The following viewpoint grew out of my Alan Merry Oration titled “Towards Equity” at the 2022 NZSA/ASA Combined Scientific Congress in Wellington, New Zealand.
The assessment of New Zealand (NZ) patients for anesthetic risk involves an extra dimension – the extent to which anesthetic risk may be affected by the patient’s ethnicity. Māori (indigenous New Zealanders) have greater vulnerabilities than Pākehā (New Zealanders of European descent).
The reasons for this phenomenon are not yet fully understood, but they can be illustrated by the example of Mr. X, an 85-year-old Māori man who presented for anesthesia for an elective colorectal resection. He was diagnosed with colorectal cancer after presenting with iron deficiency anaemia, which was subsequently corrected. His anesthesiologist then assessed him as ASA Physical Status 4, based on his hypertension, type 2 diabetes, and controlled heart failure.
As part of his preanesthesia assessment, his mortality risk was calculated using the NZRisk calculator (asamonitor.pub/3PRibqO):
- As Mr. X is Māori, his 30-day all-cause mortality would be estimated at 11%.
- If he were of NZ European ethnicity, it would be estimated at 6.8%.
That is, being Māori, Mr. X would be at risk of a significantly worse outcome. This is independent of clinical risk factors, including age, comorbidities, and whether presenting electively or acutely.
While we accept that clinical factors will affect health care outcomes, considerations of equity mean that those other factors, including ethnicity, socioeconomic status (SES), domicile, and their interaction with each other, should have a negligible effect (asamonitor.pub/3PRibqO). Sadly, as noted above, that is not so in NZ.
Using nationally collected data from NZ, Perioperative Mortality Review Committee (POMRC) review of mortality after acute laparotomy has shown that, after age standardisation, the Māori mortality rate is about 60% greater than non-Māori, with only 25% of that difference being accounted for by comorbidities. Māori have an earlier age of disease onset, a greater burden of disease, and 21% more laparotomies at a younger age (approximately 10 years). Māori were 40% more likely to have presented to the ED in the 90 days before their operation, potentially indicating inequity in access to appropriate treatment (asamonitor.pub/3F6RjOg).
POMRC data on consequences for those hospitalized after major trauma, who often require operations, show similar effects, with increased mortality for Māori, and with Māori being 30% less likely to receive a CT scan even after adjustment for other relevant factors, an indication of different care being delivered (asamonitor.pub/46H2hGd).
Gurney et al. showed regional variation in both postoperative mortality and differences in mortality between Māori and NZ Europeans (ANZ J Surg 2022;92:1015-25). Haynes et al. showed geographical inequalities in cancer survival, with those living rurally having worse outcomes for some cancers (Soc Sci Med 2008;67:928-37).
POMRC demonstrated the effect of SES on perioperative outcomes, after allowing for the other clinical and nonclinical variables – compared with the least deprived 20% of the population, the most deprived 20% were more likely to be admitted to the hospital, had 14% more elective admissions, had twice as many acute admissions, and were more likely to have an operation after acute admission. Those in the most deprived quintile, if also Māori, were 16% more likely to die after adjusting for clinical and other sociodemographic factors, noting that 41% of Māori live in the most deprived quintile, and only 9% live in the least deprived quintile (asamonitor.pub/3RNKJE3).
An example from the wider context of health care is the difference in health outcomes with the recent pandemic in age-standardized mortality for COVID-19 for the different ethnicities and different levels of poverty in NZ. Māori mortality is 2.2 times that of NZ European/other, and Pacific people’s mortality is 2.8 times that of NZ European/other. Considering poverty (or SES), the most deprived fifth of our population are 3.6 times more likely to die of COVID than the least deprived fifth of our population (asamonitor.pub/3Q3LCa7). Age standardization is used because of different age structures of the different ethnic populations in NZ. This reflects life expectancy, with Māori life expectancy at 77.1 years for females and 73.4 years for males, compared with 83.5 and 80, respectively, for the whole population (asamonitor.pub/3ZIXPUW).
