Correspondence
I read with interest Linda Aiken and colleagues’ study (May 24, p 1824),1 that found improved nurse staffing and education was associated with a decreased risk of mortality in patients undergoing general, orthopaedic, or vascular surgery in nine European countries. This study raises a number of interesting points. There seems to be great disparity in the level of formal education among nurses in Europe. As evidenced by the present study, this heterogeneity might contribute to increased patient mortality. A bachelors degree in medicine and surgery is internationally recognised as a compulsory requirement for all doctors. Given that nurses spend arguably more time in the acute monitoring and management of patients than other health professionals,2,3 it is somewhat surprising that similar basic formal qualifications are yet to be universally implemented in nursing. The authors assessed only one outcome, mortality. Future studies should also consider the effect of iatrogenic factors such as medication dispensing errors and patient complications such as hospital-acquired infection. Although the present study is the largest to date, results should be interpreted with caution given that in the survey, from which nurse staffing and education measures were derived, response rate was below 50% in some countries. Furthermore, as with any survey, a potential for response bias exists. Additionally, in research drawing on administrative patient outcomes data, a potential for variation in consistency of diagnostic coding across hospitals and between different countries exists.4 I declare no competing interests.
Rele Ologunde [email protected]
www.thelancet.com Vol 384 September 6, 2014
Faculty of Medicine, Imperial College London, London SW7 2AZ, UK 1
2
3
4
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383: 1824–30. Westbrook JI, Duffield C, Li L, Creswick NJ. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses’ patterns of task time distribution and interactions with health professionals. BMC Health Serv Res 2011; 11: 319. Westbrook JI, Ampt A, Kearney L, Rob MI. All in a day’s work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Austr 2008; 188: 506–09. Iezzoni LI. Risk adjustment for measuring healthcare outcomes, 2nd edn. Chicago: Health Administration Press, 1997.
Linda Aiken and colleagues assessed the effects of two nursing factors (staffing and education) on mortality for 422 730 patients who underwent common surgeries.1 Although Aiken and colleagues did not clearly refer to the turnover rate of the nurses, it is known that turnover of health-care staff negatively but significantly influences the costs.2 In a previous report,3 reasonable workloads and nurse–patient ratios were manageable to promote retention among all generations of nurses in the acute care hospital workforce. Another report4 showed that the turnover rate of the nurses with a bachelor degree was less than that of the nurses without a bachelor degree. Therefore, data and analysis of turnover rate will be important information. I declare no competing interests.
Masako Sugihara [email protected] Department of Neuropsychiatry, Keio University School of Medicine, 160-8582 Tokyo, Japan 1
2
3
4
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383: 1824–30. Waldman JD, Kelly F, Arora S, Smith HL, et al. The shocking cost of turnover in health care. Health Care Manage Rev 2004; 29: 2–7. Tourangeau AE, Thomson H, Cummings G, et al. Generation-specific incentives and disincentives for nurses to remain employed in acute care hospitals. J Nurs Manag 2013; 21: 473–82. Suzuki E, Itomine I, Kanoya Y, Katsuki T, Horii S, Sato C. Factors affecting rapid turnover of novice nurses in university hospitals. J Occup Health 2006; 48: 49–61.
Authors’ reply Hospital mortality varies substantially within European countries. Our paper1 provides scientific evidence that failure to standardise nursing education at the bachelor’s level puts patients at higher risk of dying after common surgeries. We concur with Rele Ologunde that it is alarming that formal bachelor’s qualifications are yet to be universally implemented in nursing. We used in our study state-of-thescience techniques using existing administrative data on patient outcomes. Others have shown2 that routinely collected administrative data in Europe predict risk of hospital death with discrimination similar to that obtained from clinical data. Mortality is the one standardised outcome across European countries in administrative data. In the USA where performance reporting on standardised measures is required, nurse resources are associated with a wide range of outcomes including readmissions, poor glycaemic control, hospital acquired infections, falls, and patient safety indicators.3,4 Concerning potential non-response bias, response at the hospital level is a priority in research on hospital performance. In RN4CAST, most hospitals selected through stratified sampling methods used to ensure representativeness agreed to participate. Nurses in hospitals were informants through surveys about their own characteristics such as educational qualifications and how many patients they cared for on their last shift, measures that are reasonably objective. Our overall nurse response rate across nine countries was 62%, acceptable by current standards in health services research. In a similarly designed study in the USA, we compared survey respondents and non-respondents and found no informative non-response bias.5 Previously published research5 from RN4CAST using a different independent measure of patient outcome (ie, patient satisfaction) produced a similar finding of the
Belmonte/BSIP/Science Photo Library
Staffing and education of nurses and hospital mortality in Europe
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
851
Correspondence
association between nursing resources and patient outcomes. Masako Sugihara raises the important issue of nurse turnover. Administrative data on hospital nurse turnover are not available in Europe. However, we created proxy measures of turnover by calculating the percent of nurses surveyed with intentions to leave within a year, and alternately the percent of nurses employed for less than 2 years. Neither measure is significantly related to percent of bachelor’s nurses or nurse workloads, nor are they related to mortality. They would have to be related to both nursing factors and mortality to alter the effects we find. Importantly, patients are less satisfied with care in hospitals in which a larger proportion of nurses intend to leave,6 and turnover contributes to nurse shortage, making this nurse turnover a matter of policy concern. We declare no competing interests.
