Background Nurses are responsible for surveillance to prevent patient falls. Staffing inadequacies may compromise surveillance. Accurate measurement of staffing adequacy is needed to guide staffing decisions. Staffing metrics may differ in explained variance in fall rates. Purpose Evaluate whether objective and subjective staffing metrics are associated with fall rates across nursing units with differing patient acuity. Methods In a cross-sectional design, objective and subjective staffing metrics from the 2024 National Database of Nursing Quality Indicators were linked to fall rates on 1,269 adult medical-surgical, stepdown, and adult critical care units from 217 U.S. hospitals. Findings Registered nurse hours-per-patient-day was associated with falls in critical care and stepdown units. Perceived staffing adequacy was significantly associated with fall rates in acute care and stepdown units. Discussion The findings inform nurse staffing decision-making and fulfillment of new hospital accreditation standards requiring a nurse staffing plan with an adequate number of nurses.

Since 1990, the National Assessment of Educational Progress (NAEP) has been the primary benchmark for tracking the progress of state education reform. The focus on math and reading achievement is motivated by the cross-sectional relationship between test scores and adult outcomes, such as earnings and college completion. But do changes in NAEP scores predict changes in long-term economic and social outcomes for future earners-or do they reflect other factors unrelated to earnings such as teaching to the test? We investigate by linking long-term outcomes by year and state of birth to NAEP scores. We find that more recent birth cohorts in states with large increases in NAEP math achievement enjoyed higher incomes, improved educational attainment, and declines in teen motherhood, incarceration, and arrest rates compared to those in states with smaller increases. In fact, the relationship between changes in NAEP achievement and cohort earnings is about two thirds the size of the cross-sectional relationship observed in prior research: a 6% to 8% rise in earnings per standard deviation rise in 8th grade math. The results are not sensitive to controls for student demographics, labor market conditions, or measures of children's health (such as low birthweight).

We analyze admissions and transcript records for students at multiple Ivy Plus colleges to study the relationship between standardized (SAT/ACT) test scores, high school GPA, and first-year college grades. Standardized test scores predict academic outcomes four times better than high school GPA conditional on students' race, gender, and socioeconomic status. Standardized test scores also exhibit no calibration bias, as they do not underpredict college performance for students from less advantaged backgrounds. Collectively, these results suggest that standardized test scores provide important information to measure applicants' academic preparation that is not available elsewhere in the application file.

BackgroundA structurally fluent workforce is essential to demonstrate structural competency-the ability to recognize and address how social, political, and economic structures affect health. Such a workforce understands the role of external factors and social determinants in health inequities. Evidence shows that minority patients receive better care from a diverse workforce. The racial composition of hospital nurses and its correlation to patients remains unreported.ObjectiveThe aim of this study was to evaluate patient-nurse racial concordance at the hospital level in a large geographically representative hospital sample.MethodsA cross-sectional descriptive study design was employed using the 2015 Annual Registered Nurse Survey of the National Database of Nursing Quality Indicators and 2019 Medicare patient data. Concordance was measured by subtracting the hospital nurse percentage from the patient percentage. We defined Black-serving hospital (BSH) status by classifying hospitals into categories (25/50/25) by low, medium, and high representation of Black patients. Descriptive and correlation statistics were calculated on nurse and patient race and their concordance at the hospital and BSH levels.ResultsAmong 574 hospitals, the proportion of Black nurses was significantly lower than that of Black patients, with considerable variation across hospitals. The representation of Black nurses and patients was strongly associated with hospitals that served more Black patients and generally employed more Black nurses. When grouped into low, medium, and high BSHs, the percentage of Black nurses differed considerably across the categories. High BSH had the greatest discordance.DiscussionAlthough Black nurses and Black patients are often clustered in the same hospitals, there are relatively few Black nurses in hospitals where Black patients primarily receive care. This study underscores the urgent need for healthcare institutions and policymakers to prioritize building structural competency and diversifying the nursing workforce, particularly in hospitals serving higher Black patient populations. Future research is warranted on whether patient-nurse racial concordance or a nursing workforce more reflective of the patient population it serves reduces disparities.

