The Impact of Nursing on Racial Disparities in Surgical Outcomes

护理对手术结果种族差异的影响 美国国立卫生研究院和美国外科医生学会最近提出， 对手术结果中种族差异的解释是，少数民族和白色患者可能接受治疗， 提供不同质量护理的医院。很少有研究能够确定潜在的因素， 医院之间的质量差异，是通过系统重新设计进行干预的可操作目标。我们 工作集中在一个系统的功能，很少注意在外科差异的研究-差异， 各医院的护理资源，包括注册护士人数和技能组合， 至少有一个护理学士学位（BSN）和护士工作环境。尽管有大量的 将这些护理特征与手术结果联系起来的证据，尚不清楚是否：1） 医院的护理资源有助于观察到的手术差异; 2）少数民族患者， 由于相对风险的差异，对有限的护理资源更敏感; 3）是否有 是护理资源的特定组合，最有效地减少差距。我们的研究将 回答这些问题该应用程序建立在两个研究团队的成功科学计划的基础上： 一个具有独特的数据和能力，用于评估护理对手术结果和差异的影响， 另一家公司则率先采用了“锥形多元匹配”方法， 少数民族和白色手术患者之间的临床风险，以明确识别结果的基础 差距。我们合并这两个非常成功的程序，并将联合收割机新颖的锥形多变量匹配 在700多家医院的医院护理和手术患者结果的独特新数据， 四个大国明确确定条件，在护理资源方面，最好的服务，以减少 手术差异。我们的第一个目标是确定是否以及在何种程度上的差异，手术结果 （死亡率、抢救失败、再入院、住院时间、重症监护使用） 少数民族和白色患者之间的差异 本身;和B）护理资源（包括护士教育，人员配备，技能组合， 护士工作环境）和其它特征（例如，通常非常不同的医院， 少数民族和白色患者主要接受护理。我们的第二个目标将使我们能够确定， 少数患者的亚群（例如，高风险与低风险;特定手术/合并症组合） 从具体的护理资源配置中受益更多。我们的最终目标是利用面板数据， 近十年来，700多家医院和其中的病人，以确定护理的变化是否 相关的变化，加强了一个案例，协会，我们发现，在横截面 研究可能是因果关系。关于外科手术中护理与种族差异之间关系的更好证据 结果可以刺激以证据为基础的干预措施，针对护理的可修改方面，以减少差距。

The Impact of Nursing on Racial Disparities in Surgical Outcomes The National Institutes of Health and the American College of Surgeons recently suggested that one potential explanation for racial disparities in surgical outcomes is that minority and white patients may receive care in hospitals that provide differing quality of care. Few studies have been able to identify the factors underlying the between-hospital quality differences that are actionable targets for intervention through system redesign. Our work focuses on a systems feature given little attention in surgical disparities studies—differences in the nursing resources across hospitals, including registered nurse staffing and skill mix, the percentage of nurses with at least a bachelors in nursing (BSN) degree, and nurse work environments. Despite the large body of evidence linking these nursing features to surgical outcomes, it is not clear whether: 1) differences across hospitals in nursing resources are contributing to observed surgical disparities; 2) whether minority patients, because of differences in relative risk, are more sensitive to limited nursing resources; and 3) whether there are particular combinations of nursing resources that are most effective in reducing disparities. Our study will answer these questions. This application builds upon the successful scientific programs of two research teams: one with unique data and capabilities for evaluating the impact of nursing on surgical outcomes and disparities, and another which has pioneered Tapered Multivariate Matching methods to carefully control for differences in clinical risk between minority and white surgical patients in order to clearly identify the basis of outcomes disparities. We merge these two highly successful programs and combine novel Tapered Multivariate Matching approaches with unique new data on hospital nursing and surgical patient outcomes in over 700 hospitals in four large states to explicitly identify the conditions, in terms of nursing resources, that best serve to reduce surgical disparities. Our first aim is to determine whether and to what extent disparities in surgical outcomes (mortality, failure to rescue, readmissions, length of stay, intensive care use) between minority and white patients undergoing the exact same procedure result from: a) differences between minority and white patients themselves; and b) differences in nursing resources (including nurse education, staffing, skill mix, and the nurse work environment) and other characteristics (e.g., volume) of the often very different hospitals where minority and white patients predominantly receive care. Our second aim will allow us to identify if subpopulations of minority patients (e.g., high vs. low risk; specific procedure/comorbidity combinations) benefit more from specific nursing resource configurations. Our final aim will capitalize on panel data, spanning nearly a decade for over 700 hospitals and the patients in them, to determine whether changes in nursing are associated with changes in disparities—strengthening a case that associations we find in cross-sectional studies may be causal. Better evidence about the relationship between nursing and racial disparities in surgical outcomes can spur evidence-based interventions targeting modifiable aspects of nursing to reduce disparities.