DiSRUPT: Dismantling Structural Racism Underlying the Organization of Ambulatory PracTices: an observational study of clinical desegregation

DiSRUPT：消除门诊实践组织中的结构性种族主义：临床废除种族隔离的观察性研究

• 批准号: 10474861
• 负责人: Nina A. Bickell
• 金额: $ 84.5万
• 依托单位: ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-06-19 至 2027-02-28
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10474861
• 关键词: Academic Medical Centers; Address; Ambulatory Care; Appointment; Area; Attention; Black race; Black, Indigenous, People of Color; Caring; Characteristics; Chronic Disease; Clinic; Clinical; Clinical Research; Complex; Data; Desegregation; Discipline of obstetrics; Discrimination; Disease Management; Economics; Education; Educational process of instructing; Ethnic Origin; Evaluation; Faculty; Family Practice; Financial compensation; Geographic Locations; Health; Health Policy; Health system; Healthcare; Healthcare Systems; Hospitals; Hour; Indigent; Individual; Institution; Insurance; Intervention; Interview; Latinx; Laws; Legal; Length; Maintenance; Measures; Medicaid; Medical; Medical Education; Medical Residency; Modeling; Natural experiment; New York City; Observational Study; Occupational; Outcome; Outpatients; Patient-Focused Outcomes; Patients; Pediatrics; Perception; Physicians; Policies; Population; Prejudice; Preventive care; Preventive measure; Process; Provider; Quality of Care; Race; Reimbursement Mechanisms; Research; Resources; Sampling; Services; Site; Societies; Socioeconomic Status; Specific qualifier value; Structural Racism; Structure; Students; Surveys; System; Techniques; Time; Training; Uninsured; Urban Hospitals; Visit; Wait Time; anti-racism; base; billing data; bundled payment; cardiometabolism; care delivery; care outcomes; clinical practice; design; ethnic minority; experience; indexing; medical specialties; medically underserved population; models and simulation; perceived discrimination; programs; prospective; racial and ethnic; racial disparity; racism; residential segregation; segregation; social group; Academic Medical Centers; Address; Ambulatory Care; Appointment; Area; Attention; Black race; Black, Indigenous, People of Color; Caring; Characteristics; Chronic Disease; Clinic; Clinical; Clinical Research; Complex; Data; Desegregation; Discipline of obstetrics; Discrimination; Disease Management; Economics; Education; Educational process of instructing; Ethnic Origin; Evaluation; Faculty; Family Practice; Financial compensation; Geographic Locations; Health; Health Policy; Health system; Healthcare; Healthcare Systems; Hospitals; Hour; Indigent; Individual; Institution; Insurance; Intervention; Interview; Latinx; Laws; Legal; Length; Maintenance; Measures; Medicaid; Medical; Medical Education; Medical Residency; Modeling; Natural experiment; New York City; Observational Study; Occupational; Outcome; Outpatients; Patient-Focused Outcomes; Patients; Pediatrics; Perception; Physicians; Policies; Population; Prejudice; Preventive care; Preventive measure; Process; Provider; Quality of Care; Race; Reimbursement Mechanisms; Research; Resources; Sampling; Services; Site; Societies; Socioeconomic Status; Specific qualifier value; Structural Racism; Structure; Students; Surveys; System; Techniques; Time; Training; Uninsured; Urban Hospitals; Visit; Wait Time; anti-racism; base; billing data; bundled payment; cardiometabolism; care delivery; care outcomes; clinical practice; design; ethnic minority; experience; indexing; medical specialties; medically underserved population; models and simulation; perceived discrimination; programs; prospective; racial and ethnic; racial disparity; racism; residential segregation; segregation; social group

