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Organization of hospital nursing and 30-day readmissions in Medicare patients undergoing surgery

Background: Growing scrutiny of readmissions has placed hospitals at the center of readmission prevention. Little is known, however, about hospital nursing - a critical organizational component of hospital service system - in relation to readmissions.

Objectives: To determine the relationships between hospital nursing factors - nurse work environment, nurse staffing, and nurse education - and 30-day readmissions among Medicare patients undergoing general, orthopedic, and vascular surgery.

Method and Design: We linked Medicare patient discharge data, multi-state nurse survey data, and American Hospital Association Annual Survey data. Our sample included 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in four states (CA, FL, NJ, & PA). Risk-adjusted robust logistic regressions were used for analyses.

Results: The average 30-day readmission rate was 10% in our sample (general surgery: 11%; orthopedic surgery: 8%; vascular surgery: 12%). Readmission rates varied widely across surgical procedures and could be as high as 26% (upper limb and toe amputation for circulatory system disorders). Each additional patient per nurse increased the odds of readmission by 3% (OR=1.03, 95% CI: 1.00-1.05). Patients cared in hospitals with better nurse work environments had lower odds of readmission (OR=0.97, 95% CI: 0.95-0.99). Administrative support to nursing practice (OR=0.96, 95% CI: 0.94-0.99) and nurse-physician relations (OR=0.97, 95% CI: 0.95-0.99) were two main attributes of the work environment that were associated with readmissions.

Conclusions: Better nurse staffing and work environment were significantly associated with 30-day readmission, and can be considered as system-level interventions to reduce readmissions and associated financial penalties.