A Panel Study of Hospital Nursing Resources and Racial Disparities in Elder Outcomes More than 10 years since the Institute of Medicine's landmark Unequal Treatment report, racial and ethnic disparities in costly and often preventable poor outcomes persist for hospitalized older adults. Evidence points to differences in the hospitals where minorities and whites receive care as a source of disparities. Our original study findings suggest that nursing resource differences (nurse staffing, nurses' educational and skill levels, and nurse work environments) between hospitals may be an important factor underlying racial disparities. Our work thus far however has been restricted to cross-sectional data, preventing us from concluding whether the relationship between nursing resources and disparities is a causal one and whether interventions to improve nursing resources will work as intended. The study we propose in this renewal application takes the important next step to advance policy interventions by using new and unique panel data on hospital nursing and older adult patient outcomes in four large states to evaluate whether differences in outcomes between minority and white patients result from differences between minority and white patients, differences in nursing resources in the hospitals that minority and white patients receive care in, and/or differences in the care minority and white patients receive, even when they are treated in the same hospitals with similar nursing resources. We make efficient use of existing data from repeated cross-sections of hundreds of thousands of patients nested in a panel of over six hundred hospitals at two points in time. This provides a unique opportunity to examine well- known but poorly understood disparities from two distinct but complementary vantage points. First, by examining cross-sections spanning nearly a decade, we gain a better understanding of the role of individual and organizational factors in disparities in older adult hospital outcomes. Importantly, we will learn whether associations between nursing and outcomes disparities in 2015 are similar to those in the same hospital sample in 2006 and whether they differ for whites and minorities. Evidence supporting the stability of associations over time increases our warrant for concluding that connections are causal.
Our second aim i s to examine hospital-level changes in nursing resources over time, determine whether those changes differed for hospitals predominantly serving minority patients, and determine whether changes in outcomes disparities between minority and white patients result from changes in hospital nursing resources over time. It is important for causation and policy implications to know whether nursing resources improved less in minority serving hospitals. The panel data we will analyze will allow us to assess this, and to determine whether hospital outcomes disparities have grown (or narrowed) and whether nursing resource changes are linked with these changes. Furthermore, we will determine if the changes in nursing resources in minority serving hospitals has contributed to widening or reducing outcomes disparities between white and minority patients. Better causal evidence between nursing resources and patient outcomes can spur evidence-based decision-making.
There is evidence that 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 studying a large panel of hundreds of hospitals over nearly a decade, we will learn whether changes in hospital nursing resources have had consequences for disparities in quality of care and outcomes for hospitalized older adults. Understanding more about the causal links between investments in nursing and disparities in outcomes will inform how to target hospital investments in nursing to maximize safe, effective care for all patients.
