Institute for Clinical Outcomes Research Salt Lake City, Utah Cost-Benefit Analysis of Nursing Home...
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Transcript of Institute for Clinical Outcomes Research Salt Lake City, Utah Cost-Benefit Analysis of Nursing Home...
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.
3
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).
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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.
18
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
19
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.
22
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