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

描述(由申请人提供)：由于常见的心力衰竭、肺炎和急性心肌梗死等常见情况，死亡、再入院和长期住院造成的代价高昂且往往可以预防的后果方面，有很好的种族和民族差异。然而，造成这些差距的原因和解决方案尚不清楚。有证据表明，大多数少数族裔和非少数族裔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，两个重要因素及其相互关系没有得到足够的关注，这两个因素可能解释了医院差异是如何与差异相关的，并指出了有针对性的干预机会：患者所在医院的护理质量以及不同医院服务的患者所在社区的特点。护士提供重要的床边护理、全天候监测、教育和护理协调，这可能会缩小差距，但人们对少数族裔患者在护理质量较低的医院得到的治疗程度以及这些差异对差距的影响知之甚少。护理作为一个系统因素是一个吸引人的研究特征，因为与许多医院特征不同，它可以通过管理者或政策制定者的干预来改善。有证据表明，大多数少数族裔老年人在相对较小比例的医院得到照顾。护理环境的质量(包括护士人员配备水平、护士教育水平和支持专业护理实践的护理环境)可能因医院而异，这些因素会影响患者的预后。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族裔人群的医院的护理策略。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的人群的差异。尽管研究人员经常考虑个体特征的差异，但很少将医院环境的影响与患者居住的社区的影响联系起来进行检查。研究表明，老年人所在社区的社会生态特征(例如，社会经济地位、种族隔离和初级保健服务的可获得性)会影响健康结果。除了独立的影响，我们预计社区因素还会影响老年人获得包括优质护理在内的高质量医院服务的机会。我们将使用多层次和交叉分类模型以及地理信息系统(GIS)方法来检查来自医院护士的独特调查数据，以及经过地理编码并与邻里数据相关联的联邦医疗保险索赔数据。我们的方法将使我们能够理清医院护理环境和患者社区对老年人住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，并确定最能从干预中受益的社区和医院。 与公共卫生相关：老年人住院结果中的种族和民族差异，在一定程度上是少数族裔和非少数族裔接受护理的医院的差异所致。通过研究医院护理环境和医院吸引患者所在社区的相互关联影响，我们的研究将有助于解释以前未被探索的种族和民族差异的原因，为改善医院护理环境的努力提供信息，并将有限的资源集中到最能从中受益的医院和社区。

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. PUBLIC HEALTH RELEVANCE: Racial and ethnic disparities in hospital outcomes for older adults are, in part, a function of differences in hospitals where minorities and non-minorities receive care. By examining the inter-related effects of the hospital care environment and the neighborhoods from which hospitals draw patients, our study will help explain previously unexplored causes of racial and ethnic disparities, inform efforts to improve the hospital care environment, and target limited resources to the hospitals and communities that could most benefit from them.