School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
BMJ Qual Saf. 2021 Jan;30(1):46-55. doi: 10.1136/bmjqs-2019-010534. Epub 2020 Mar 27.
There are known clinical benefits associated with investments in nursing. Less is known about their value.
To compare surgical patient outcomes and costs in hospitals with better versus worse nursing resources and to determine if value differs across these hospitals for patients with different mortality risks.
Retrospective matched-cohort design of patient outcomes at hospitals with better versus worse nursing resources, defined by patient-to-nurse ratios, skill mix, proportions of bachelors-degree nurses and nurse work environments. The sample included 62 715 pairs of surgical patients in 76 better nursing resourced hospitals and 230 worse nursing resourced hospitals from 2013 to 2015. Patients were exactly matched on principal procedures and their hospital's size category, teaching and technology status, and were closely matched on comorbidities and other risk factors.
Patients in hospitals with better nursing resources had lower 30-day mortality: 2.7% vs 3.1% (p<0.001), lower failure-to-rescue: 5.4% vs 6.2% (p<0.001), lower readmissions: 12.6% vs 13.5% (p<0.001), shorter lengths of stay: 4.70 days vs 4.76 days (p<0.001), more intensive care unit admissions: 17.2% vs 15.4% (p<0.001) and marginally higher nurse-adjusted costs (which account for the costs of better nursing resources): $20 096 vs $19 358 (p<0.001), as compared with patients in worse nursing resourced hospitals. The nurse-adjusted cost associated with a 1% improvement in mortality at better nursing hospitals was $2035. Patients with the highest mortality risk realised the greatest value from nursing resources.
Hospitals with better nursing resources provided better clinical outcomes for surgical patients at a small additional cost. Generally, the sicker the patient, the greater the value at better nursing resourced hospitals.
投资护理可带来明确的临床效益。但人们对其价值的了解较少。
比较护理资源较好与较差的医院中外科患者的结局和成本，并确定对死亡率不同的患者而言，这些医院之间的价值是否存在差异。
采用回顾性队列设计，比较了护理资源较好（根据护患比、技能组合、护理学士学位护士的比例和护士工作环境来定义）与较差的医院中外科患者的结局和成本。该研究样本包括 2013 年至 2015 年期间，来自 76 家护理资源较好的医院和 230 家护理资源较差的医院的 62715 对手术患者。患者根据主要手术、所在医院的规模类别、教学和技术状态进行精确匹配，并根据合并症和其他风险因素进行紧密匹配。
护理资源较好的医院的患者 30 天死亡率较低：2.7%比 3.1%（p<0.001），挽救失败率较低：5.4%比 6.2%（p<0.001），再入院率较低：12.6%比 13.5%（p<0.001），住院时间较短：4.70 天比 4.76 天（p<0.001），重症监护病房入院率较高：17.2%比 15.4%（p<0.001），护士调整后的成本（包括较好护理资源的成本）较高：20096 美元比 19358 美元（p<0.001）。与护理资源较差的医院相比，护理资源较好的医院每降低 1%的死亡率，成本增加 2035 美元。死亡率最高的患者从护理资源中获益最大。
护理资源较好的医院为外科患者提供了更好的临床结局，仅增加了少量成本。通常情况下，患者病情越重，在护理资源较好的医院中获益越大。
