Cost-effectiveness of recommended nurse staffing levels for short-stay skilled nursing facility patients

Abstract

Background: Among patients in skilled nursing facilities for post-acute care, increased registered nurse, total licensed staff, and nurse assistant staffing is associated with a decreased rate of hospital transfer for selected diagnoses. However, the cost-effectiveness of increasing staffing to recommended levels is unknown.

Methods: Using a Markov cohort simulation, we estimated the incremental cost-effectiveness of recommended staffing versus median staffing in patients admitted to skilled nursing facilities for post-acute care. The outcomes of interest were life expectancy, quality-adjusted life expectancy, and incremental cost-effectiveness.

Results: The incremental cost-effectiveness of recommended staffing versus median staffing was $321,000 per discounted quality-adjusted life year gained. One-way sensitivity analyses demonstrated that the cost-effectiveness ratio was most sensitive to the likelihood of acute hospitalization from the nursing home. The cost-effectiveness ratio was also sensitive to the rapidity with which patients in the recommended staffing scenario recovered health-related quality of life as compared to the median staffing scenario. The cost-effectiveness ratio was not sensitive to other parameters.

Conclusion: Adopting recommended nurse staffing for short-stay nursing home patients cannot be justified on the basis of decreased hospital transfer rates alone, except in facilities with high baseline hospital transfer rates. Increasing nurse staffing would be justified if health-related quality of life of nursing home patients improved substantially from greater nurse and nurse assistant presence.

Figure 1

Schematic diagram of Markov model. The model has a cycle length of one day. All patients begin in the bolded state entitled "SNF day 1." From SNF day 1, patients can transition to a second SNF day, be hospitalized for any one of five conditions, or die. If patients spend 30 consecutive days in the SNF without being hospitalized, they transition to the "Discharged" state, where they remain until they die. If patients are hospitalized, they spend five or six days in the hospital, depending on the condition for which they are hospitalized, unless they die while in hospital. Upon completing their hospital course, patients then return to SNF day 1. Abbreviations: SNF, skilled nursing facility; CHF, congestive heart failure; EI, electrolyte imbalance; RI, respiratory infection; UTI, urinary tract infection.