INTRODUCTION:Patients enrolled in randomized trials are carefully selected and may have different comorbidities than patients treated in everyday practice. METHODS:We compared characteristics of 1815 patients enrolled in the Best Endovascular or Surgical Treatment for Critical Limb Ischemia (BEST-CLI, NCT02060630) with 104,877 patients receiving endovascular treatment and 32,120 patients undergoing bypass in the Vascular Quality Initiative's (VQI) registry from 2014 to 2020 using descriptive statistics. We studied mortality by treatment type among patients in both the trial and registry using Cox regression. We adjusted for differences in patient characteristics using inverse probability weighting with propensity scores. RESULTS:Compared to the BEST-CLI participants, patients in the VQI registry were commonly older, female, and of non-Hispanic ethnicity. Chronic obstructive pulmonary disease and congestive heart failure were more prevalent in VQI, while coronary artery disease and diabetes rates were higher in BEST-CLI. The unadjusted 1-y mortality in VQI was 12.5% following endovascular treatment and 10.2% following bypass. After weighting VQI patients to represent the BEST-CLI sample, the cumulative 5-y mortality was higher in those undergoing endovascular treatment versus bypass (26.3% versus 23.7%, P < 0.001). Bypass was associated with an 8% lower mortality than endovascular treatment (hazard ratio = 0.92, 95% CI:0.87-0.98, P = 0.005). This effect remained across all weighting schemes, even when limiting to patients treated at a BEST-CLI site. CONCLUSIONS:Patients enrolled in BEST-CLI differ from patients treated in VQI. However, reweighting VQI data to represent BEST-CLI yields similar estimates of treatment effects in VQI data, supporting a role for registry-based analytic models in answering comparative, real-world clinical questions.

Many school districts have turned to summer school as a strategy for addressing persistent declines in student achievement after COVID-19. We examine the impact of 2023 summer programs on academic recovery across 400,000 students in eight large U.S. districts. Using value-added models, we find modest but significant improvements in student math achievement (average effect = 0.024 SD), and no significant improvements in reading. Effects were similar to 2022, despite small declines in participation and dosage. In four districts, we also examine differences in summer 2023 impacts for students who attended the districts’ summer school the prior year and those who did not. Students attending for a second consecutive summer generally benefited as much or more than first-time attendees.

BACKGROUND:Patients in hospitals that serve disproportionately patients of Black race have worse outcomes than patients in other hospitals, but the modifiable nursing factors that may contribute to such disparities have not been explored. OBJECTIVE:The study objective was to examine whether nurse staffing differs in hospitals that serve predominantly patients of Black race (Black-serving hospitals) as compared to other hospitals. METHODS:A cross-sectional correlational design using a nurse survey in a national hospital sample was used to fulfill the study objective. Nurse staffing was measured as the maximum number of patients cared for on the last shift from the 2015 annual registered nurse survey conducted in National Database of Nursing Quality Indicators hospitals. Hospitals were classified into subgroups of low, medium, and high percentages of patients of Black race using the 2019 Medicare Provider Analysis and Review database. RESULTS:In survey data from 179,336 registered nurses in 574 hospitals, nurse staffing was significantly worse in high-Black-serving hospitals as compared to medium- and low-Black-serving hospitals. In Poisson regression models that adjusted for nursing unit type and hospital characteristics, nurses in high-Black-serving hospitals and medium-Black-serving hospitals had more patients-per-nurse than did nurses in low-Black-serving hospitals. DISCUSSION:Small, statistically significant differences in nurse staffing that are worse in hospitals where Black patients disproportionately access their care were found using nurse survey data accounting for nursing unit type. The poorer nurse staffing in Black-serving hospitals may compromise the care and outcomes of the seven in 10 hospitalized Black older adults who receive care in Black-serving hospitals. The consequences for patient outcome disparities of poorer nurse staffing in Black-serving hospitals deserve investigation. Policies to increase nurse staffing in hospitals serving a higher proportion of patients of Black race are needed to contribute to efforts to reduce health disparities.

