RN salary & FB/yr$691 per UTI, hospitalization not counted, $53,900K RN salary & FB/yr

Net Cost $199,507Net Cost $199,507

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Sensitivity Analyses

• Sensitivity analyses revealed a robust

set of estimates with no single or

paired elements reaching cost/benefit

equality threshold.

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Sensitivity

Event Rate sensitivities per 100 bed Nursing Home

$0.00

$50,000.00

$100,000.00

$150,000.00

$200,000.00

$250,000.00

$300,000.00

$350,000.00

$400,000.00

UTI Hospitalizations Pressure Ulcers Wages

Event rate categories

Ben

efi

t (c

ost)

, $,

per

NH

+10%

-10%

Estimate

UTI Hospitalizations Pressure Ulcers Wages

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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.

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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.

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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.

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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 ResultsLong Term Care CPI ResultsOutcome: Develop Pressure UlcerOutcome: Develop Pressure Ulcer

GeneralGeneral AssessmentAssessment

IncontinenceIncontinenceInterventionsInterventions

Pressure ReliefPressure ReliefInterventionsInterventions

StaffingStaffingInterventionsInterventions

+ Age + Age 85 85

+ Male+ Male

+ Severity of Illness+ Severity of Illness

+ History of PU+ History of PU

+ Dependency in + Dependency in 7 7 ADLsADLs

+ Diabetes+ Diabetes

+ History of tobacco use+ History of tobacco use

+ Mechanical devices for + Mechanical devices for the containment of urine the containment of urine (catheters) (treatment (catheters) (treatment time time 14 days) 14 days)

- Disposable briefs- Disposable briefs (treatment time (treatment time 14 14 days) days)

- Toileting Program - Toileting Program (treatment time (treatment time 21days 21days))

+ Static pressure + Static pressure reduction: protective reduction: protective device (treatment time device (treatment time 14 days) 14 days)

+ Positioning: protective + Positioning: protective

device (treatment time device (treatment time

14 days) (p=.07)14 days) (p=.07)

- RN hours per resident - RN hours per resident per day per day 0 .250 .25

- CNA hours per - CNA hours per

resident per day resident per day 22

- LPN hours per resident - LPN hours per resident

per day per day 0.750.75

General CareGeneral Care

MedicationsMedications

- AntidepressantAntidepressant

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Long Term Care CPI ResultsLong Term Care CPI ResultsOutcome: Develop Pressure UlcerOutcome: Develop Pressure Ulcer

NutritionalNutritional AssessmentAssessment

NutritionalNutritionalInterventionsInterventions

+ Dehydration signs and + Dehydration signs and

symptoms: symptoms: low systolic blood low systolic blood

pressure, high temperature, pressure, high temperature,

dysphagia, high BUN, diarrhea, dysphagia, high BUN, diarrhea,

dehydration dehydration

+ Weight Loss: + Weight Loss: >=5% in last 30 >=5% in last 30

days or >=10% in last 180 daysdays or >=10% in last 180 days

- Fluid Order- Fluid Order

- Nutritional Supplements- Nutritional Supplements

• standard medicalstandard medical

- Enteral Supplements- Enteral Supplements

• disease-specificdisease-specific• high calorie/high high calorie/high protein protein

Nutritional CareNutritional Care

Horn et al, J. Amer Geriatr Soc March 2004 Horn et al, J. Amer Geriatr Soc March 2004