Targeting racial inequities in inpatient pulmonary specialty care access

Health care organizations (HCOs) play a pivotal role in reducing health disparities. To maximize the impact of interventions targeting health disparities, HCOs must address care delivery among patients who experience the greatest inequities, for example, race-based disparities in respiratory disease. Although these disparities stem from multiple social determinants of health domains, subspecialty care access is an important driver of inequity, exacerbating respiratory health disparities. Specifically, outpatient pulmonary care is associated with improved care quality, guideline adherence, and outcomes. To the authors’ knowledge, inpatient pulmonary subspecialty care access has not been evaluated to date, but it may serve as an important target for HCOs. As part of a systemwide initiative to promote health equity, the authors evaluated drivers of inequity among hospitalized patients with respiratory disease. They sought to (1) evaluate racial disparities in access to inpatient pulmonary care and associations with outcomes and (2) leverage quantitative and quality improvement (QI) methods to explore drivers of disparities and develop system-level mitigation interventions. They (1) measured race-based inpatient pulmonary care disparities and tested associations with outcomes and (2) defined admission processes, identified root causes of inequitable allocation, and developed and implemented countermeasures to promote equitable access. The authors performed retrospective cohort analyses of patients who self-identified as Black or white and were admitted with pulmonary diagnoses to either (1) a dedicated pulmonary versus general medicine service or (2) a nonpulmonary service with versus without pulmonary consultation in an academic medical center from April 2017 through February 2020. They performed multivariable regression to evaluate racial disparities in service allocation and pulmonary consultation and to test associations of race, pulmonary access, and the interaction between the two with outcomes. Black patients were 63% (P < 0.001) less likely to be admitted to the dedicated pulmonary service and 25% (P = 0.04) less likely to receive pulmonary consultation. Black race was associated with increased likelihood of discharge to skilled nursing facilities, readmissions, and in-hospital mortality and decreased likelihood of postdischarge pulmonary follow-up, all moderated by pulmonary subspecialty care. In secondary analyses among Black patients, having an outpatient health system pulmonologist was strongly associated with pulmonary service admission, suggesting that allocation processes propagated outpatient access disparities. These findings informed the QI initiative, which identified misapplication of pulmonary service admission guidelines as a root cause of inequitable service allocation, favoring pulmonary service admission for patients with outpatient health system pulmonologists despite the absence of such a policy. After countermeasure implementation, including multidisciplinary admitting guidelines revisions and stakeholder education, race-based service allocation disparities were moderated. Combining quantitative and QI methods facilitated a nuanced exploration of associations among race, outcomes, and structural inequities, leading to hospital process changes to promote equity. The authors’ approach is adaptable to other settings, serving as a framework for exploring and mitigating structural inequities within health systems.

Caitlin B. Clancy, Janae K. Heath, Anna Winston, Jessica T. Lee, Rachel Kohn