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

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.