BACKGROUND:The pandemic profoundly stressed practicing nurses and could have thereby affected trends in nursing-sensitive quality indicators (NSIs), measures that detect changes in patient health status directly affected by nursing care. OBJECTIVES:The aim of the study was to determine if NSIs have worsened in response to the pandemic and then returned to prepandemic levels using data from 2019 through 2022. METHODS:We conducted a cross-sectional descriptive study of annual trends, examining unit data from the National Database of Nursing Quality Indicators (NDNQI) from 2019 through 2022 for five indicators: rates of falls, central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), hospital-acquired pressure injuries (HAPI), and ventilator-associated events (VAE). The NDNQI is the largest repository of nursing quality indicators, which are derived from patient-level events, reported at the nursing unit level, and submitted quarterly by over 2,000 member hospitals. Adult medical-surgical or critical care inpatient nursing units with complete data for the 4 years were included, with samples ranging from 456 to 5,818 nursing units in 2,346 hospitals. Analysis of variance was conducted by comparing the 2019 rates to each subsequent year. RESULTS:In decreasing order of prevalence, the mean prepandemic rates were 6.58 VAE per 1,000 ventilator days (critical care only), 2.41 HAPI per 1,000 device days, 2.20 falls per 1,000 patient days, 0.96 CAUTI per 1,000 catheter days, and 0.68 CLABSI per 1,000 central line days for medical-surgical and critical care units combined. The rates for all five nurse-sensitive indicators increased significantly beginning in 2020 and have begun to decline but have not returned to baseline by 2022. The maximum rate was observed in 2020 for falls and 2021 for the remaining indicators. These increases to the maximum ranged from a 12% increase in CAUTI to 49% for CLABSI. DISCUSSION:NSIs increased during the pandemic and are now returning to baseline. The pandemic underscored the importance of nursing practice. The pandemic's enduring negative effects on the nursing workforce must be addressed to preserve patient safety.

We measure the effect of district use of federal pandemic relief during the 2022-23 school year for a sample of more than 5000 districts in 29 states. We rely on several plausibly exogenous sources of variation in federal grants: differences in state Title I funding formulas, estimation error in Census local area poverty rates and differences in eligibility for federal Title I and subsidized lunch eligibility. We find that each $1000 in spending per student was associated with a .0086 SD improvement in math and a .0049 SD improvement in reading. Both are consistent with a recent meta-analysis of spending impacts by Jackson and Mackevicius (2023). As a placebo test, we find no relationship between federal dollars that were not yet spent during the 2022-23 year. We also find similar results using synthetic control group methods to compare high-poverty districts with high and low amounts of federal aid, but with similar trends in achievement through 2022. Because the federal aid was targeted at higher poverty districts, we find the federal dollars not only contributed to the recovery, but also helped narrow the gaps in achievement which had widened during the pandemic.

Pandemic-era disruptions to schooling resulted in academic setbacks for many students. To help students catch up, school districts nationwide are implementing a range of academic recovery interventions. In this paper, we use multiple data sources to evaluate the impact and implementation of academic recovery interventions in four school districts during the 2021-2022 school year. Our estimates suggest the interventions failed to reach the expected number of students and had little detectable impact on students’ test scores. Interviews with district officials highlight a host of challenges districts faced during the 2021-2022 school year. Considering the overall scale of pandemic learning loss, our results raise urgent questions about the adequacy of academic recovery efforts relative to students’ needs. The results also have implications for how districts might respond to disrupted learning in the future (e.g. in the wake of natural disasters).

Importance Health care delivery systems rely on a well-prepared and adequately sized registered nurse (RN) workforce. The US RN workforce decreased by more than 100 000 in 2021 during the COVID-19 pandemic—a far greater single-year drop than observed over the past 4 decades. The implication for the longer-term growth of the RN workforce is unknown. Objective To describe recent trends in RN employment through 2023 and forecast the growth of the RN workforce through 2035. Design, Setting, and Participants Descriptive analysis of recent trends since the start of the COVID-19 pandemic in RN employment using data from the US Bureau of the Census Current Population Survey and including employed RNs aged 23 to 69 years from 1982 through 2023, and retrospective cohort analysis of employment trends by birth year and age to project the age distribution and employment of RNs through 2035. Main Outcome and Measures Annual full-time equivalent (FTE) employment of RNs by age, demographics, and sector of employment; forecast of RN workforce by age through 2035. Results The final sample included 455 085 RN respondents aged 23 to 69 years. After a sharp decline in 2021, RN employment recovered, and the total number of FTE RNs in 2022 and 2023 was 6% higher than in 2019 (3.35 million vs 3.16 million, respectively). Using data on employment, education, and population through 2022, the size of the RN workforce was projected to increase by roughly 1.2 million FTEs to 4.56 million by 2035, close to prepandemic forecasts. Growth will be driven primarily by RNs aged 35 to 49 years, who are projected to compose nearly half (47%) of the RN workforce in 2035, up from 38% in 2022. Conclusions and Relevance In this study, the rebound in the total size of the US RN workforce during 2022 and 2023 indicates that the earlier drop in RN employment during the first 2 years of the COVID-19 pandemic was likely transitory. Updated forecasts of the future RN workforce are very close to those made before the pandemic.

