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Hospital Nursing and 30-Day Readmissions Among Medicare Patients With Heart Failure, Acute Myocardial Infarction, and Pneumonia

McHugh, Matthew D. PhD, JD, MPH, RN; Ma, Chenjuan PhD, RN

doi: 10.1097/MLR.0b013e3182763284
Original Articles

Background: Provisions of the Affordable Care Act that increase hospitals’ financial accountability for preventable readmissions have heightened interest in identifying system-level interventions to reduce readmissions.

Objectives: To determine the relationship between hospital nursing; that is, nurse work environment, nurse staffing levels, and nurse education, and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia.

Method and Design: Analysis of linked data from California, New Jersey, and Pennsylvania that included information on the organization of hospital nursing (ie, work environment, patient-to-nurse ratios, and proportion of nurses holding a BSN degree) from a survey of nurses, as well as patient discharge data, and American Hospital Association Annual Survey data. Robust logistic regression was used to estimate the relationship between nursing factors and 30-day readmission.

Results: Nearly 1 quarter of heart failure index admissions [23.3% (n=39,954)], 19.1% (n=12,131) of myocardial infarction admissions, and 17.8% (n=25,169) of pneumonia admissions were readmitted within 30 days. Each additional patient per nurse in the average nurse’s workload was associated with a 7% higher odds of readmission for heart failure [odds ratio (OR)=1.07; confidence interval CI, 1.05–1.09], 6% for pneumonia patients (OR=1.06; CI, 1.03–1.09), and 9% for myocardial infarction patients (OR=1.09; CI, 1.05–1.13). Care in a hospital with a good versus poor work environment was associated with odds of readmission that were 7% lower for heart failure (OR=0.93; CI, 0.89–0.97), 6% lower for myocardial infarction (OR=0.94; CI, 0.88–0.98), and 10% lower for pneumonia (OR=0.90; CI, 0.85–0.96) patients.

Conclusions: Improving nurses’ work environments and staffing may be effective interventions for preventing readmissions.

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Center for Health Outcomes and Policy Research, University of Pennsylvania, Philadelphia, PA

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Funded by the National Institute on Aging (R01AG041099-01, McHugh), National Institute of Nursing Research (R01-NR-004513, P30-NR-005043; Aiken), Robert Wood Johnson Foundation Health and Society Research and Training special projects grant (McHugh), Penn Institute on Urban Research, Elder Friendly Urban Environment (Sullivan-Marx), Frank Morgan Jones Fund (McHugh), and Robert Wood Johnson Foundation Nurse Faculty Scholars program (McHugh).

The authors declare no conflict of interest.

Reprints: Matthew D. McHugh, PhD, JD, MPH, RN, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, 418 Curie Blvd., Philadelphia, PA 19104-4217. E-mail:

© 2013 Lippincott Williams & Wilkins, Inc.