Exploring Nursing Cost Using Patient Level Data
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NI= f (time spent with patient) + (skill level of nurse) Nursing intensity was a function of time spent with the patient measured using Clairvia demand-driven patient assignment software. Nursing intensity was calculated in the patient assignment software based on the following methodology. The acuity score was a 1-12 point scale derived from an outcomes-driven model grounded in the Pesut and Herman conceptual framework, the Outcome-Present State-Test Model of Clinical Reasoning. 10 Nurses rated patients every shift or when condition changed on several outcomes using a 1-5 point scale that contributes to an algorithm producing the nursing intensity score. A monthly audit was completed to assure interrater reliability of acuity measurement and the result was 86% accuracy. Skill level of the nurse was recorded in the Clairvia software as RN, LPN, and Patient Care Associate. NW= f (experience, years of service, education, certification) Nursing wage was operationalized using actual hourly wage for each nurse providing direct care. The principle diagnosis was measured through the DRG. Complications were measured using a four level variable 'compcode'. The four value labels of the variable were 0 = no drg, 1= without complications, 2 = with complications, 3 = with major complications. Using the same DRG without, with, and with major complications allowed for a comparison of nurses assigned to increasingly complex patients. Nurse characteristics were measured and analyzed in relationship to cost of nursing care. Variables describing the nursing unit that are contextual included unit type, number of beds, average acuity per patient, unit skill mix. Nurse characteristics measured included skill level, age, education level, years of service at institution, years of service on the unit, and float. De-identified data from three databases were merged into a single file and analyzed using Stata software. Correlation analysis and regression analysis were used to explore relationships among patient characteristics, nursing characteristics, and nursing cost per acute care episode. Microeconometric measurement was used to determine the elasticity of nursing characteristics on patient acuity and direct nursing cost per patient. IRB expedited approval and continuation was obtained from the study site and the researcher's University. Results: Key findings included 1) patients with the same diagnosis have large variability in nursing intensity and nursing cost by shift, day and acute care episode (i.e. cost per day range DRG 192 $5.68-287.37, 191 $5.96-257.56, 190 $10.06-366.86); 2) nurses may not be assigned patients based on experience and education level; 3) direct nursing cost per patient on the study unit was $96.48 on average per day, which was only 5.8-7.3% of the daily room and board charge. Conclusion: There is large variability in direct NCACE for patients with similar DRGs. An example is patients with COPD without complications (NCACE range $54-1570, M $325, SD $242); COPD with complications (NCACE range $17-3674, M 408, SD $427); COPD with major complications (NCACE range $132-1455, M $462, SD $316). Nurse scientists have provided evidence for variability in nursing cost for patients with similar DRGs for decades, yet hospitals in America continue to be reimbursed under an assumption that patients with similar DRGs receive the same amount of nursing care. 11,12,13,14 This study refutes the assumption. RN years experience in the organization was the nurse characteristic most associated with direct nursing cost. A 10% increase or 9.3 total nurse years experience in the organization for the patient episode of care is associated with a 9.9% or $34.92 increase in direct cost of nursing care per episode for patients on the study unit holding all other variables constant. Data did not support the hypothesis that nurses with greater experience or education level are assigned sicker patients. Average RN experience assigned per patient episode was not significant when regressed on average patient acuity. Percent of BSN nurses assigned was significant in the model with nominal effect. The mean nursing direct cost per day for all patients in the study was $96.48 ($55.73, range-$.33-600.81). The room and board charge for each patient in a medical/surgical unit at the study hospital ranges from $1321-1650 per day. Therefore, the direct nursing cost per day is only 5.8-7.3% of the daily room and board charge. Direct nursing care is a small percent of the cost, but patients don't know this because direct nursing cost is included in the room and board charge and not itemized on the patient bill. Limitations of the study include de-identified data from a secondary source were used and cases with missing data were excluded. Data from large databases have been entered by multiple sources so threats to reliability and validity of data exist. Overtime and differential wage data were not obtained due to burden of extraction. The study was completed using data from a single unit in a one organization; hence the results of the study are not generalizable beyond the study unit. The methodology of using patient level data to explore direct nursing cost can be replicated and expanded using all units the patient is on during an acute care episode. Innovative patient assignment software provides a convenient source of data for nurse scientists and nurse leaders to use in creating next generation nursing science.