Saville, Christina, Jones, Jeremy, Meredith, Paul, Dall'ora, Chiara and Griffiths, Peter (2025) Cost-effectiveness of eliminating hospital understaffing by nursing staff: a retrospective longitudinal study and economic evaluation. BMJ Quality and Safety, [018138]. (doi:10.1136/bmjqs-2024-018138).
Abstract
Background: understaffing by nursing staff in hospitals is linked to patients coming to harm and dying unnecessarily. There is a vicious cycle whereby poor work conditions including understaffing can lead to nursing vacancies, which in turn leads to further understaffing. Is hospital investment in nursing staff, to eliminate understaffing on wards, cost-effective?
Methods: this longitudinal observational study analysed data on 185 adult acute units in 4 hospital Trusts in England over a 5-year period. We modelled the association between a patient’s exposure to ward nurse understaffing (days where staffing was below the ward mean) over the first 5 days of stay and risk of death, risk of readmission and length of stay, using survival analysis and linear mixed models. We estimated the incremental cost-effectiveness of eliminating understaffing by registered nurses (RN) and nursing support (NS) staff, estimating net costs per quality-adjusted life year. We took a hospital cost perspective.
Findings: exposure to RN understaffing is associated with increased hazard of death (adjusted Hazard Ratio [aHR] 1.079, 95% Confidence Interval [CI] 1.070 - 1.089), increased chance of readmission (aHR 1.010, 95% CI 1.005-1.016) and increased length of stay (ratio 1.687, CI 1.666-1.707), while exposure to NS understaffing is associated with smaller increases in hazard of death (aHR 1.072, CI 1.062 - 1.081) and length of stay (ratio 1.608, CI 1.589-1.627) but reduced readmissions (aHR 0.994, 95% CI 0.988-0.999). Eliminating both RN and NS understaffing is estimated to cost £2,778 per quality-adjusted life year (staff costs only), £2,685 (including benefits of reduced staff sickness and readmissions) or save £4,728 (including benefits of reduced lengths of stay). Using agency staff to eliminate understaffing is less cost-effective and would save fewer lives than using permanent members of staff. Targeting specific patient groups with improved staffing would save fewer lives and, in the scenarios tested, cost more per quality-adjusted life year than eliminating all understaffing.
Interpretation: rectifying understaffing on inpatient wards is crucial to reduce length of stay, readmissions and deaths. According to the NICE £10,000 per QALY threshold, it is cost-effective to eliminate understaffing by nursing staff. This research points towards investing in RNs over NS staff, and permanent over temporary workers. Targeting particular patient groups would benefit fewer patients and is less cost-effective.
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