Patient Outcomes and Nurse Understaffing in For-Profit Hospitals

Abstract

Background: For-profit hospital ownership has been associated with worse patient outcomes, but the mechanisms remain unclear. Underinvestment in nurse staffing is a plausible pathway linking for-profit ownership to performance. Objectives: To examine whether differences in nurse staffing mediate associations between for-profit hospital ownership and patient, nurse, and hospital outcomes. Design: Cross-sectional study using 2024 data on hospital ownership, registered nurse survey responses, Medicare claims, and Hospital Compare measures. Subjects: A total of 143 for-profit and 798 nonprofit adult, nonfederal, acute care hospitals across 10 US states; >1.17 million Medicare fee-for-service admissions; and 17,368 direct-care bedside registered nurses. Measures: Patient-level 30-day mortality and readmission (Medicare Provider Analysis and Review); hospital-level hybrid risk-standardized mortality and readmission and HCAHPS overall hospital rating (CMS Hospital Compare); nurse burnout (Maslach Burnout Inventory emotional exhaustion subscale) and related outcomes (Penn Nurses All survey). The hypothesized mediator was hospital-level nurse staffing. Results: Among surgical patients, for-profit ownership was associated with a 0.48 percentage-point higher 30-day mortality (95% CI: 0.24–0.73), 45% mediated through staffing. Among medical patients, 1.13 percentage-point higher 30-day mortality (95% CI: 0.52–1.73), 40% mediated. Readmission findings were similar. For-profit status was associated with worse HCAHPS ratings (−4.45 percentage points; 95% CI: −5.20 to −3.60), 31% mediated. Nurse burnout was 9 percentage points higher (95% CI: 5.8–12.4), 67% mediated. Conclusions: For-profit hospital ownership is associated with worse patient and nurse outcomes, and differences in nurse staffing account for a share of these disparities.