*Linda H Aiken, Douglas M Sloane, Luk Bruyneel, Peter Griffiths, Walter Sermeus [email protected] Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA (LHA, DMS); Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium (LB, WS); and Faculty of Health Sciences, University of Southampton, Southampton, UK (PG) 1
2
3
4
5
6
852
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383: 1824–30. Aylin P, Bottle A, Majeed A. Use of administrative data or clinical databases as predictors of risk of death in hospital: comparison of models. BMJ 2007; 334: 1044. McHugh MD, Ma C. Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Med Care 2013; 51: 52–59. Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care–associated infection. Am J Infect Control 2012; 40: 486–90. Aiken LH, Cimiotti J, Sloane DM, Smith HL, Flynn L, Neff D. The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care 2011; 49: 1047–53. Aiken LH, Sermeus W, Vanden Heede K, et al. Patient safety, satisfaction, and quality of hospital care: cross-sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 2012; 344: e1717.
Is tiered pricing the way for vaccines? Seth B e r k l e y ’s Viewpoint (June 28, p 2265)1 on improving access to vaccines through tiered pricing touches on important issues. Berkley identifies two key challenges for the global vaccination community: concerns about the sustainability of immunisation programmes in countries that will graduate from GAVI support2 and the high price that many countries, especially middle-income countries, and vaccine providers, like Médecins Sans Frontières (MSF), have to pay for newer vaccines. These are issues that push us, as a public health community, in considering how to achieve equity. Berkley’s proposal of tiered pricing as the solution, however, is deficient for several reasons. The general shortcomings of tiered pricing— including its inferiority to genuine competition, arbitrary divisions between populations, and the lack of transparency on price setting—have been documented.3 Berkley notes that tiered pricing already exists and has been credited with lowering prices paid by the GAVI Alliance for the world’s poorest countries. The negative effects of the tiered pricing system will also be seen, however, as countries face the double challenge of losing GAVI subsidies to pay for costly vaccines and, as Berkley notes, “that they [graduating countries] could be at risk of suspending vaccination programmes because they face a so-called pricing cliff, with steep increases when they no longer have access to GAVI prices.”1 Furthermore, gross national income (GNI)—the often-suggested criterion for establishing tiers and which determines GAVI eligibility—is an unsophisticated measure of country welfare and inappropriate from a public health perspective. There are currently 20 countries graduating from GAVI support (more than 25% of the total supported), 28 countries that have never been GAVI-eligible have a GNI
lower than the highest GNI-graduating country.4 Therefore, it is important for the public health community to aggressively use several strategies to address the underlying deficiencies in the vaccine market. These strategies include, as Berkley notes, demand forecasting and pooled procurement, but they also must include collaboration between agencies and governments to effectively negotiate with manufacturers, and investment to broaden the manufacturing base, thus promoting competition and a broader supply base. Transparency around research and development and manufacturing costs, as well as vaccine pricing, will be important to help realise this change. Pricing must be set in a fair way that both rewards innovation and ensures that cash-strapped health systems can ultimately afford products beyond donor support. Lastly, the question of who should be governing the search for solutions is also essential. GAVI and other stakeholders can have a critical role but it is vital that governments, including key emerging economies, are the drivers of future effort. It is only in this way that all stakeholders can feel confident in buying into a new global strategy. I declare no competing interests.
Manica Balasegaram [email protected] Médecins Sans Frontières Access Campaign, Geneva, Switzerland 1
2
3
4
Berkley S. Improving access to vaccines through tiered pricing. Lancet 2014; 383: 2265–67. Saxenian H, Hecht R, Kaddar M, Schmitt S, Ryckman T, Cornejo S. Overcoming challenges to sustainable immunization financing: early experiences from GAVI graduating countries. Health Policy Plan 2014; published online Feb 8. DOI:10.1093/heapol/czu003. Moon S, Jambert E, Childs M, von Schoen-Angerer T. A win-win solution? A critical analysis of tiered pricing to improve access to medicines in developing countries. Global Health 2011; 7: 39. Kaddar M, Schmitt S, Makinen M, Milstien J. Global support for new vaccine implementation in middle-income countries. Vaccine 2013; 31: B81–96.
