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表示，一种潜在的 对手术结果中种族差异的解释是，少数族裔和白人患者可能会在 提供不同质量护理的医院。很少有研究能够确定导致这种疾病的因素 医院间质量差异是通过系统重新设计进行干预的可操作目标。我们的 工作集中在一个系统特征上，在外科差异研究中很少被关注-在 各医院的护理资源，包括注册护士的配置和技能组合、护士的百分比 至少拥有护理(BSN)学士学位和护士工作环境。尽管有一大堆 将这些护理特征与手术结果联系起来的证据尚不清楚：1)不同 医院在护理资源方面对观察到的手术差异有贡献；2)无论少数族裔患者， 由于相对风险的差异，他们对有限的护理资源更敏感；以及3)是否有 是护理资源的特殊组合，在减少差异方面最有效。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成功的科学计划之上： 拥有独特的数据和能力来评估护理对手术结果和差异的影响， 另一家开创了多元匹配方法的先河，以谨慎地控制 少数族裔和白人外科患者之间的临床风险，以便清楚地确定结果的基础 差距。我们合并了这两个非常成功的方案，并结合了新颖的渐变多元匹配 年700多家医院的医院护理和外科患者预后的独特新数据的方法 四个大州明确确定在护理资源方面最有利于减少 外科手术的差异。我们的首要目标是确定手术结果是否存在差异以及差异有多大。 (死亡率、抢救失败、重新入院、住院时间、重症监护使用)介于少数族裔和白人之间 接受完全相同手术的患者的结果是：a)少数族裔患者和白人患者之间的差异 以及b)护理资源的差异(包括护士教育、人员配置、技能组合和 护士工作环境)以及通常非常不同的医院的其他特征(例如，容量 少数族裔和白人患者主要接受治疗。我们的第二个目标将使我们能够确定 少数族裔患者的亚群(例如，高风险与低风险；特定程序/共病组合) 从特定的护理资源配置中获益更多。我们的最终目标将利用面板数据，跨越 近十年来，700多家医院和其中的患者，以确定护理的变化是否 与差异的变化相关联--加强了我们在横截面中发现的关联 研究可能是因果的。外科护理与种族差异关系的更好证据 结果可以刺激针对护理的可修改方面的循证干预，以减少差异。

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.