Anesthesiologists as Leaders in Health Equity

I know there will be some anesthesiologists reading this article thinking, “Why should I be concerned about advancing health equity? Isn’t this a problem for primary care physicians and policymakers?” The moral and ethical obligations of addressing inequities are obvious and are consistent with the values and mission of most organizations. Moreover, quality and patient safety are at the core of our specialty.

In 1983, at a scientific symposium attended by various stakeholders, presenters discussed the morphology and teleology of anesthetic accidents. Recognizing the potentially immense loss of life and danger posed by anesthesia, an agreement was forged to share statistics and to define the parameters of future studies to promote safety under anesthesia. A year later, the Anesthesia Patient Safety Foundation (APSF) was born – a foundation with the mission to ensure “that no one shall be harmed by anesthesia care” (asamonitor.pub/3LQYPkd). The APSF seeks to improve safety by fostering investigations that will provide a better understanding of preventable anesthetic injuries, encouraging programs that will reduce the number of anesthetic injuries, and promoting national and international information and ideas about the causes and prevention of anesthetic morbidity and mortality (asamonitor.pub/3tmqm6V). Similarly, several reports have brought to light the potential serious morbidity that directly results from health inequities (Curr Anesthesiol Rep 2023;13:108-16). A recent Statement on Quality Metrics from the ASA Committee on Obstetric Anesthesia included equity (providing care that does not vary in quality because of personal characteristics) as a domain within quality (asamonitor.pub/46p6Bdg). This Statement on Quality Metrics is consistent with a recent article in JAMA Network titled “Equity and Quality – Improving Health Care Delivery Requires Both” (JAMA 2022;327:519-20).

In anesthesiology, quality is a top priority, but health equity has not been widely prioritized. We maintain that there is no quality without equity and no equity without quality (JAMA 2022;327:519-20). Additionally, there is a hefty financial burden associated with health inequities; a recent study found that health inequities in 2018 cost nearly $1 trillion (JAMA 2023;329:1682-92).

The Centers for Disease Control and Prevention (CDC) defines health equity as “the state in which everyone has a fair and just opportunity to attain their highest level of health” (asamonitor.pub/3rHefkk). There are widespread inequities within perioperative medicine; rural populations, populations with low socioeconomic status, and racial and ethnic minority populations have less access to quality health care services (Surgery 2018;163:243-50). Despite access to health care services, there is differential management by patient demographics (Am J Cardiol 2022;185:46-52). Patients with limited English proficiency also have worse perioperative outcomes, likely due to poor communication with the medical team (JAMA Netw Open 2023;6:e2322743).

Strategies that have been put forth to advance health equity include diversifying the medical workforce, ensuring an equity lens, and addressing medical mistrust. While these are worthy goals, there are other tangible steps that must be taken to improve health equity in perioperative medicine. The American Medical Association’s Declaration of Professional Responsibility encourages physicians to “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being” (asamonitor.pub/3PDUySi). Physicians, our specialty societies, and the institutions that employ us can do better by strongly advocating and implementing strategies to reduce health inequities within and outside of health care systems.

To bring about sustainable, measurable change, we must elevate health inequities to the same standards we have for patient safety and quality, which might be achieved by the following:

1. Charge a governing body – A designated governing body should be charged with the mission of annihilating health inequities. This governing body should be awarded resources to investigate and identify opportunities for improvement, set tangible standards, and implement them throughout perioperative medicine. Just as ASA advocates for patient safety and quality, we should be working with our lobbyists to identify opportunities to advocate for equitable care for our patients.
2. Delineate standards in educating the medical workforce on diversity – As we work to diversify our medical workforce, we should ensure our existing workforce has the tools, resources, and education to manage and communicate with diverse patients. This includes identifying unconscious biases and unconscious bias training. Training for cultural agility can also help anesthesiologists care for diverse patients. All of these strategies should help improve patient-clinician communication; patients with limited English proficiency, female patients, older patients, and patients from racial and ethnic minority populations generally rate worse patient-clinician communication, and studies have found that some of those same patient populations receive less empathy and less time for relationship-building during clinical encounters (Patient Educ Couns 2006;62:355-60). We need to ensure that we spend the appropriate amount of time communicating with these patient populations so that everyone has a fair and just opportunity to attain their highest level of health (asamonitor.pub/3rHefkk).
3. Develop an equity lens – To effectively and efficiently advance equity, it is essential to have a health equity lens (asamonitor.pub/3ROm966); Xavier Becerra, Secretary of the Department of Health and Human Services, describes this as equity by design – we must be intentional about efforts to advance equity. In the absence of intentional efforts, the status quo will remain in place. When decisions and policies are created, we need the right people at the table and insight on how the policies will perpetuate or address inequities; this requires disaggregating data and not focusing only on the majority population or group. Several studies have examined trends in opioid overdose deaths, and when data were disaggregated, a misclassification of opioid-involved overdose was noted for Black and Hispanic individuals, which may have limited preventive services and led to an increase in opioid-involved overdose deaths in those populations; a similar misclassification has been noted for suicide and may explain the suicide paradox (Am J Public Health 2021;111:1627-35; Addiction 2021;116:677-83; BMC Psychiatry 2010;10:35). This health equity lens is important for the workplace as well as for policies and procedures related to perioperative medicine.
4. Establish action plans to address social determinants of health – Social determinants of health (SDoH) are defined “as conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (asamonitor.pub/3F6s0vU). Although SDoH account for a significant portion of the variability in health outcomes by patient demographics, physicians and health care systems have not dedicated resources or time to help patients address their health-related social needs; this will likely change as The Joint Commission and the Centers for Medicare & Medicaid Services are now requiring collection of health-related social needs (asamonitor.pub/3PI4udx; asamonitor.pub/3t53GYl). Our specialty has the opportunity to address SDoH that may impact recovery during the perioperative period. This can happen during preoperative clinic visits by ensuring that patients have reliable transportation for follow-up appointments, resources for medication and equipment following surgery, and access to quality care following surgery. Addressing SDoH can be a form of prehabilitation and will help improve the clinical outcomes of our patients – one of the primary goals of our specialty (Semin Cardiothorac Vasc Anesth 2022;26:295-303). There are also platforms embedded within EMRs that can be used to connect patients with community resources to address SDoH (asamonitor.pub/3tnGJQA).
5. All hands on deck – The burden of advancing health equity is not equitably distributed among anesthesiologists. Overburdened and underrepresented anesthesiologists are often tasked with leading DEI activities without compensation, often described as the “minority tax.” This is concerning as these underrepresented anesthesiologists often receive lower compensation and are less likely to be in leadership positions and higher academic ranks (Anesth Analg 2023;137:268-76; Anesth Analg 2021;133:1009-18; Can J Anaesth 2021;68:272-3). The anesthesiologists engaged in health equity work should be supported and compensated, and this should be a priority of the entire department, not just a few anesthesiologists.
6. Serve as gatekeepers – S. Ramani Moonesinghe, MD, recently published a commentary in Anesthesia & Analgesia titled “The Anesthesiologist as Public Health Physician” (Anesth Analg 2023;136:675-8). In this commentary, Dr. Moonesinghe describes how anesthesiologists can serve as “gatekeepers in the prevention of poor decision-making.” Anesthesiologists can serve as gatekeepers to reduce inequitable care, including canceling cases if patients do not have the resources and support to have a safe and healthy postoperative experience. This also means not being a bystander when inappropriate surgeries are scheduled or when inappropriate monitoring (or lack of monitoring) is used (JAMA Otolaryngol Head Neck Surg 2016;142:584-9).
7. Investigations and innovation in health equity – We need to ensure we are conducting and publishing research to understand barriers to care and opportunities to improve the delivery of safe and equitable care (Anesth Analg 2023;137:722-3). Journals focused on perioperative medicine should have sections dedicated to equitable care and have anesthesiologists with expertise in health equity within their editorial boards and among their reviewers. There should also be research funding to develop innovative interventions to advance health equity. Similarly, there should be resources dedicated to educating our specialty on health inequities.

Anesthesiologists are the leaders in quality and patient safety, and we have an opportunity to be the LEADER in health equity. But we must be intentional, dedicate resources, and prioritize health equity efforts. There is no quality without equity and no equity without quality.

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

– Dr. Martin Luther King Jr.