Differences in Hospital Nursing Resources among Black-Serving Hospitals as a Driver of Patient Outcomes Disparities

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Black Americans are more likely to receive care in lower quality hospitals that confer worse health outcomes to patients. The intractable hospital outcomes disparities have been described for decades and most recently came to the forefront of public attention with COVID-19 mortality disproportionally affecting Black communities. Despite multiple studies which attribute a large share of outcome disparities to quality differences in hospitals where significant proportions of Black patients are treated (i.e., Black-serving hospitals), little is known about what modifiable factors underlie the poorer quality care. This proposal takes a multilevel perspective to identify the contributions of individual, social, and hospital determinants to identify modifiable factors that can be targeted through `upstream' interventions to achieve health equity for Black individuals. We hypothesize that disparities in hospital outcomes are due, in large part, to inequities in the modifiable nurse resources of hospitals—with fewer nurse resources in Black-serving hospitals. This uneven distribution of nurse resources is a vestige of racism that continues to pervade hospital care more than 50 years after the legal desegregation of hospitals. We focus on nurse resources, since having enough nursing staff to deliver timely and effective care, a favorable work environment in which nurses have clinical autonomy in their practice and strong interdisciplinary teamwork, a skill mix rich in registered nurses, and high proportions of bachelors-prepared nurses and advanced practice nurses, have all been associated with better patient outcomes, particularly for minority patients. In this study, we evaluate the impact of hospital-level differences in nurse resources on patient outcomes, including in-hospital and 30-day mortality, readmission, and hospital length of stay. This observational study of over 900,000 older adult patients in nearly 250 hospitals investigates (1) whether differences in nurse resources between Black-serving and other hospitals explain outcomes disparities; (2) whether the outcomes-advantages of having superior hospital nurse resources are enhanced in the presence of other hospital characteristics, including for example, physician staffing, greater numbers of APRNs, or teaching hospitals; and (3) estimates the improvements in patient outcomes, such as lives saved, that could be expected if nurse resources in Black-serving hospitals were similar to other hospitals. Nurse resources are measured using survey data from over 16,000 nurses in nearly 250 hospitals to describe multiple aspects of the clinical nurse resources. Using a unique hospital identifier, nurse responses will be linked with Medicare patient records, demographic and social determinant of health indices. Our analytic approach uses multi-level nested (hierarchically-related) linear and logistic regression models (with interaction terms) to accomplish our aims. If our hypotheses are confirmed, the findings will add evidence to inform high-impact actionable `upstream' solutions to dismantle structural remnants of racism that pervade our healthcare system, by leveraging the most abundant patient care resource already existing in every hospital—nurses.