Importance For neonates with very low birth weight (VLBW), randomized clinical trials (RCTs) indicate that probiotic treatment decreases the risk of necrotizing enterocolitis (NEC), with smaller decreases in the risk of sepsis and death. There is little evidence on the rate of probiotic adoption in US neonatal intensive care units (NICUs) and whether the benefits seen in trials have materialized in practice. Objective To estimate changes in probiotic use among neonates with VLBW and to test whether neonates with VLBW treated at NICUs adopting routine probiotic use experience better outcomes compared with neonates treated at nonadopting NICUs. Design, Setting, and Participants This cohort study used Vermont Oxford Network data on neonates with VLBW in US NICUs from January 1, 2012, to December 31, 2019. Data were analyzed from January 2022 through February 2023. Exposure Probiotics adoption vs nonadoption. Adopting NICUs were defined as those that currently or previously treated at least 20% of neonates with VLBW with probiotics. Main Outcomes The primary outcomes were rates of NEC, in-hospital mortality, and sepsis, defined as bacterial or fungal infection occurring after day 3 from birth. A difference-in-differences analysis compared changes in VLBW infant outcomes between adopting and nonadopting NICUs before and after hospital-level adoption of probiotics. Additional analyses used the proportion of neonates treated with probiotics in each neonate’s birth NICU and year. Results The analysis included 307 905 neonates with VLBW (mean [SD] gestational age, 28.4 [2.9] weeks; 50.0% male) at 807 US hospitals. The rate of probiotic treatment of neonates with VLBW rose from 1572 of 38 296 neonates (4.1%) in 2012 to 4788 of 37 910 (12.6%) in 2019. Only 123 of 745 NICUs (16.5%) adopted probiotics by 2019, with 4591 of 6017 neonates with VLBW (76.3%) receiving probiotics in 2019 at adopting NICUs. Incidence of NEC declined by 18% at adopting NICUs (odds ratio [OR], 0.82; 95% CI, 0.70-0.95; P = .10) compared with nonadopting NICUs. Probiotic adoption was not associated with a significant reduction in sepsis (OR, 1.11; 95% CI, 0.98-1.25; P = .09) or mortality (OR, 0.93; 95% CI, 0.80-1.08; P = .33). Conclusion and Relevance In this cohort study, adoption of routine use of probiotics increased slowly in US NICUs and was associated with lower NEC risk but not with sepsis or mortality among neonates with VLBW. The findings for probiotic adoption and NEC, sepsis, and mortality were smaller than would have been predicted by the totality of RCT evidence but are consistent with a meta-analysis restricted to studies at low risk of bias.

Educators must balance the needs of students who start the school year behind grade level with their obligation to teach grade-appropriate content to all students. Educational software could help educators strike this balance by targeting content to students’ differing levels of mastery. Using a regression discontinuity design and detailed software log and administrative data, we compare two versions of an online mathematics program used by students in three education agencies. We find that although students assigned the modified curriculum did progress through content objectives more quickly than students assigned the default curriculum, they did not perform better on pre- and post-objective quizzes embedded in the software, and most never progressed far enough to reach the grade-level content. Furthermore, there was no statistically significant effect of the modified curriculum on formative test scores. These findings suggest policymakers and practitioners should exercise caution when assigning exclusively remedial content to students who start the school year behind grade level, even though this is a common feature of many math educational software programs.

