Yang Sherry, Santacroce Leah, Collins Jamie E, Feldman Candace H
Harvard Medical School, Harvard University, Cambridge, MA, USA; Harvard Kennedy School of Government, Harvard University, Cambridge, MA, USA.
Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA.
Lancet Rheumatol. 2025 Jan;7(1):e33-e43. doi: 10.1016/S2665-9913(24)00235-2. Epub 2024 Nov 19.
Structural racism lies at the root of inequities; however its impact on rheumatology care is understudied. Redlining was a US federal government-sponsored practice that mapped areas with high concentrations of Black and immigrant residents as hazardous for investment. We aimed to investigate the association of historical redlining and present-day racialised economic segregation, on health-care utilisation among individuals with rheumatic conditions in the US state of Massachusetts and surrounding areas.
This retrospective observational cohort study used multihospital data from the Mass General Brigham Research Patient Data Registry to identify individuals aged ≥ 18 years living in Massachusetts and surrounding areas, with two or more International Classification of Diseases codes for a rheumatic condition. Individuals were included if they received care between Jan 1, 2000, and May 1, 2023, at rheumatology practices affiliated with Mass General Brigham (Boston, MA, USA). Addresses were geocoded and overlaid with 1930s Home Owners' Loan Corporation (HOLC) redlining files. The Index of Concentration at the Extremes (ICE) for combined racial and income polarisation was constructed from US Census data. We used multilevel, multinomial logistic regression models to examine the odds of health-care utilisation separately by historical HOLC grade (A [best] to D [hazardous]) and ICE quintile (most deprived [1] to most privileged [5] race and income), adjusting for demographics, insurance, and comorbidities. People with lived experience of a rheumatic condition were not involved in the design or implementation of this study.
The cohort comprised 5597 individuals; 3944 (70·5%) of 5597 patients were female, 1653 (29·5%) were male, 657 (11·7%) were Black, 224 (4·0%) were Hispanic, and the median age was 63 (50-73) years. 1295 (23·1%) of 5597 individuals lived in the most historically redlined areas (HOLC D) and 1780 (31·8%) lived in areas with the most concentrated present-day racialised economic deprivation (ICE quintile 1). Individuals in historically redlined areas (HOLC D) had greater odds of having four or more missed appointments (odds ratio [OR] 1·78 [95% CI 1·21-2·61]; p=0·0033) and of three or more emergency department visits (2·69 [1·48-4·89]; p=0·0011) compared with those in the most desirable neighbourhoods (HOLC A). Individuals in areas with highly concentrated racial and economic deprivation (ICE quintile 1) had greater odds of four or more missed appointments (OR 2·11 [95% CI 1·65-2·71]; p<0·0001) and of three or more emergency department visits (2·97 [2·02-4·35]; p<0·0001) versus those in areas with highly concentrated privilege (ICE quintile 5).
Historical redlining could be a structural determinant of inequities in present-day health-care utilisation patterns. Policy interventions that dismantle structural racism could reduce inequities in access to care for individuals with rheumatic conditions.
Bristol Myers Squibb Foundation.
结构性种族主义是不平等现象的根源；然而，其对风湿病护理的影响尚未得到充分研究。红线划定是美国联邦政府发起的一项做法，将黑人和移民居民高度集中的地区划定为投资危险区。我们旨在调查历史上的红线划定和当今的种族化经济隔离与美国马萨诸塞州及周边地区风湿病患者医疗保健利用之间的关联。
这项回顾性观察队列研究使用了麻省总医院布莱根妇女医院研究患者数据登记处的多医院数据，以识别居住在马萨诸塞州及周边地区、年龄≥18岁且有两个或更多风湿病国际疾病分类代码的个体。如果个体在2000年1月1日至2023年5月1日期间在麻省总医院布莱根妇女医院（美国马萨诸塞州波士顿）附属的风湿病诊所接受治疗，则纳入研究。对地址进行地理编码，并与20世纪30年代房主贷款公司（HOLC）的红线划定文件进行叠加。根据美国人口普查数据构建极端集中度指数（ICE），用于衡量种族和收入两极分化的综合情况。我们使用多级多项逻辑回归模型，分别按历史HOLC等级（A[最佳]至D[危险]）和ICE五分位数（最贫困[1]至最特权[5]的种族和收入）来检验医疗保健利用的几率，并对人口统计学、保险和合并症进行了调整。有风湿病实际经历的人未参与本研究的设计或实施。
该队列包括5597名个体；5597名患者中，3944名（70.5%）为女性，1653名（29.5%）为男性，657名（11.7%）为黑人，224名（4.0%）为西班牙裔，中位年龄为63（50 - 73）岁。5597名个体中，1295名（23.1%）生活在历史上红线划定最严重的地区（HOLC D），1780名（31.8%）生活在当今种族化经济剥夺最集中的地区（ICE五分位数1）。与最理想社区（HOLC A）的个体相比，历史上红线划定地区（HOLC D）的个体错过四次或更多预约的几率更高（优势比[OR]1.78[95%CI 1.21 - 2.61]；p = 0.0033），急诊就诊三次或更多次的几率也更高（2.69[1.48 - 4.89]；p = 0.0011）。与特权高度集中地区（ICE五分位数5）的个体相比，种族和经济剥夺高度集中地区（ICE五分位数1）的个体错过四次或更多预约的几率更高（OR 2.11[95%CI 1.65 - 2.71]；p < 0.0001），急诊就诊三次或更多次的几率也更高（2.97[2.02 - 4.35]；p < 0.0001）。
历史上的红线划定可能是当今医疗保健利用模式不平等的一个结构性决定因素。消除结构性种族主义的政策干预措施可以减少风湿病患者在获得护理方面的不平等。
百时美施贵宝基金会。
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