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

项目摘要 结构性种族主义不仅仅是个人持有的偏见的积累， 在规则、政策、法律、实践和规范中的种族主义。结构性种族主义最突出的例子是 居住隔离，社会群体在特定的范围内彼此分开居住的程度。 地理区域。种族隔离是一个多层面的复杂结构，它导致了种族差异 在许多领域。隔离的设施和组织在整个社会都存在，包括在医疗保健领域， 例如，学术医疗中心的教学服务通常位于人口众多的地区， 医疗服务不足的群体;和歧视性的保险计划永久维持 为贫困病人提供单独的门诊服务。然而，令人惊讶的是， 在医疗保健或其直接（不同的质量和访问）和间接（感知歧视，不信任）的影响 提供护理或健康成果。消除医疗保健领域的结构性种族主义和歧视 我们必须确定、量化和解决这些因素。DiSRUPT研究将使用回顾性 来自纽约市（NYC）五个学术医疗中心的1200万患者的门诊访视数据 从INSIGHT临床研究网络（CRN）获得，以评估门诊患者的隔离水平 这一做法及其对护理过程和护理结果的影响。我们将使用详细的并发和 关于西奈山卫生系统（西奈）临床结构、流程和政策的前瞻性数据 确定结构性种族主义和歧视在多个领域内运作的特点，并评估 当前和计划中的股权干预措施的影响。西奈半岛正在进行一系列改革， 消除全系统结构性种族主义的举措，包括统一（废除） 实践，创造一个“自然实验”。我们的目标是：1）使用CRN数据来描述隔离水平， （使用相异指数和隔离指数），在纽约市的医院和教师实践门诊站点 及其与预防性护理（儿科），程序性护理（产科）， 和慢性疾病管理（一般和家庭医学）为黑人，拉丁裔，和医疗补助人群; 2） 确定纽约市一个大型学术医疗中心的统一做法和不统一做法之间的结构差异 以及它们与质量测量以及与患者、工作人员、提供者和受训者对 3）观察公平干预措施随着时间的推移对隔离程度、质量措施的影响， 种族主义，并使用微观模拟技术，估计广泛的潜在社会影响， 在选定的心脏代谢结局上取消隔离。我们将用我们的发现来建立一个蓝图， 医疗保健系统可以遵循，以消除实践隔离。建议的研究将增加我们的 了解门诊做法中的种族主义结构和歧视过程， 潜在的战略，以告知机构和社会的努力，以消除他们从医疗保健系统。

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.