1. Institute for Clinical Outcomes Research Salt Lake City, Utah Cost-Benefit Analysis of Nursing Home Registered Nurse Staffing Times Presented by Susan D. Horn, Ph.D. Senior Scientist Institute for Clinical Outcomes Research Salt Lake City, Utah Lead author: David Dorr, MD, University of Utah Co-author: Randall Smout, MS, ICOR

2. 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. 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. 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. 5 CPI Study Design Process to Develop Decidable and Executable Dynamic Protocols Process Factors Management StrategiesManagement Strategies InterventionsInterventions MedicationsMedications Patient Factors DiseaseDisease Severity of DiseaseSeverity of Disease physiologic signs and symptoms physiologic signs and symptoms complexity/psychosocial factors complexity/psychosocial factors Multiple Points in TimeMultiple Points in Time Outcomes ClinicalClinical Health StatusHealth Status Cost/LOS/EncountersCost/LOS/Encounters Improve/Standardize: Control for: Measure:

6. 6 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 < 17 at risk of developing pressure ulcers with Braden Scale score < 17 no pressure ulcer on study entry no pressure ulcer on study entry Outcomes: Develop Pressure Ulcer (PU), hospitalization, urinary tract infection (UTI)Outcomes: Develop Pressure Ulcer (PU), hospitalization, urinary tract infection (UTI) Funded by Ross Products Division, Abbott Laboratories

7. 7 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.

8. 8 DEVELOP PRESSURE ULCER by RN Time Chi-Square (6 df) = 50.86, p<.0001, n=1,376 % Pressure Ulcers RN Time Per Resident Per Day

9. 9 DEVELOP PRESSURE ULCER by RN Time 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 0.0140 Oral_eat prob 0.39 9.33 0.0023 Catheter 0.78 16.98 <.0001 Entcalpr -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: DEVELOP PU -- RN/LPN/CNA Time and Other Effects

10. 10 HOSPITALIZATION by RN Time Chi-Square (4 df) = 35.17, p<.0001, n=1,542 % Hospitalization RN Time Per Resident Per Day

11. 11 Effects of RN Time RN time of 30-40 min/resident/day is associated with Fewer UTIs Fewer UTIs Fewer catheterizations Fewer catheterizations Less weight loss Less weight loss Less decline in ADLs Less decline in ADLs More nutrition supplements More nutrition supplements

12. 12 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

13. 13 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).

14. 14 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

15. 15 Cost of additional 30 min RN care per resident day $472,814 Societal Perspective Economic Value of Nurses Savings in avoided PU treatment cost $242,426 Savings in avoided hospitalizations $518,627 Savings in avoided UTI costs 30,882 Cost/Benefit Analysis of More RN Time $ Per 100 at-risk residents per year (FY2001 dollars) Assumptions: $1,727 wtd avg to treat PU across stages, $8,523 avg for Medicare hospitalization, $53,900K RN salary & FB/yr Net Savings $319,121

16. 16 Cost of additional 30 min RN care per resident day $472,814 Institutional Perspective Economic Value of Nurses Savings in avoided PU treatment cost $242,426 Savings in avoided hospitalizations $518,627 Savings in avoided UTI costs 30,882 Institutional Analysis of More RN Time $ Per 100 at-risk residents per year (FY2001 dollars) Assumptions: $1,727 wtd avg to treat PU across stages, $691 per UTI, hospitalization not counted, $53,900K RN salary & FB/yr Net Cost $199,507

17. 17 Sensitivity Analyses Sensitivity analyses revealed a robust set of estimates with no single or paired elements reaching cost/benefit equality threshold.

18. 18 Sensitivity

19. 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.

20. 20 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.

21. 21 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. 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).

23. 23 Long Term Care CPI Results Outcome: Develop Pressure Ulcer General Assessment AssessmentIncontinenceInterventions Pressure Relief InterventionsStaffingInterventions + Age 85 + Age 85 + Male + Male + Severity of Illness + Severity of Illness + History of PU + History of PU + Dependency in 7 + Dependency in 7 ADLs ADLs + Diabetes + Diabetes + History of tobacco use + History of tobacco use + Mechanical devices for the containment of urine (catheters) (treatment time 14 days) + Mechanical devices for the containment of urine (catheters) (treatment time 14 days) - Disposable briefs (treatment time 14 days) - Disposable briefs (treatment time 14 days) - Toileting Program (treatment time 21days ) - Toileting Program (treatment time 21days ) + Static pressure reduction: protective device (treatment time 14 days) + Static pressure reduction: protective device (treatment time 14 days) + Positioning: protective device (treatment time 14 days) (p=.07) + Positioning: protective device (treatment time 14 days) (p=.07) - RN hours per resident per day 0.25 - RN hours per resident per day 0.25 - CNA hours per resident per day 2 - CNA hours per resident per day 2 - LPN hours per resident per day 0.75 - LPN hours per resident per day 0.75 General Care Medications Antidepressant - Antidepressant

24. 24 Long Term Care CPI Results Outcome: Develop Pressure Ulcer Nutritional Assessment AssessmentNutritionalInterventions + Dehydration signs and symptoms: low systolic blood pressure, high temperature, dysphagia, high BUN, diarrhea, dehydration + Weight Loss: >=5% in last 30 days or >=10% in last 180 days - Fluid Order - Nutritional Supplements standard medical standard medical - Enteral Supplements disease-specific disease-specific high calorie/high high calorie/high protein protein Nutritional Care Horn et al, J. Amer Geriatr Soc March 2004