PROJECT SUMMARY Structural racism is not simply an accumulation of individually held prejudices, but rather, it is the embodiment of racism in rules, policies, laws, practices, and norms. The most conspicuous example of structural racism is residential segregation, the degree to which social groups live separately from one another within a specified geographic area. Segregation is a multi-dimensional, complex construct that has contributed to racial disparities across many domains. Segregated facilities and organizations persist throughout society, including in healthcare, where for example, teaching services in academic medical centers are often located in areas with large numbers of medically underserved groups; and discriminatory insurance programs perpetuate the maintenance of separate outpatient practices for indigent patients. There is, however, surprisingly little research on segregation in healthcare or its direct (disparate quality and access) and indirect (perceived discrimination, mistrust) impacts on the delivery of care or health outcomes. To eliminate structural racism and discrimination from healthcare systems, we must identify, quantify, and address these factors. The DiSRUPT study will use retrospective ambulatory visit data for 12 million patients from five academic medical centers across New York City (NYC) obtained from the INSIGHT Clinical Research Network (CRN) to assess the level of segregation of ambulatory practices and its impact on processes of care and care outcomes. We will use detailed concurrent and prospective data regarding clinical structures, processes, and policies at the Mount Sinai Health System (Sinai) to characterize the multiple domains within which structural racism and discrimination operate and to evaluate the impact of current and planned equity interventions. Sinai is undertaking a transformational set of equity initiatives to dismantle structural racism system-wide, including the unification (desegregation) of ambulatory practices, creating a “natural experiment”. We aim to: 1) use CRN data to describe the level of segregation, (using Dissimilarity Index and Isolation Index), in hospital-based and faculty practice ambulatory sites in NYC and its association with selected quality measures of preventive care (pediatrics), procedural care (obstetrics), and chronic disease management (general and family medicine) for Black, Latinx, and Medicaid populations; 2) identify structural differences between more and less unified practices in a large NYC academic medical center and their association both with quality measures and with patient, staff, provider and trainee perceptions of racism; and 3) observe effects of equity interventions over time on level of segregation, quality measures, and perceived racism and, using microsimulation techniques, estimate the potential societal impact of widespread desegregation on selected cardiometabolic outcomes. We will use our findings to build a blueprint that other healthcare systems can follow to eliminate practice segregation. The proposed study will increase our understanding of the racist structures and discriminatory processes embedded in ambulatory practices and of potential strategies to inform institutional and societal efforts to eliminate them from the healthcare system.

项目摘要 结构性种族主义不仅仅是单独持有的偏见的积累，而是它的体现 规则，政策，法律，实践和规范中的种族主义。结构性种族主义的最显着例子是 住宅隔离，社会群体在指定中彼此分开生活的程度 地理区域。隔离是一种多维的复杂结构，促成种族分布 在许多领域。隔离的设施和组织在整个社会中一直存在，包括医疗保健， 例如，在学术医学中心的教学服务通常位于数量庞大的地区 在医学上服务不足的群体；并歧视保险计划使维护的维护 贫穷患者的单独门诊习惯。但是，关于隔离的研究很少 在医疗保健或其直接（不同的质量和访问）以及间接（感知的歧视，不信任）中的影响 关于护理或健康成果的交付。消除结构性种族主义和医疗保健的歧视 系统，我们必须识别，量化和解决这些因素。干扰研究将使用回顾性 来自纽约市五个学术医疗中心（NYC）的1200万患者的卧床访问数据 从Insight临床研究网络（CRN）中获得，以评估卧床的隔离水平 实践及其对护理和护理结果的影响。我们将使用详细的并发和 西奈山卫生系统（Sinai）的临床结构，过程和政策的预期数据 表征结构性种族主义和歧视在其中运作和评估的多个领域 当前和计划的股权干预措施的影响。西奈正在进行一套变革的公平集 范围内拆除结构性种族主义的举措，包括卧床的统一（种族隔离） 实践，创建一个“自然实验”。我们的目的是：1）使用CRN数据来描述隔离水平， （使用差异指数和隔离指数） 及其与预防保健（儿科），程序护理（妇产科）（妇产科）的选定质量指标的关联， 黑人，拉丁裔和医疗补助人群的慢性疾病管理（一般和家庭医学）； 2） 确定大型纽约市学术医学中心中更多和统一实践之间的结构差异 以及他们与质量措施以及患者，员工，提供者和学员的关联 种族主义; 3）观察股票干预措施随着时间的推移对隔离水平，质量措施和 感知的种族主义并使用微观仿真技术估算了宽度的潜在社会影响 选定的心脏代谢结果上的种族隔离。我们将使用我们的发现来构建其他的蓝图 医疗保健系统可以遵循以消除实践隔离。拟议的研究将增加我们的 了解种族主义结构和嵌入在门诊实践中的种族主义结构和歧视过程 潜在的策略来告知机构和社会努力，以将其从医疗体系中消除。