Health Care Disparities Affecting Regional Anesthesia Identified

Patients of color and individuals on Medicaid have consistently lower odds for receiving neuraxial anesthesia and peripheral nerve blocks than their counterparts.

Well founded in other specialties of medicine, care disparities that are based on race and socioeconomic status also exist in the delivery of anesthesia care, new research has shown.

“Although we know from other medical specialties that disparities do exist, anesthesia doesn’t have much of a track record in this area,” said Crispiana Cozowicz, MD, a research fellow at the Hospital for Special Surgery, in New York City. “And with evidence mounting that regional anesthesia can have an impact on postoperative outcomes, it’s interesting to look at how anesthesia practice is actually distributed among various patient populations.”

With that in mind, the investigators aimed to see whether the use of either neuraxial anesthesia or peripheral nerve block differs according to patient or certain hospital factors. Patient factors included age, race, sex and insurance type; hospital factors were size, location and teaching status. “Our hypothesis,” she said, “was that disparities do, indeed, exist.”

Dr. Cozowicz and her colleagues turned to the claims-based Premier Perspective database to extract data from 1,062,152 hip and knee arthroplasty procedures from 540 hospitals nationwide. Both univariate analyses and multilevel multivariate logistic regression models were used to measure associations between patient and hospital factors and either neuraxial anesthesia or peripheral nerve block use.

Large Database

At the 2015 annual meeting of the American Society of Anesthesiologists (abstract A2098), Dr. Cozowicz revealed that 22.2% of patients in the cohort (n=236,083) received a neuraxial anesthetic, while 17.9% (n=189,732) received a peripheral nerve block. Perhaps not surprisingly, the use of neuraxial anesthesia declined slowly between 2006 and 2013 (23.6% to 19.6%); over the same period, peripheral nerve blocks increased sharply (13.3% to 19.5%; P<0.0001).

Univariate analysis found that age (higher odds with increasing age), race (lower odds for blacks and Hispanics) and insurance type (lower odds for Medicaid patients) were all significantly associated with receiving neuraxial anesthesia or peripheral nerve block. Of interest, hospital factors also showed strong associations, the strongest one being for teaching hospitals (vs. nonteaching hospitals) eschewing neuraxial anesthesia (odds ratio [OR], 0.57; 95% CI, 0.57-0.58; P<0.0001).

“When we looked at the multivariate regression analysis, we found black patients have lower odds to receive neuraxial anesthesia versus white patients [OR, 0.83-0.92],” Dr. Cozowicz said. “Furthermore, patients on Medicaid, Medicare and uninsured patients all had lower odds to receive neuraxial anesthesia compared to those on commercial insurance [OR, 0.79-0.91].” The same was true for peripheral nerve blocks. “We saw that this is even more pronounced in Hispanic populations,” she said. Indeed, the OR for Hispanics to receive peripheral nerve blocks was 0.27 to 0.64.

These findings, Dr. Cozowicz discussed, may unnecessarily put certain patient populations at risk for worse outcomes. “There is mounting evidence suggesting that outcomes can be improved by choosing neuraxial anesthesia and peripheral nerve blocks,” she said. “Some researchers have even shown mortality to be lower in patients who had received regional anesthesia. So in view of this evidence, it’s unfortunate if these trends prove true.”

More Research Needed

Now that these disparities have been identified, the investigators acknowledged that further research is necessary, if only as a stepping stone toward equal care for all. “We believe that these data are important and show that we should do more research to find out if others see the same patterns,” Dr. Cozowicz added. “Then we need to see if we can tease out the reasons for the disparities, and implement strategies to counter them.”

According to Kasey Fiorini, MD, assistant professor of anesthesiology at The Ohio State University Wexner Medical Center, in Columbus, disparities in care are well documented in several medical specialties. “Dr. Cozowicz and her colleagues have demonstrated that disparities based on age, insurance type, race and ethnicity may exist in anesthesiology as well, and identifying disparities in anesthesiology practice is an important first step,” she said.

“However, further research is needed to determine the source of this variation in practice,” Dr. Fiorini continued. “Variation may be provider driven, as hypothesized by the authors, or it may be patient driven, as certain patient groups may be less likely to accept neuraxial anesthesia or peripheral nerve blockade. If this is the case, taking time to build trust and educate at-risk patients during the preoperative assessment and consent process will be particularly beneficial.”