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RWJ 08-274 – HSR Study

RWJ 08-274
VA Supplement to INQRI Proposal
Ciaran S. Phibbs, PhD MA BA
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: March 2009 - February 2011
There is growing evidence of the effect of nurse staffing levels on patient outcomes in acute-care hospitals, but the evidence is more limited for long term care (LTC). In the private sector, many LTC facilities have very high staff turnover rates, and this has been associated with worse patient outcomes.

This study examines relationships between nurse staffing levels, skill-mix, job tenure (turnover) and experience, and patient outcomes in VA LTC units. In addition to the clinical outcomes, we also consider the cost implications.
Aim 1: Controlling for confounding variables, examine whether there is a causal relationship between the nursing inputs (i.e., staffing levels, general human capital, facility-specific human capital, and team-specific human capital) and nursing sensitive-patient outcomes in LTC facilities.
Aim 2: Analyze efficiency in providing LTC services by studying the trade-offs between nursing personnel costs and cost savings from a reduction in nursing-sensitive adverse events. This will be the first study to consider how expenditures on nursing in LTC may result in cost savings due to improved patient outcomes. Policymakers who are interested in quantifying the value created by nurses will also benefit from this research project.

All skilled nursing and LTC (or CLC) unit data for FY 03-08 were examined. Staffing data for all nursing personnel types (i.e., registered nurses [RN], licensed vocational nurses [LVN] and aides or unlicensed personal (UAP)) were obtained from the Decision Support System. Payroll data were used to determine each nurse's education and tenure on the unit and overall staff turnover. Patient data were obtained from the Patient Treatment File and the Minimum Dataset. Acute care hospitalizations, pressure ulcers, catheter-associated infections, and costs were the outcomes. All data were aggregated by month for each unit. Fixed-effects regressions were used to control for unobserved heterogeneity. Site visits were conducted at selected VA facilities to talk with LTC nursing staff.

On average, the total nursing hours per bed day (HPPD) was 4.8 and 33% of these hours were provided by RNs. Mean time a nurse had been working on the specific unit was 4.3 years, and this was similar for RNs, LVNs, and aides. The fixed-effects models use each unit as its own control; the estimates are powered by the within unit variance, compared to the unit mean. Thus, the estimates control for unobserved factors that can affect outcomes, such as the quality of the unit management, unit culture, etc. Higher HPPD, lower use of aides, and lower staff turnover were weakly associated with lower adverse event rates (pressure ulcers, catheter associated infections, acute care hospitalizations). The magnitude of these effects was quite small, e.g. a 1 hour increase in HPPD (a 20% increase in staffing) was associated with a 1% reduction in acute care hospitalizations. Event rates were higher for units that had more short stay (<90 days) patients. The cost regressions showed that the net effects on costs of increased staffing levels and skill mix were small, variable, and not statistically significant (increasing HPPD was associated with a small cost increase and increasing the share of RNs was associated with a small cost decrease.

Conclusions: Compared to the norm in the private sector, VA LTC units had relatively high staffing levels, more use of RNs, and much lower turnover. Even at the high levels observed, staffing did have an effect on outcomes, but these effects were much smaller than has been observed in the private sector. The fact that increased staffing is not associated with increased costs actually isn't surprising. Even though the effect was small, the average acute care hospitalization from VA LTC units cost $18,500 and almost 10% of these patients were admitted to acute care units from LTC care units.

Nurse staffing at VA LTC facilities is different than the private sector. The higher staffing levels and lower turnover in VA LTC units contributes to lower rates of preventable complications. These prevented adverse events associated with better savings essentially pay for the costs of the better VA LTC nurse staffing levels.

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Journal Articles

  1. Bartel AP, Beaulieu N, Phibbs CS, Stone PW. Human Capital and Productivity in a Team environment: Evidence from the Healthcare Sector. American economic journal. Applied economics. 2014 Apr 17; 6(2):28. [view]
Conference Presentations

  1. Phibbs CS. A longitudinal study of the effects of nurse staffing levels, nurse human capital, and nursing teams on patient outcomes for VA inpatient care. Paper presented at: International Health Economics Association Biennial World Congress on Health Economics; 2011 Jul 12; Toronto, Canada. [view]
  2. Phibbs CS, Bartel AP, Stone PW. A longitudinal study of the effects of nurse staffing levels, nursing characteristics, and job tenure on patient outcomes for VA long term care. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD. [view]
  3. Phibbs CS, Bartel AP, Stone PW. A Longitudinal Study of the Effects of Nurse Staffing Levels, Nursing Characteristics, and Job Tenure on Patient Outcomes for VA Longer Term Care. Presented at: RWJ Foundation Interdisciplinary Nursing Quality Research Initiative Annual National Conference; 2012 Apr 26; Washington, DC. [view]
  4. Uchida M, Stone P, Schmitt S, Phibbs CS. Nurse Workforce Characteristics and Quality of Care in Department of Veterans Affairs Community Living Centers. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 23; Baltimore, MD. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: none
Keywords: Long-term care, Nursing, Quality Measure
MeSH Terms: none

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