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: 10650244
• 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/10650244
• 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; Compensation; Complex; Data; Desegregation; Dimensions; Discipline of obstetrics; Discrimination; Disease Management; Disparate; Economics; Education; Educational process of instructing; Equity; Ethnic Origin; Evaluation; Faculty; Family Practice; 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; Racial Segregation; 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; access disparities; anti-racism; billing data; bundled payment; cardiometabolism; care delivery; care outcomes; clinical practice; design; ethnic minority; ethnic segregation; experience; indexing; medical specialties; medically underserved population; models and simulation; perceived discrimination; programs; prospective; racial disparity; racial minority; racism; residential segregation; segregation; simulation; 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.

项目概要 结构性种族主义不仅仅是个人偏见的积累，而是具体体现 规则、政策、法律、实践和规范中的种族主义 结构性种族主义最明显的例子是。 居住隔离，即社会群体在特定范围内彼此分开居住的程度 地理区域隔离是一种多维、复杂的结构，导致了种族差异。 隔离的设施和组织在整个社会中持续存在，包括医疗保健、 例如，学术医疗中心的教学服务通常位于人口较多的地区 医疗服务不足的群体；以及歧视性保险计划使 然而，令人惊讶的是，关于隔离的研究却很少。 医疗保健或其直接（不同的质量和获取）和间接（感知到的歧视、不信任）影响 从结构上消除医疗保健中的种族主义和歧视。 系统，我们必须识别、量化和解决这些因素。DiSRUPT 研究将采用回顾性方法。 来自纽约市 (NYC) 五个学术医疗中心的 1200 万患者的门诊数据 从 INSIGHT 临床研究网络 (CRN) 获得，用于评估门诊隔离水平 我们将使用详细的并发和护理结果。 有关西奈山卫生系统（西奈）临床结构、流程和政策的前瞻性数据 描述结构性种族主义和歧视运作的多个领域并评估 当前和计划中的股权干预措施的影响，西奈半岛正在采取一系列变革性措施。 消除全系统结构性种族主义的举措，包括统一（废除种族隔离）流动性 实践，创建一个“自然实验”，我们的目标是：1）使用 CRN 数据来描述隔离水平， （使用差异指数和隔离指数），在纽约市的医院和教职员工门诊实践场所 及其与预防性护理（儿科）、程序性护理（产科）的选定质量措施的关联， 黑人、拉丁裔和医疗补助人群的慢性病管理（普通医学和家庭医学）2) 确定纽约市大型学术医疗中心统一实践与不统一实践之间的结构差异 以及它们与质量措施以及患者、工作人员、提供者和受训者对质量的看法的关联 种族主义；3) 观察公平干预措施对种族隔离程度、质量衡量标准的长期影响，以及 感知到的种族主义，并使用微观模拟技术，估计广泛存在的种族主义的潜在社会影响 我们将利用我们的发现来构建其他人可以参考的蓝图。 医疗保健系统可以遵循这项研究来消除实践隔离。 了解流动实践中所蕴含的种族主义结构和歧视过程以及 为机构和社会努力提供信息以将其从医疗保健系统中消除的潜在策略。