Using testing data from over two million students in nearly 10,000 schools in 49 states (plus the District of Columbia), we investigate the role of remote and hybrid instruction in widening gaps in achievement by race and school poverty. We find that remote instruction was a primary driver of the widening gaps. Math gaps did not widen in areas that remained in person (although reading gaps did). We estimate that high-poverty districts that went remote in 2020–2021 will need to spend nearly all of their federal aid on helping students recover from pandemic-related academic achievement losses. (JEL H75, I12, I21, I24, I32, J15)

Hospitals play a key role in patient outcomes and spending, but efforts to improve their quality are hindered because we do not know whether hospital quality indicators are causal or biased.We evaluate the validity of commonly used quality indicators, such as mortality, readmissions, inpatient costs, and length-of-stay, using a quasi-experimental design where hospital closures reallocate large numbers of patients to hospitals of different quality.This setting allows us to measure whether patient outcomes improve as much as quality indicators predict when a relatively low-quality hospital closes, or decline as predicted when a relatively high-quality hospital closes.Using more than 20 years of Medicare claims for over 30 million patients admitted with five common diagnoses, we find that hospital quality indicators overstate differences in the causal impact of hospitals on mortality and readmission rates by 7 percent or less, but overstate differences in the causal impact of hospitals on inpatient cost and length-ofstay measures by closer to 40 percent.On average, hospital closures reduce patient mortality by shifting patients to higher quality hospitals, but the but the effect varies widely depending on the relative quality of the closing hospital.

Purpose Rural registered nurses (RNs) play an integral role in providing care for an underserved population with worse health outcomes than urban counterparts. However, little information is available on the profile of this workforce, which is necessary to understand the capacity of these nurses to provide quality and demanded care presently and in the future. Methods We utilize data from the American Community Survey to provide a contemporary analysis on the supply of rural RNs in the United States. Findings While the number of physicians serving rural populations has decreased in recent years, and rural nurse practitioners (NPs) remain in short supply, rural RNs have steadily grown in numbers at a rate comparable to urban RNs. Rural RNs are markedly less diverse than the populations they serve and only half of rural RNs had a bachelor's degree or higher compared to over 70% for urban RNs. In their supply, young rural nurses appear on pace with urban nurses to adequately replace older nurses and continue to grow the workforce, based on data through 2019. Conclusions The rural RN workforce is projected to steadily grow amidst declining rural physicians and limited rural NPs. The burgeoning investments in the rural health workforce present opportunities to help diversify, increase educational access, and further rural readiness for rural RNs moving forward.

ImportanceA better understanding of the association between family structure and sex gaps in physician earnings and hours worked over the life cycle is needed to advance policies addressing persistent sex disparities.ObjectiveTo investigate differences in earnings and hours worked for male and female physicians at various ages and family status.Design, Setting, and ParticipantsThis retrospective, cross-sectional study used data on physicians aged 25 to 64 years responding to the American Community Survey between 2005 and 2019.ExposuresEarned income and work hours.Main Outcomes and MeasuresOutcomes included annual earned income, usual hours worked per week, and earnings per hour worked. Gaps in earnings and hours by sex were calculated by family status and physician age and, in some analyses, adjusted for demographic characteristics and year of survey. Data analyses were conducted between 2019 and 2022.ResultsThe sample included 95 435 physicians (35.8% female, 64.2% male, 19.8% Asian, 4.8% Black, 5.9% Hispanic, 67.3% White, and 2.2% other race or ethnicity) with a mean (SD) age of 44.4 (10.4) years. Relative to male physicians, female physicians were more likely to be single (18.8% vs 11.2%) and less likely to have children (53.3% vs 58.2%). Male-female earnings gaps grew with age and, when accumulated from age 25 to 64 years, were approximately $1.6 million for single physicians, $2.5 million for married physicians without children, and $3.1 million for physicians with children. Gaps in earnings per hour did not vary by family structure, with male physicians earning between 21.4% and 23.9% more per hour than female physicians. The male-female gap in hours worked was 0.6% for single physicians, 7.0% for married physicians without children, and 17.5% for physicians with children.Conclusions and RelevanceIn this cross-sectional study of US physicians, marriage and children were associated with a greater earnings penalty for female physicians, primarily due to fewer hours worked relative to men. Addressing the barriers that lead to women working fewer hours could contribute to a reduction in the male-female earnings gap while helping to expand the effective physician workforce.