Health care disparities are prevalent, multifaceted, and have been shown to exist in all medical and surgical specialties, including anesthesiology (Anesth Analg 2018;126:588-99; Anesthesiology 2023;138:587-601). The Agency for Healthcare Research and Quality (AHRQ) defines disparities as a difference or gap that exists between two groups that is statistically significant, greater than 10%, and indicates poor quality care for the minority group. Disparities relate to the principle of justice and to the balance between the personal needs of the patient and societal resources, including the fair distribution of goods (that are in short supply) in society, and the role of entitlements (Beauchamp et al.). In March 2002, the Institute of Medicine (IOM) published, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” which documented a consistent body of research underlying significant variation in the rates of medical procedures by race. This report highlighted the fact that racial and ethnic minorities are less likely to receive even routine medical procedures and that they experience a lower quality of health services. Unfortunately, 20 years later, health care disparities (and disparities in society) are still pervasive. This tragic reality is illustrated by the Black-White maternal mortality and severe maternal morbidity gap, researched anesthesia-specific differences in care (as identified in anesthesia procedure times, use of blood transfusions, neuraxial or regional anesthesia use, intraoperative medication utilization), and high-profile, tragic, police-related deaths as reported by the national media (asamonitor.pub/3LVzx4i). Herein, in this article, we highlight anesthesia-specific disparities of care, the concepts of health care equity and justice, and steps needed to achieve health care equity and justice.
Our recent Anesthesiology study, “Antiemetic Administration and Its Association with Race: A Retrospective Cohort Study,” involved 5.1 million anesthetic cases from 39 Multicenter Perioperative Outcomes Group (MPOG) institutions located in the U.S. and the Netherlands. It demonstrated that Black patients were less likely to receive antiemetic administration with either ondansetron or dexamethasone than White patients (Anesthesiology 2023;138:587-601). This difference persisted even when adjusted for hospital-, procedure, and patient-level cofounders such as the four chief Apfel simplified risk score factors for postoperative nausea and vomiting (PONV), such as sex, smoking status, history of postoperative nausea, vomiting or motion sickness, and use of postoperative opioids. This implies that the found differences are not explained by a difference in the likelihood of PONV risk factors between Black and White patients. Management of PONV prophylaxis has widely accepted explicit consensus guidelines that are specific and based upon measurable risk factors. PONV is treated with medications that are inexpensive and widely available, with few contraindications. This puts much of the onus of decision-making (and the introduction of bias) on individual anesthesiologists (Anesthesiology 2023;138:587-601). Disparities in antiemetic administration matter and are a formative measure of anesthesia quality. PONV is a patient-centered outcome measure and is associated with increased length of postanesthesia care unit stay, unplanned hospital admissions, and greater resource utilization (Anesthesiology 2023;138:587-601; Anesth Analg 2020;131:411-8). Further, we posit that PONV administration can be construed as a reflective measure of overall anesthesiologist perioperative process inequality.
While all anesthetic care deserves reflection and improvement concerning health care disparities and promotion of equity, a major public health focus for several years has been addressing the unparalleled maternal morbidity and mortality crises in which Black mothers die at rates two to four times higher than White mothers. Maternal mortality consistently ranks among the top causes of death among women aged 20-44 years in the U.S. Unlike other high-resourced countries where rates have remained the same or declined, the U.S. maternal mortality rate has steadily increased since the 1990s (asamonitor.pub/3Fhz9cF). Maternal mortality due to anesthesia-related complications (the lowest reported cause of maternal mortality) was 0.4%; however, there are still disparities in obstetrical anesthesia care provision that could influence overall outcomes. One disparity includes differential use of neuraxial analgesia for vaginal delivery, with Black women more likely to deliver without neuraxial analgesia (neuraxial analgesia for labor has been associated with reductions in postpartum hemorrhage and severe maternal morbidity). Another is related to differential use of neuraxial versus general anesthesia use for cesarean delivery, with Black women more likely to receive general anesthesia (the use of potentially avoidable general anesthesia has been associated with an increased risk of anesthesia-related complications, surgical site infection, and venous thromboembolism).
Disparities in the management of obstetrical anesthesia-associated complications such as postdural puncture headache exist. Postdural puncture headache (PDPH) is the most prevalent adverse outcome associated with labor neuraxial procedures. A cross-sectional study of New York State mothers from 1998 to 2016 by Lee et al. found lower use of epidural blood patch (EBP) in the treatment of PDPH among Black (36%) and Hispanic (41.7%) mothers compared to non-Hispanic White mothers (53%), as well as delayed timing in administration of EBP among Black and Hispanic mothers. Median timing of EBP for White mothers was two days, compared with Black and Hispanic mothers, who had a median of three days. Of note, patient preferences, refusal of treatment, clinician bias, and language barriers were not assessed in this study. Consequently, it is unclear whether these additional factors may help explain the association between race/ethnicity and PDPH management (Pain Manag 2023;13:415-22; JAMA Netw Open 2022;5:e228520).
