Using the Kitagawa Decomposition to Measure Overall-and Individual Facility Contributions to-Within-facility and Between-facility Differences Analyzing Racial and Ethnic Wait Time Disparities in the Veterans Health Administration

Background:Identifying whether differences in health care disparities are due to within-facility or between-facility differences is key to disparity reductions. The Kitagawa decomposition divides the difference between 2 means into within-facility differences and between-facility differences that are measured on the same scale as the original disparity. It also enables the identification of facilities that contribute most to within-facility differences (based on facility-level disparities and the proportion of patient population served) and between-facility differences. Objectives:Illustrate the value of a 2-stage Kitagawa decomposition to partition a disparity into within-facility and between-facility differences and to measure the contribution of individual facilities to each type of difference. Subjects:Veterans receiving a new outpatient consult for cardiology or orthopedic services during fiscal years 2019-2021. Measures:Wait time for a new-patient consult Methods:In stage 1, we predicted wait time for each Veteran from a multivariable model; in stage 2, we aggregated individual predictions to determine mean adjusted wait times for Hispanic, Black, and White Veterans and then decomposed differences in wait times between White Veterans and each of the other groups. Results:Noticeably longer wait times were experienced by Hispanic Veterans for cardiology (2.32 d, 6.8% longer) and Black Veterans for orthopedics (3.49 d, 10.3% longer) in both cases due entirely to within-facility differences. The results for Hispanic Veterans using orthopedics illustrate how positive within-facility differences (0.57 d) can be offset by negative between-facility differences (-0.34 d), resulting in a smaller overall disparity (0.23 d). Selecting 10 facilities for interventions in orthopedics based on the largest contributions to within-in facility differences instead of the largest disparities resulted in a higher percentage of Veterans impacted (31% and 12% of Black and White Veterans, respectively, versus 9% and 10% of Black and White Veterans, respectively) and explained 21% of the overall within-facility difference versus 11%. Conclusions:The Kitagawa approach allows the identification of disparities that might otherwise be undetected. It also allows the targeting of interventions at those facilities where improvements will have the largest impact on the overall disparity.