Measuring racial segregation in health system networks using the dissimilarity index

• Main Authors: Austin, A.M (Author), Bynum, J.P.W (Author), Carmichael, D.Q (Author), Skinner, J.S (Author)
• Format: Article
• Language: English
• Published: Elsevier Ltd 2019
• Subjects: African Continental Ancestry Group; aged; Aged; Aged, 80 and over; Alzheimer disease; Alzheimer disease and related dementia; Alzheimer's disease and related dementias; ancestry group; Article; Black person; brain; Caucasian; classification; cohort analysis; Cohort Studies; Columbus [Georgia]; community care; Community Networks; Continental Population Groups; controlled study; correlational study; Delivery of Health Care; disease; dissimilarity index; District of Columbia; End-of-life care; European Continental Ancestry Group; female; Female; Georgia; Georgia (U.S.); Greenville [North Carolina]; health care delivery; health care disparity; health care quality; health care system; health services; Healthcare Disparities; hospice care; human; Humans; intensive care unit; major clinical study; male; Male; medicare; Mississippi; neurology; North Carolina; patient care; patient referral; procedures; quantitative analysis; racial segregation; social network; Social networks; social segregation; Social Segregation; terminal care; Terminal Care; United States; very elderly; Washington; Washington [District of Columbia]
• Online Access: View Fulltext in Publisher

 Racial disparities in the end-of-life treatment of patients are a well observed fact of the U.S. healthcare system. Less is known about how the physicians treating patients at the end-of-life influence the care received. Social networks have been widely used to study interactions with the healthcare system using physician patient-sharing networks. In this paper, we propose an extension of the dissimilarity index (DI), classically used to study geographic racial segregation, to study differences in patient care patterns in the healthcare system. Using the proposed measure, we quantify the unevenness of referrals (sharing) by physicians in a given region by their patients' race and how this relates to the treatments they receive at the end-of-life in a cohort of Medicare fee-for-service patients with Alzheimer's disease and related dementias. We apply the measure nationwide to physician patient-sharing networks, and in a sub-study comparing four regions with similar racial distribution, Washington, DC, Greenville, NC, Columbus, GA, and Meridian, MS. We show that among regions with similar racial distribution, a large dissimilarity index in a region (Washington, DC DI = 0.86 vs. Meridian, MS DI = 0.55), which corresponds to more distinct referral networks for black and white patients by the same physician, is correlated with black patients with Alzheimer's disease and related dementias receiving more aggressive care at the end-of-life (including ICU and ventilator use), and less aggressive quality care (early hospice care). © 2019 Elsevier Ltd