Better hospital work environments and staffing levels for nurses may lower the risk for Medicare readmissions, according to the results of a new survey.
For patients with 3 common conditions, 30-day readmission rates were significantly lower in hospitals with a good work environment compared with those with poor work environments, Matthew D. McHugh, PhD, JD, MPH, RN, and Chenjuan Ma, PhD, RN, from the Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, report in an article published in the January issue of Medical Care. Readmission risk went up with each additional patient per nurse in the average nurse's workload.
Preventable hospital readmissions cost Medicare more than $15 billion annually, but little research has been done on the relationship between readmissions and hospital nursing, write Dr. McHugh and Dr. Ma. "Our results suggest that improving nurses' work environment and reducing nurses' workload are organization-wide reforms that could result in fewer readmissions for Medicare beneficiaries with common medical conditions."
These findings are particularly timely because, under the Affordable Care Act, the Centers for Medicare and Medicaid Services will reduce payments to hospitals with higher-than-expected readmission rates.
The authors obtained nurse information from a cross-sectional survey they conducted in 2005 to 2006 of registered nurses in California, Pennsylvania, and New Jersey, with a total of 20,585 nurses participating. They obtained data on the structural characteristics of hospitals from the American Hospital Association Annual Survey. The sample included 210 hospitals in California, 134 in Pennsylvania, and 68 in New Jersey.
Nurse work environment was measured using the Practice Environment Scale of the Revised Nursing Work Index, in which nurses state the degree to which their practice setting incorporates various organizational features. The scale has been endorsed by the National Quality Forum. The index consists of 5 subscales: nursing foundations for quality care; staffing and resource adequacy; nurse participation in hospital affairs; nurse manager ability, leadership, and support; and nurse–physician relations.
The researchers considered hospitals that scored above the median on 4 or 5 subscales to have good working environments. Above-median scores on 2 to 3 subscales indicated a mixed environment, and hospitals scoring above the median on 0 or 1 subscales were classified as poor work environments.
The investigators identified 30-day readmissions based on validated Risk-Standardized Readmission Measures from the Centers for Medicare and Medicaid Services. The authors looked at readmission rates for heart failure, acute myocardial infarction, and pneumonia. They adjusted their analysis for a variety of hospital-related covariates including size, teaching status, nonprofit or for-profit status, and volume of patients.
On logistic regression analysis, the odds of 30-day readmission for people with heart failure were 7% lower in hospitals with a good rather than poor work environment (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.89 - 0.97; P = .001). With acute myocardial infarction, the odds were 6% lower (OR, 0.94; 95% CI, 0.88 - 0.98; P = .01), and they were 10% lower for patients with pneumonia (OR, 0.90; 95% CI, 0.85 - 0.96; P < .001).
Each additional patient in a nurse's workload was associated with a 7% increase in the odds of readmission for patients with heart failure (OR, 1.07; 95% CI, 1.05 - 1.09; P < .001), a 9% increase for patients with acute myocardial infarction (OR, 1.09; 95% CI, 1.05 - 1.13; P < .001), and a 6% increase for patients with pneumonia (OR, 1.06; 95% CI, 1.03 - 1.09; P < .001).
Good work environments and adequate staffing ratios allow nurses to better care for patients throughout their hospital stay and to continually prepare them for discharge, the authors write. "If a hospital with a poor work environment could improve to a good environment, we would expect its readmission rate to decline from roughly the 84th to 50th percentile or the 50th to 16th percentile in this distribution of hospitals. A hospital that could change its work environment from poor to good and reduce nurse workloads from 6 to 4 patients per nurse would, all else being equal, see their readmission rates reduced from 25% to 21%."
The cost of increasing nursing staff could be offset through enhanced productivity, lower costs associated with turnover and training of new staff, improved patient outcomes, and lower patient use of postdischarge services and resources, according to the authors.
Fundamental nursing processes can make the difference between good and bad outcomes, the investigators conclude. "The challenge of readmissions will require a range of interventions. One potentially effective means of reducing overall readmissions may come through improving the organization and delivery of hospital nursing services."
This study was supported by the National Institute on Aging, National Institute of Nursing Research, Robert Wood Johnson Foundation Health and Society Research and Training special projects grant, Penn Institute on Urban Research, Elder Friendly Urban Environment, Frank Morgan Jones Fund, and Robert Wood Johnson Foundation Nurse Faculty Scholars program. The authors have disclosed no other relevant financial relationships.
