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

美国黑人更有可能在质量较低的医院接受护理，这些医院的健康状况更差， 患者几十年来，人们一直在描述难以解决的医院结局差异， 由于COVID-19死亡率严重影响黑人社区， 尽管多项研究将结果差异的很大一部分归因于医院的质量差异， 在治疗黑人患者的显著比例的地方（即，黑人服务的医院），很少有人知道 哪些可改变的因素导致了较差的医疗质量。本提案采用多层次视角， 个人、社会和医院决定因素对确定可以改变的因素的贡献 目标是通过“上游”干预措施实现黑人个人的健康公平。我们假设 医院结果的差异在很大程度上是由于可改变的护士资源的不公平， 医院-黑人服务医院的护士资源较少。这种护士资源的不均衡分布 在法律的废除种族隔离50多年后， 医院。我们专注于护士资源，因为有足够的护理人员提供及时和有效的 护理，一个有利的工作环境，护士在实践中有临床自主权， 跨学科的团队合作，注册护士的技能组合丰富，以及高比例的学士学位准备 护士和高级实践护士，都与更好的患者结局相关，特别是对于 少数民族患者在这项研究中，我们评估了护士资源的医院水平差异对 患者结局，包括住院和30天死亡率、再入院和住院时间。这 对近250家医院的90多万老年患者进行的观察性研究调查了（1） 黑人服务医院和其他医院之间护士资源的差异解释了结果的差异;（2） 是否提高了拥有上级医院护士资源的成果优势， 其他医院特征，包括例如，医生配备，更多的APRN，或 教学医院;（3）估计患者结局的改善，例如挽救的生命， 如果黑人服务医院的护士资源与其他医院相似，护士资源 使用来自近250家医院的16，000多名护士的调查数据进行测量， 临床护理资源。使用唯一的医院标识符，护士的反应将与医疗保险联系起来 患者记录、人口统计学和健康指数的社会决定因素。我们的分析方法使用多层次 嵌套（分层相关）线性和逻辑回归模型（含交互作用项），以完成我们的 目标。如果我们的假设得到证实，调查结果将增加证据，为高影响力的可操作性提供信息。 “上游”解决方案，消除遍布我们医疗保健系统的结构性种族主义残余，方法是 利用每个医院现有的最丰富的病人护理资源-护士。

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.