Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study

Abstract

Background: Sepsis affects 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 and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention.

Methods: Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, 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.

Discussion: This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene 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.

Keywords: Health Systems; Intervention Studies; Leadership; Organizational Culture; Racial Disparities; Sepsis; Structural Racism.

Fig. 1

Conceptual model of how racism is manifest across the sepsis care continuum. This novel conceptual model below, developed based on synthesis of existing evidence on race-based inequities in healthcare and outcomes, shows how racism is manifest across the sepsis care continuum, and provides a starting point for our work to measure and intervene on the domains of organizational culture that are required to mitigate structural racism

Fig. 2

Study Timeline. We will employ a longitudinal mixed methods interventional study design that includes three aims: delivery of the intervention, evaluation of the impact of the intervention on organizational culture, and evaluation of the impact of the intervention on racial inequities in care and outcomes for patients with sepsis. The study is projected to take place over a 5-year project period

Fig. 3

Convergent mixed methods design. As is recommended for evaluating complex interventions, we propose a convergent, longitudinal mixed methods design with: 1) a novel survey instrument (quant), 2) in-depth interviews (qual) and 3) ethnographic observations (qual), integrating quantitative and qualitative data at the analysis phase to develop a comprehensive understanding of intervention impact on organizational culture and mechanisms by which the impact may have occurred