Source: Medical Care. 2013;51:52-59
For patients with 3 common conditions, 30-day readmission rates were significantly lower in hospitals with a good work environment compared with those with poor work environments, Matthew D. McHugh, PhD, JD, MPH, RN, and Chenjuan Ma, PhD, RN, from the Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, report in an article published in the January issue of Medical Care. Readmission risk went up with each additional patient per nurse in the average nurse's workload.
Preventable hospital readmissions cost Medicare more than $15 billion annually, but little research has been done on the relationship between readmissions and hospital nursing, write Dr. McHugh and Dr. Ma. "Our results suggest that improving nurses' work environment and reducing nurses' workload are organization-wide reforms that could result in fewer readmissions for Medicare beneficiaries with common medical conditions."
These findings are particularly timely because, under the Affordable Care Act, the Centers for Medicare and Medicaid Services will reduce payments to hospitals with higher-than-expected readmission rates.
The authors obtained nurse information from a cross-sectional survey they conducted in 2005 to 2006 of registered nurses in California, Pennsylvania, and New Jersey, with a total of 20,585 nurses participating. They obtained data on the structural characteristics of hospitals from the American Hospital Association Annual Survey. The sample included 210 hospitals in California, 134 in Pennsylvania, and 68 in New Jersey.
Nurse work environment was measured using the Practice Environment Scale of the Revised Nursing Work Index, in which nurses state the degree to which their practice setting incorporates various organizational features. The scale has been endorsed by the National Quality Forum. The index consists of 5 subscales: nursing foundations for quality care; staffing and resource adequacy; nurse participation in hospital affairs; nurse manager ability, leadership, and support; and nurse–physician relations.
The researchers considered hospitals that scored above the median on 4 or 5 subscales to have good working environments. Above-median scores on 2 to 3 subscales indicated a mixed environment, and hospitals scoring above the median on 0 or 1 subscales were classified as poor work environments.
The investigators identified 30-day readmissions based on validated Risk-Standardized Readmission Measures from the Centers for Medicare and Medicaid Services. The authors looked at readmission rates for heart failure, acute myocardial infarction, and pneumonia. They adjusted their analysis for a variety of hospital-related covariates including size, teaching status, nonprofit or for-profit status, and volume of patients.
On logistic regression analysis, the odds of 30-day readmission for people with heart failure were 7% lower in hospitals with a good rather than poor work environment (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.89 - 0.97; P = .001). With acute myocardial infarction, the odds were 6% lower (OR, 0.94; 95% CI, 0.88 - 0.98; P = .01), and they were 10% lower for patients with pneumonia (OR, 0.90; 95% CI, 0.85 - 0.96; P < .001).
Each additional patient in a nurse's workload was associated with a 7% increase in the odds of readmission for patients with heart failure (OR, 1.07; 95% CI, 1.05 - 1.09; P < .001), a 9% increase for patients with acute myocardial infarction (OR, 1.09; 95% CI, 1.05 - 1.13; P < .001), and a 6% increase for patients with pneumonia (OR, 1.06; 95% CI, 1.03 - 1.09; P < .001).
Good work environments and adequate staffing ratios allow nurses to better care for patients throughout their hospital stay and to continually prepare them for discharge, the authors write. "If a hospital with a poor work environment could improve to a good environment, we would expect its readmission rate to decline from roughly the 84th to 50th percentile or the 50th to 16th percentile in this distribution of hospitals. A hospital that could change its work environment from poor to good and reduce nurse workloads from 6 to 4 patients per nurse would, all else being equal, see their readmission rates reduced from 25% to 21%."
The cost of increasing nursing staff could be offset through enhanced productivity, lower costs associated with turnover and training of new staff, improved patient outcomes, and lower patient use of postdischarge services and resources, according to the authors.
Fundamental nursing processes can make the difference between good and bad outcomes, the investigators conclude. "The challenge of readmissions will require a range of interventions. One potentially effective means of reducing overall readmissions may come through improving the organization and delivery of hospital nursing services."
This study was supported by the National Institute on Aging, National Institute of Nursing Research, Robert Wood Johnson Foundation Health and Society Research and Training special projects grant, Penn Institute on Urban Research, Elder Friendly Urban Environment, Frank Morgan Jones Fund, and Robert Wood Johnson Foundation Nurse Faculty Scholars program. The authors have disclosed no other relevant financial relationships.
Source: Medical Care. 2013;51:52-59
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