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 i s 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.
Our study focuses on a systems feature given little attention in research on racial disparities in surgical patient outcomes?differences in the nursing resources across hospitals. By using new multivariate matching methods to study patients in a large panel of hundreds of hospitals over nearly a decade, we will separately determine the effects of patient, surgeon, nursing, and hospital characteristics on racial disparities, closely examine the relationship between nursing and disparities in specific procedure and patient groups, and learn whether changes in nursing resources over time have had consequences for racial disparities in surgery outcomes. Our research can translate into interventions tailored to reduce surgical disparities by addressing the mismatch for some minority patients in terms of the specific nursing resources needed to yield the best outcomes.