www.thelancet.com Vol 384 September 6, 2014
I read with interest Linda Aiken and colleagues’ study (May 24, p 1824),1 that found improved nurse staffing and education was associated with a decreased risk of mortality in patients undergoing general, orthopaedic, or vascular surgery in nine European countries. This study raises a number of interesting points. There seems to be great disparity in the level of formal education among nurses in Europe. As evidenced by the present study, this heterogeneity might contribute to increased patient mortality. A bachelors degree in medicine and surgery is internationally recognised as a compulsory requirement for all doctors. Given that nurses spend arguably more time in the acute monitoring and management of patients than other health professionals,2,3 it is somewhat surprising that similar basic formal qualifications are yet to be universally implemented in nursing. The authors assessed only one outcome, mortality. Future studies should also consider the effect of iatrogenic factors such as medication dispensing errors and patient complications such as hospital-acquired infection. Although the present study is the largest to date, results should be interpreted with caution given that in the survey, from which nurse staffing and education measures were derived, response rate was below 50% in some countries. Furthermore, as with any survey, a potential for response bias exists. Additionally, in research drawing on administrative patient outcomes data, a potential for variation in consistency of diagnostic coding across hospitals and between different countries exists.4 I declare no competing interests.
Rele Ologunde [email protected]
www.thelancet.com Vol 384 September 6, 2014
Faculty of Medicine, Imperial College London, London SW7 2AZ, UK 1
2
3
4
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383: 1824–30. Westbrook JI, Duffield C, Li L, Creswick NJ. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses’ patterns of task time distribution and interactions with health professionals. BMC Health Serv Res 2011; 11: 319. Westbrook JI, Ampt A, Kearney L, Rob MI. All in a day’s work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Med J Austr 2008; 188: 506–09. Iezzoni LI. Risk adjustment for measuring healthcare outcomes, 2nd edn. Chicago: Health Administration Press, 1997.
Linda Aiken and colleagues assessed the effects of two nursing factors (staffing and education) on mortality for 422 730 patients who underwent common surgeries.1 Although Aiken and colleagues did not clearly refer to the turnover rate of the nurses, it is known that turnover of health-care staff negatively but significantly influences the costs.2 In a previous report,3 reasonable workloads and nurse–patient ratios were manageable to promote retention among all generations of nurses in the acute care hospital workforce. Another report4 showed that the turnover rate of the nurses with a bachelor degree was less than that of the nurses without a bachelor degree. Therefore, data and analysis of turnover rate will be important information. I declare no competing interests.
Masako Sugihara [email protected] Department of Neuropsychiatry, Keio University School of Medicine, 160-8582 Tokyo, Japan 1
2
3
4
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383: 1824–30. Waldman JD, Kelly F, Arora S, Smith HL, et al. The shocking cost of turnover in health care. Health Care Manage Rev 2004; 29: 2–7. Tourangeau AE, Thomson H, Cummings G, et al. Generation-specific incentives and disincentives for nurses to remain employed in acute care hospitals. J Nurs Manag 2013; 21: 473–82. Suzuki E, Itomine I, Kanoya Y, Katsuki T, Horii S, Sato C. Factors affecting rapid turnover of novice nurses in university hospitals. J Occup Health 2006; 48: 49–61.
Authors’ reply Hospital mortality varies substantially within European countries. Our paper1 provides scientific evidence that failure to standardise nursing education at the bachelor’s level puts patients at higher risk of dying after common surgeries. We concur with Rele Ologunde that it is alarming that formal bachelor’s qualifications are yet to be universally implemented in nursing. We used in our study state-of-thescience techniques using existing administrative data on patient outcomes. Others have shown2 that routinely collected administrative data in Europe predict risk of hospital death with discrimination similar to that obtained from clinical data. Mortality is the one standardised outcome across European countries in administrative data. In the USA where performance reporting on standardised measures is required, nurse resources are associated with a wide range of outcomes including readmissions, poor glycaemic control, hospital acquired infections, falls, and patient safety indicators.3,4 Concerning potential non-response bias, response at the hospital level is a priority in research on hospital performance. In RN4CAST, most hospitals selected through stratified sampling methods used to ensure representativeness agreed to participate. Nurses in hospitals were informants through surveys about their own characteristics such as educational qualifications and how many patients they cared for on their last shift, measures that are reasonably objective. Our overall nurse response rate across nine countries was 62%, acceptable by current standards in health services research. In a similarly designed study in the USA, we compared survey respondents and non-respondents and found no informative non-response bias.5 Previously published research5 from RN4CAST using a different independent measure of patient outcome (ie, patient satisfaction) produced a similar finding of the
Belmonte/BSIP/Science Photo Library
Staffing and education of nurses and hospital mortality in Europe
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
851
Correspondence
association between nursing resources and patient outcomes. Masako Sugihara raises the important issue of nurse turnover. Administrative data on hospital nurse turnover are not available in Europe. However, we created proxy measures of turnover by calculating the percent of nurses surveyed with intentions to leave within a year, and alternately the percent of nurses employed for less than 2 years. Neither measure is significantly related to percent of bachelor’s nurses or nurse workloads, nor are they related to mortality. They would have to be related to both nursing factors and mortality to alter the effects we find. Importantly, patients are less satisfied with care in hospitals in which a larger proportion of nurses intend to leave,6 and turnover contributes to nurse shortage, making this nurse turnover a matter of policy concern. We declare no competing interests.
