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

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.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.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.Transfer back to the hospital is a common problem for patients admitted to skilled nursing facilities (SNF), with an estimated 18% of patients transferring to the hospital within the first 30 days of admission, and 38% within the first 90 days [1]. Avoiding hospital transfer in frail older individuals is desirable if care can be provided in the SNF because of the many adverse effects associated with hospitalization [2]. In addition, evidence suggests that SNF patients are often inappropriately hospitalized. One study which reviewed 100 unscheduled transfers to hospital found that 36% of transfers to the emergency room and 40% of hospital admissions from SNF were inappropriate, with poor quality of care i