A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
Health disparities affecting minority and vulnerable populations are increasingly well-recognized after the disproportionate impacts of the COVID-19 pandemic. Across a large number of quality metrics, the Agency for Healthcare Research and Quality’s latest National Healthcare Quality and Disparities Report found that Blacks, American Indians, Alaskan Natives, and Hispanics receive overall worse medical care than white patients. Additionally, a recent report by the Commonwealth Fund demonstrated the persistence of these racial and ethnic disparities across geographic regions in the United States.
Well-described examples of health disparities include a higher maternal mortality rate among Black women, more advanced stages of disease in minority patients at the time of presentation, and the adverse effects of food insecurity on children’s health. In the surgical and perioperative setting, Black patients are more likely to receive surgical care at lower-quality hospitals and have higher mortality rates after many common surgical procedures. A study using the New York State Perinatal Database found that Black and Hispanic women in labor are less likely to receive epidural analgesia than white women. The causes of disparities in obstetric anesthesia are multifactorial. Cultural preferences, patient knowledge about anesthesia, type of insurance, availability of anesthesia services in the hospital, and obstetric provider selection are among the possible causes.
Potential sources of disparities in anesthetic care include language barriers and differences in health literacy and education efforts, which may affect preoperative planning in the weeks leading up to surgery. While we may believe we are delivering standard anesthetic care to all patients, recognizing that systemic prejudice can drive differences in the perioperative care of minority patients makes perioperative health disparities an important and intervenable patient safety issue.
Medical societies and public health advocates have identified the long history of structural racism as one of the potential mechanisms underpinning these health care disparities. Building more equity and bridging the health gap in underserved communities should be a key priority for stakeholders in the health care system.
In January 2021, President Biden signed Order 13985 to advance racial equity and federal support for underserved communities. The Center for Medicare and Medicaid Services (CMS) proposed policies to advance health equity and maternal health care in alignment with this goal. The first CMS-proposed health equity measure evaluates hospitals in five domains: strategic planning, data collection, data analysis, quality improvement, and leadership engagement. Specifically, CMS is adopting measures to evaluate hospital commitment to health equity, screening for social drivers of health, and inpatient malnutrition care. One of these measures is the Hospital Inpatient Quality Reporting Program, which aims to collect quality data from hospitals and share it with the public to collaborate with consumers’ decision-making and improve patient care. Failure to comply with the reporting requirements of the Hospital Inpatient Quality Reporting Program will negatively impact hospital reimbursement. Finally, beginning in fall 2023, CMS will award hospitals participating in equity-focused measures a new designation called “Birthing-Friendly,” as a publicly reported indicator of safe and high-quality maternity care.
The fact that the government and public and private institutions are placing a spotlight on structural inequities and prioritizing health equity is an invaluable step towards mitigating health disparities. While these efforts continue at the system level, they offer an opportunity for physicians to reflect on their personal practice working in the perioperative domain.
Other initiatives to mitigate health disparities at a clinician level include recognition of personal bias, participation in continuing education about health disparities, engagement in community outreach initiatives, and advocacy for health equity at the legislative level. At the system level, institutions and hospitals need to create a culture of equity, provide health equity training, encourage health equity initiatives in the research and clinical field, promote governance that supports health equity, and provide financial incentives for measures that are linked to health equity.
While it is still too soon to evaluate the impact of the new CMS health equity measures on patients’ health outcomes, we expect that the new measures will provide a strong incentive to advance health equity in the nation.
Lilibeth Fermin and Govind Rangrass are anesthesiologists.