*Linda H Aiken, Douglas M Sloane, Luk Bruyneel, Peter Griffiths, Walter Sermeus [email protected] Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA 19104, USA (LHA, DMS); Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium (LB, WS); and Faculty of Health Sciences, University of Southampton, Southampton, UK (PG) 1
2
3
4
5
6
852
Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383: 1824–30. Aylin P, Bottle A, Majeed A. Use of administrative data or clinical databases as predictors of risk of death in hospital: comparison of models. BMJ 2007; 334: 1044. McHugh MD, Ma C. Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Med Care 2013; 51: 52–59. Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care–associated infection. Am J Infect Control 2012; 40: 486–90. Aiken LH, Cimiotti J, Sloane DM, Smith HL, Flynn L, Neff D. The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care 2011; 49: 1047–53. Aiken LH, Sermeus W, Vanden Heede K, et al. Patient safety, satisfaction, and quality of hospital care: cross-sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 2012; 344: e1717.
Is tiered pricing the way for vaccines? Seth B e r k l e y ’s Viewpoint (June 28, p 2265)1 on improving access to vaccines through tiered pricing touches on important issues. Berkley identifies two key challenges for the global vaccination community: concerns about the sustainability of immunisation programmes in countries that will graduate from GAVI support2 and the high price that many countries, especially middle-income countries, and vaccine providers, like Médecins Sans Frontières (MSF), have to pay for newer vaccines. These are issues that push us, as a public health community, in considering how to achieve equity. Berkley’s proposal of tiered pricing as the solution, however, is deficient for several reasons. The general shortcomings of tiered pricing— including its inferiority to genuine competition, arbitrary divisions between populations, and the lack of transparency on price setting—have been documented.3 Berkley notes that tiered pricing already exists and has been credited with lowering prices paid by the GAVI Alliance for the world’s poorest countries. The negative effects of the tiered pricing system will also be seen, however, as countries face the double challenge of losing GAVI subsidies to pay for costly vaccines and, as Berkley notes, “that they [graduating countries] could be at risk of suspending vaccination programmes because they face a so-called pricing cliff, with steep increases when they no longer have access to GAVI prices.”1 Furthermore, gross national income (GNI)—the often-suggested criterion for establishing tiers and which determines GAVI eligibility—is an unsophisticated measure of country welfare and inappropriate from a public health perspective. There are currently 20 countries graduating from GAVI support (more than 25% of the total supported), 28 countries that have never been GAVI-eligible have a GNI
lower than the highest GNI-graduating country.4 Therefore, it is important for the public health community to aggressively use several strategies to address the underlying deficiencies in the vaccine market. These strategies include, as Berkley notes, demand forecasting and pooled procurement, but they also must include collaboration between agencies and governments to effectively negotiate with manufacturers, and investment to broaden the manufacturing base, thus promoting competition and a broader supply base. Transparency around research and development and manufacturing costs, as well as vaccine pricing, will be important to help realise this change. Pricing must be set in a fair way that both rewards innovation and ensures that cash-strapped health systems can ultimately afford products beyond donor support. Lastly, the question of who should be governing the search for solutions is also essential. GAVI and other stakeholders can have a critical role but it is vital that governments, including key emerging economies, are the drivers of future effort. It is only in this way that all stakeholders can feel confident in buying into a new global strategy. I declare no competing interests.
Manica Balasegaram [email protected] Médecins Sans Frontières Access Campaign, Geneva, Switzerland 1
2
3
4
Berkley S. Improving access to vaccines through tiered pricing. Lancet 2014; 383: 2265–67. Saxenian H, Hecht R, Kaddar M, Schmitt S, Ryckman T, Cornejo S. Overcoming challenges to sustainable immunization financing: early experiences from GAVI graduating countries. Health Policy Plan 2014; published online Feb 8. DOI:10.1093/heapol/czu003. Moon S, Jambert E, Childs M, von Schoen-Angerer T. A win-win solution? A critical analysis of tiered pricing to improve access to medicines in developing countries. Global Health 2011; 7: 39. Kaddar M, Schmitt S, Makinen M, Milstien J. Global support for new vaccine implementation in middle-income countries. Vaccine 2013; 31: B81–96.
www.thelancet.com Vol 384 September 6, 2014
