Hospital Care Environment, Neighborhood, and Racial Disparities in Elder Outcomes

描述（由申请人提供）：由于心力衰竭、肺炎和急性心肌梗死等常见疾病，在死亡、再入院和住院时间延长等成本高昂且通常可预防的结局方面存在充分记录的种族和民族差异。然而，造成这些差异的原因和解决办法尚不清楚。有证据开始指出，大多数少数民族和非少数民族接受护理的医院存在差异，这是差异的一个来源。令人惊讶的是，两个重要的因素及其相互关系，这可能会解释医院的差异是如何与差异，并指出有针对性的干预的机会，没有得到足够的重视：在医院的护理质量，病人的照顾和不同的医院服务的病人的社区的特点。护士提供重要的床边护理，24/7监测，教育和护理协调，可能缩小差距，但很少有人知道少数民族患者在医院接受治疗的程度较低的质量护理和这些差异的影响差异。护理作为一个系统因素是一个有吸引力的特点，研究，因为不像许多医院的特点，它可以通过管理者或决策者的干预得到改善。有证据表明，大多数少数族裔老年人在比例相对较小的医院接受护理。护理环境的质量（包括护士人员配备水平，护士教育水平和护理环境支持专业护理实践）可以显着不同的医院，这些因素影响患者的结果。如果护理环境的差异被证明与差异有关，则可以实施针对主要服务于少数群体的医院的护理策略。 我们还必须考虑到，不同医院的结果差异可能反映了不同医院治疗人群的差异，尽管研究人员经常考虑个体特征的差异，但医院环境的影响很少与患者居住的社区的影响有关。研究表明，老年人社区的社会生态质量（例如，社会经济地位，隔离和初级保健服务的可用性）影响健康结果。除了一个独立的影响，我们预计，邻里因素影响老年人获得高质量的医院服务，包括优质护理。我们将使用多层次和交叉分类模型以及地理信息系统（GIS）的方法来检查独特的调查数据，从医院护士沿着医疗保险索赔数据，是地理编码和邻里数据。 我们的方法将使我们能够解开医院护理环境和患者社区对老年人医院结果中种族和民族差异的相互关联的影响，指出可能扭转差异的干预措施，并确定最能从干预措施中受益的社区和医院。

DESCRIPTION (provided by applicant): There are well-documented racial and ethnic disparities in the costly and often preventable outcomes of mortality, readmission, and prolonged hospitalization due to the common conditions of heart failure, pneumonia, and acute myocardial infarction. The causes and solutions for these disparities, however, are not clear. Evidence has begun to point toward differences in the hospitals where most minorities and non- minorities receive care as a source of disparities. Surprisingly, two important factors and their interrelationship, which may explain how hospital differences are associated with disparities and point to opportunities for targeted intervention, have received insufficient attention: the quality of nursing in the hospital in which patients are cared for and the characteristics of the neighborhoods of patients served by different hospitals. Nurses provide vital bedside care, 24/7 surveillance, education, and care coordination that may narrow disparity gaps, but little is known about the degree to which minority patients are treated in hospitals with lower quality nursing and the effect of these differences on disparities. Nursing as a systems factor is an appealing feature to study because unlike many hospital characteristics, it can be improved through intervention by administrators or policymakers. Evidence suggests that most minority older adults are cared for in a relatively small proportion of hospitals. The quality of the nursing care environment (including nurse staffing level, level of nurse education, and a care environment supportive of professional nursing practice) can vary significantly from hospital to hospital and these factors affect patient outcomes. If differences in nursing care environment are shown to be associated with disparities, strategies targeting nursing in hospitals that predominantly serve minority- populations could be implemented. We must also consider that outcomes variation by hospital may reflect differences in the populations that different hospitals treat. Although researchers often account for differences in individual characteristics, the effect of the hospital environment is rarely examined in relation to the effect of the neighborhood where patients live. Research shows that the socio-ecological qualities of an older adult's neighborhood (e.g., socioeconomic position, segregation, and primary care services availability) impact health outcomes. In addition to an independent effect, we expect that neighborhood factors affect older adults' access to high-quality hospital services including quality nursing care. We will use multilevel and cross-classified models as well as geographic information systems (GIS) methods to examine unique survey data from hospital nurses along with Medicare claims data that is geocoded and linked with neighborhood data. Our approach will allow us to untangle the interrelated effects of the hospital care environment and patient neighborhood on racial and ethnic disparities in hospital outcomes among older adults, point to interventions that may reverse disparities, and identify communities and hospitals that can most benefit from interventions.