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To the Editor: Dr Aiken and colleagues¹ discounted the effect of surgeons' qualifications and overall hospital quality on patient mortality. The authors stated that "the strong and significant decrease in mortality associated with having a board-certified surgeon as operating physician is largely explained by the tendency of patients with board-certified surgeons to be treated at hospitals with other characteristics associated with better outcomes." Although hospitals with more board-certified surgeons also had more nurses with baccalaureate degrees, the authors did not examine these "other characteristics" to explain the much smaller difference in patient mortality associated with nurses' educational background.

Furthermore, the study was a secondary analysis of data that were collected to look at workload, not educational background, as the independent variable. The authors then grouped the nurses into 2 education levels depending on whether they had a BSN or higher academic degree. There are several additional gradations of nursing degrees, . . . [Full Text of this Article]

George R. Boggs, PhD
American Association of Community Colleges
Washington, DC

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