Article Text

Download PDFPDF
Valuing hospital investments in nursing: multistate matched-cohort study of surgical patients
  1. Karen B Lasater1,2,
  2. Matthew McHugh1,2,
  3. Paul R Rosenbaum2,3,
  4. Linda H Aiken1,2,
  5. Herbert Smith1,4,
  6. Joseph G Reiter5,
  7. Bijan A Niknam5,
  8. Alexander S Hill5,
  9. Lauren L Hochman5,
  10. Siddharth Jain2,5,
  11. Jeffrey H Silber5,6
  1. 1School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  4. 4Population Studies Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  5. 5Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  6. 6School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Karen B Lasater, School of Nursing, Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA 19104, USA; karenbl{at}


Background There are known clinical benefits associated with investments in nursing. Less is known about their value.

Aims 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.

Methods 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.

Results 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.

Conclusion 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.

  • health services research
  • nurses
  • patient safety
View Full Text

Statistics from


  • Twitter @k_lasater, @LindaAiken_Penn

  • Funding This study was funded by National Institute of Nursing Research (R01 NR014855R01 and NR016019).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. RN4CAST-US Nurse survey data: These data were collected under the primary grants (NR004513 and NR014855; LHA, principal investigator) for purposes of improving nurse and patient outcomes and were granted a certificate of confidentiality through the National Institute of Nursing Research/Department of Health and Human Services as per section 301(d) of the Public Health Service Act 42 U.S.C. 241(d).

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.