Health System Structure: An Opportunity to Address Structural Racism and Discrimination

Abstract

INTRODUCTION: Health systems are often organized in a “hub-and-spoke” fashion to centralize complex surgical care to one high-volume hospital. We examined the role of hub-and-spoke systems as a key factor in structural racism and discrimination. METHODS: Adult surgical patients who underwent 1 of 10 general surgery operations in 13 geographically diverse states (2016 to 2018) were identified using the Healthcare Cost and Utilization Project’s State Inpatient Databases. System status was assigned using the American Hospital Association survey. Hub designation was assigned in two ways: the hospital performing the greatest number of complex operations or the hospital performing the greatest number of each specific operation. Independent multivariable logistic regression was used to evaluate the risk-adjusted odds of receiving treatment at hubs by race and ethnicity. RESULTS: We identified 128,248 patients across 133 hospitals included in 44 systems. Most patients were White (70%), 13.5% were Black and 11.8% Hispanic. A smaller proportion of Black and Hispanic patients underwent operation at hubs compared with White patients (Black: 60.9%; Hispanic: 53.5%; White: 64.4%; p < 0.001). After adjustment for potential confounders, Black and Hispanic patients were less likely to receive care at hub hospitals relative to White patients for common and complex operations (Table). CONCLUSION: When White, Black, and Hispanic patients seek care at hospital systems, Black and Hispanic patients are less likely to receive treatment at hub hospitals. Given the established potential advantages of high-volume care, especially for complex operation, this finding highlights an important gap in the pursuit of health equity. Table. - Risk-Adjusted Odds Ratios of Treatment at Hub Hospitals (Reference = White Patients) Variable All operations Common operation Complex operation Number of observations (n) 128,248 118,764 9,484 Black patients odds ratio 0.88* 0.88* 0.85* Black patients confidence interval [0.85, 0.92] [0.85, 0.92] [0.72, 1.00] Hispanic patients odds ratio 0.79* 0.79* 0.91 Hispanic patients confidence interval [0.76, 0.82] [0.75, 0.82] 0.76, 1.10] *Significance to the level of p <0.05. Results are displayed for the second definition of hub. Similar results were noted for the alternative definition. Model covariates include age, gender, income quartile, insurance type, state, admission status, and operation type. Common operations include cholecystectomy, inguinal hernia repair, mastectomy, colon resection, and small bowel resection. Complex operations include total gastrectomy, Whipple, hepatic lobectomy, esophagectomy, and rectal resection.