Achieving Health Equity During the COVID-19 Pandemic: Lessons Learned from Nurses and High Performing Hospitals

Project Summary The COVID-19 pandemic catapulted long-standing racial/ethnic health inequities onto the national stage. Hospitalization and mortality rates for Black and Hispanic individuals with COVID-19 have been 2-3x higher than the rates of their White counterparts, drawing attention to the patient and system level factors underlying these differences, including the quality of hospitals to which minority patients are admitted. Of these studies, few have been able to identify the specific features of hospitals that explain the observed racial/ethnic differences in outcomes. Our study focuses on differences in nursing resources across hospitals, an important factor that has not been adequately addressed in the COVID-19 disparities literature. In this mixed methods proposal, we leverage administrative claims and unique survey data collected from over 22,000 nurses working in 244 New York and Illinois hospitals during the COVID pandemic (April-June 2021). We employ tapered multivariate matching, a novel approach which allows us to carefully control for differences in clinical risk and social factors between minority and white patients to clearly identify the basis of COVID-19 outcome disparities. Our primary objective is to examine how variations in nursing resources were associated with disparities in minority COVID- 19 outcomes, including mortality and readmissions. A second objective is to identify the nursing and hospital characteristics of "high performing" hospitals where such disparities were minimized. After identifying high and low performing hospitals, we will explore the open-ended responses of thousands of nurses who shared their perspectives of supports and barriers to care delivery for socially "vulnerable" populations, including racial and ethnic minorities. By examining patient, community, nurse and system-level factors, we seek to uncover whether there are particular combinations of nursing resources, organizational supports and care processes that are most effective in reducing COVID-19 disparities. If our study hypotheses are supported and we can identify characteristics of high performers, it will 1) strengthen the evidence regarding the link between nursing resources and equitable outcomes, and 2) provide a necessary composite and a set of best practices that can be shared with other hospitals. Our proposal is well-aligned with multiple goals of NINR, including dismantling structures that impede health equity, using lessons learned about health disparities from the COVID-19 pandemic and identifying upstream factors that influence health disparities. Collectively, the results of this study will provide the foundation for the next phase of our research, which includes the development of innovative models of care delivery that integrate evidence-based nursing resources and best practices that are associated with equitable outcomes.