Mitigating Structural Racism to Reduce Inequities in Sepsis Outcomes

项目摘要 败血症每年影响美国约170万患者，是导致死亡的主要原因之一， 也是美国医疗成本的主要推动力。非裔美国人/黑人(AA/B)和拉丁裔人口 脓毒症并发症、偏离标准护理以及各种原因和败血症的发生率较高 重新入院与非西班牙裔白人(NHW)人口的比较。尽管有明确的证据表明 哪些结构性种族主义加剧了医院和社区层面的因素，从而导致更严重的脓毒症 对于AA/B和Latinx患者的护理和结果，没有基于证据的前瞻性干预措施 命名和解决败血症护理中的结构性种族主义，我们也不知道有研究报告种族减少 败血症护理中的不平等是一个结果。命名和解决结构性种族主义对脓毒症护理的影响 将需要卫生系统和社区机构的集体行动，并得到工作方式的支持 (例如，组织文化)，以跨越历史、政治和组织边界进行有效协作。 我们之前的研究表明，基于联盟的领导力发展方法在 培养能够改善复杂健康结果的组织文化。我们建议调整、交付和 评估以联盟为基础的干预措施，以装备卫生系统及其周围社区 并解决结构性种族主义问题，推动败血症结果中的不平等现象显著减少。我们的特定 目标是：(1)调整和提供以联盟为基础的领导干预美国八个卫生系统和 他们周围的社区来改进组织文化领域，这些领域需要命名和 应对结构性种族主义；(2)使用纵向、趋同的混合方法评估干预的影响 量化组织文化领域变化的方法方法，需要命名和 使用一种新的调查工具解决结构性种族主义问题，并描述文化变革的经历 在每个系统内，在分析阶段整合定量和定性数据，以便制定 全面了解干预的影响和影响可能产生的机制 以及(3)评估干预对减少三个临床中的种族不平等的影响 结果：a)早期识别(使用抗生素的时间)，b)临床处理(院内败血症死亡率)和c) 使用中断的时间序列进行基于标准的随访(同一家医院、所有原因的败血症再住院) 分析和比较在培养领域实现有意义变化的系统的临床结果 需要与那些没有实现有意义的改变的国家一起解决结构性种族主义问题。建议的研究是 及时、高度相关并与NIH和脓毒症联盟的行动呼吁完全一致，以解决 败血症护理和结局中的不平等。它也是高度创新的，因为它将是第一个进行干预的国家 前瞻性地通过发展组织文化领域来减轻结构性种族主义的影响 这是反种族主义行动所必需的，对脓毒症以外的复杂健康后果中的不平等产生了影响。

PROJECT ABSTRACT Sepsis affects approximately 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black (AA/B) and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and all-cause and sepsis readmissions compared with Non-Hispanic White (NHW) populations. Despite clear evidence of the ways in which structural racism compounds factors at the hospital and community levels to generate poorer sepsis care and outcomes for AA/B and LatinX patients, there are no evidence-based, prospective interventions to name and address structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Naming and addressing the impact of structural racism on sepsis care will require collective action across health systems and community institutions, supported by ways of working (e.g., organizational culture) to collaborate effectively across historical, political, and organizational boundaries. Our prior research has shown that coalition-based leadership development approaches can be effective in cultivating organizational culture that can improve complex health outcomes. We propose to adapt, deliver, and evaluate a coalition-based intervention to equip health systems and their surrounding communities to name and address structural racism and drive measurable reductions in inequities in sepsis outcomes. Our specific aims are to: (1) Adapt and deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities to improve domains of organizational culture that are required to name and address structural racism; (2) Evaluate the impact of the intervention using a longitudinal, convergent mixed methods approach to quantify change in domains of organizational culture that are required to name and address structural racism using a novel survey instrument and describe the experience of culture change within each system, integrating quantitative and qualitative data at the analysis phase in order to develop a comprehensive understanding of the intervention impact and mechanisms by which the impact may have occurred; and (3) Evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis and comparing clinical outcomes from systems that achieved meaningful change in domains of culture required to address structural racism with those that did not achieve meaningful change. The proposed study is timely, highly relevant, and fully aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is also highly innovative, as it would be the first to intervene prospectively to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.