Drivers of health care disparities are structural racism, differences in community and patient-level social determinants of health, and health care system/provider personalized implicit bias and racism toward individual patients (N Engl J Med 2021;384:768-73; Lancet 2017;389:1453-63; Obstet Gynecol 2021;137:220-4). Structural racism is the systemic and institutionalized perpetuation of racial group inequity through public policies, institutional practices, cultural representations, and other norms that perpetuate racial group inequities; examples include the practice of redlining, differential societal spending on neighborhood-specific health care resources, and differential incarceration policies and racial bias in the justice system. Anti-Black structural racism has been linked to poorer health for Black patients, as demonstrated by racial and ethnic disparities in age-adjusted cardiovascular disease mortality rates (Circulation 2020;142:e454-e68). The Centers for Disease Control and Prevention defines social determinants of health as the conditions 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. Social determinants of health can be clustered by an individual’s identity (race or ethnicity, gender, sex), socioeconomic status (wealth, insurance status, immigration status), and geography (neighborhood built environment), demonstrating intersectionality, and are predisposed by one’s socioeconomic position and the national or local political context that they live under (asamonitor.pub/46DhBU2). Intersectionality is the interconnected nature of social categorizations as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage. Implicit bias is the influences, attitudes, or stereotypes toward minoritized racial and ethnic groups that affect health care professionals’ understanding, actions, and decisions in an unconscious manner, and has been linked to poorer patient care provision. Health care bias and stereotyping has been reinforced with race-based medicine, where race is considered a biological variable that can be linked to a disease process. More recently, race-conscious medicine has been proposed where race is used as a social and power construct that contributes to health care bias and stereotyping.
The CDC defines health equity as a state in which everyone has a fair and just opportunity to attain his or her highest level of health (asamonitor.pub/3PLBEJr). Health equity is the value underlying a commitment to reduce and ultimately eliminate preventable health disparities. This includes addressing structural racism, social determinants of health, and health care disparities. Individuals must receive the necessary tools to overcome economic, social, and other barriers to accessing health care and achieving good health. Health care justice advances this concept as it seeks to identify and remove existing health care barriers and incorporates the dismantling of political, structural, and economic barriers to health and health care (modifying or eliminating policies that facilitate housing discrimination, neighborhood built disparities, or transportation instability) (asamonitor.pub/3LVzx4i; Circulation 2020;142:e454-e68; asamonitor.pub/46DhBU2; J Law Med Ethics 2022;50:656-62; Am J Public Health 2011;101:S149-55).
Anesthesiologists can advance health equity and justice and mitigate health care disparities at a clinician and system level (asamonitor.pub/3LLCx3n). Nevertheless, to achieve lasting, widespread change, it is required that interventions are multlevel and address structural barriers at site-specific, local, and national levels. Approaches should confront and bring explicit visibility to structural racism and macrosocial factors, hospital structural characteristics, and patient-specific risk factors. Many medical societies and organizations, including ASA, the American Heart Association, and the American College of Surgeons, have taken steps to publicly acknowledge the impact of structural racism and inequality and include calls for advocacy (Anesth Analg 2018;126:588-99; asamonitor.pub/3LVzx4i; Circulation 2020;142:e454-e68; asamonitor.pub/3tjtj83). As individuals, clinicians can recognize and work to change personal implicit bias, pursue continuing education and training to learn about health disparities and cultural humility, participate in neighborhood outreach initiatives, and perform national and legislative advocacy for health equity and justice. When evaluating racial health disparities, physician-scientists should perform race-conscious medicine by interpreting race as a manifestation of structural and individual racism rather than a genetic susceptibility (outdated and misguided race-based medicine that characterizes race as a biological variable). For studies, primary data direct measurement of racism and discrimination should be incorporated when comparing racialized groups (Ann Fam Med 2022;20:157-63). For secondary data studies, researchers should avoid collapsing ethnic groups into heterogeneous categories, as each individual ethnic group’s experiences of racism are different. Consideration and justification for reference group selection should be performed and not automatically defaulted to White. To achieve health equity, researchers should implement new study strategies to estimate the impact of racism on health outcomes and provide ways to dismantle it.
Large and small health care systems can provide health equity training and education; can foster a culture of equity that promotes health equity research, clinical work (use of care coordination, quality assurance practices, standardized evidence-based care), and financial incentives; and measure health equity at the patient and provider level. Health systems can increase provider and staff diversity through hiring and retention policies that ensure appropriate racial, ethnic, and language concordance with the populations they serve. Health care systems need to emphasize cultural humility over cultural competency. Cultural competency infers cultural issues and representations of patients from different racial and ethnic backgrounds into stereotypical portrayals (practicing race-based medicine) and overlooks individual beliefs within group systems (Obstet Gynecol 2018;131:1162-3). Cultural humility views culture as not a skill to be mastered but as a continuous career-spanning learning process. Legislation can expand insurance coverage adoption; provide additional nutritional, housing, and transportation assistance; address unequal hospital funding; and can set policies that promote growth and diversity of the health workforce and advance research.
Health care disparities are widespread and multifaceted and are associated with systemic racism and social determinants of health. Anesthesiologists are patient safety advocates. As such, we should have an increased interest in addressing and mitigating disparities. Much work remains to be done to achieve health care equity and justice. Providers and health care organizations should be alert for disparities and use all resources to address them. Health care disparities do not need to be permanent.