Economic evaluation of the 80% baccalaureate nurse workforce recommendation: a patient-level analysis.

BACKGROUND Higher proportions of BSN-educated nurses were associated with improved outcomes in hospital-level studies. A recent Institute of Medicine report calls for increasing the proportion of BSN-educated nurses to 80% by 2020. Patient-level evidence of cost and quality implications of the 80% BSN threshold is needed for a business case to support these efforts. OBJECTIVES To conduct the economic analysis of meeting the 80% BSN threshold on patient outcomes and costs, using linked patient-nurse data. RESEARCH DESIGN Retrospective observational patient-level analysis of electronic data. Linear and logistic regression modeling with patient controls and diagnosis and unit fixed effects. SUBJECTS A total of 8526 adult medical-surgical patients matched with 1477 direct care nurses from an Eastern US academic medical center, during June 1, 2011-December 31, 2011. MEASURES Outcomes include hospital mortality, all-cause same-facility 30-day readmission, length-of-stay, and total hospitalization cost. BSN proportion is a continuous measure for the proportion of nurse assessment inputs into the patient's electronic medical record made by BSN-educated nurses; a dichotomous indicator for BSN proportion is 0.8-1.0. RESULTS Continuous BSN proportion was associated with lower mortality (OR=0.891, P<0.01). Compared with patients with <80% BSN care, patients receiving ≥ 80% of care from BSN nurses had lower odds of readmission (OR=0.813, P=0.04) and 1.9% shorter length-of-stay (P=0.03). Economic simulations support a strong business case for increasing the proportion of BSN-educated nurses to 80%. CONCLUSIONS A combined approach of increasing the hospital-level BSN proportion to 80% and assuring a high BSN dose through individual patient-level staffing assignments is needed to achieve projected quality and costs benefits.