Even though NZ had one of the lowest death rates with COVID-19 in the world, in many settings, COVID-19 exacerbated nonclinical differences in outcomes (Lancet 2023;402:1037-8). These differences were seen across all health care, and this is the background against which we deliver perioperative care.
In NZ, perioperative care is delivered by a mix of public and private health care institutions, with a greater proportion of acute and complex care being publicly funded. The NZ health strategy has two long-term aims: to achieve health equity for NZ’s diverse communities and to improve health outcomes for all New Zealanders (asamonitor.pub/46gmZg1). As part of their aim to minimize inequitable outcomes in health care, the Ministry of Health has stated: “People have differences in health that are not only avoidable but unfair and unjust. Equity recognizes different people with different levels of advantage require different approaches and resources to get equitable health outcomes” (asamonitor.pub/3ttFP4M). This concept acknowledges that not only are differences in health status unfair and unjust, they are also the result of differential access to the resources necessary for people to lead healthy lives. Contrasting equality with equity, equality is treating people the same while equity is treating people according to their individual needs.
While measuring those differences is the first and very necessary step, the real “gold” is in understanding why those inequities exist and taking the actions to minimize them. Some causes will be systemic, such as medical treatment being based in the dominant middle-class culture and worldview (for ethnicity-based differences, this is sometimes also called systemic racism), and some may be due to intergenerational effects of this or other forms of disadvantage, such as colonization or poverty or the challenges of living remotely from health care services. Our aim should be to make our care as equitable as possible and not to exacerbate those differences.
An important first step is to include the patient’s ethnicity, SE status (if available) and domicile, as well as the usual clinical factors, in all audits of processes and outcomes.
Risk calculators can be a good guide to treatment decisions, providing very welcome and realistic information, as these are based on what has happened to similar patients in the past – but they can also perpetuate inequities. If using risk calculators, the following questions need to be asked: Is the population they are based on relevant to this patient? Does that population base have inequities? If the answer to the second question is yes, then care needs to be exercised in using the results.
Understanding our patient’s culture will allow us to provide more targeted health care. NZ’s medical regulator, the Medical Council of New Zealand, requires physicians to meet cultural safety standards in their practice of medicine (asamonitor.pub/46zLvZq). It may also indicate outcomes important to patients that should be audited. The correct pronunciation of the patient’s name has been highlighted in NZ as very important to Māori, something that should be simple and is indicative of respect for the patient (asamonitor.pub/3td3W7O). A workforce that reflects the population it serves assists in delivering culturally appropriate care; this is close to being achieved for the recent graduating classes from both NZ medical schools (Otago and Auckland) (asamonitor.pub/46ABQBL).
Tailoring services to the patient’s needs can include understanding the patterns of illness in their ethnic group. Recognizing the difference in COVID-19 mortality, Māori or Pacific peoples can get antiviral drugs for COVID-19 at a younger age than non-Māori or non-Pacific peoples (asamonitor.pub/3tm52yg). Similarly, preoperative screening tests such as EKGs are done at a younger age for Māori, given their earlier age of onset and greater prevalence of ischemic heart disease. Tailoring health care to the patient’s culture has also involved working with community groups on initiatives such as influenza and MMR vaccination campaigns, community responses to COVID-19, and strong partnerships between Iwi (tribes) and local health providers. In some public hospitals, Māori and Pacific health navigators are available to support patients through complex perioperative pathways.
Te Aka Whai Ora, the Māori Health Authority, has recently been established to enable a more coordinated response for Māori; however, NZ is about to have a general election after this is written, but before it will be read, with Te Aka Whai Ora’s establishment a contested topic (asamonitor.pub/46EBeuW).
Mitigating the effect of poverty on health outcomes is multifactorial, with many influences such as housing being outside health care. Ensuring unfair demands are not placed on those with limited financial means, such as multiple attendances at clinics, is a “work in progress.”
The establishment of one unified health authority for all of NZ (Te Whatu Ora Health New Zealand) aims to deliver consistent health care across the nation and minimize the risks of “post code lottery” (asamonitor.pub/46gnDKt). However, as it’s been very recently established, NZ is still awaiting the results of this significant restructuring of our publicly provided health care.
NZ has embarked on a pathway to minimize inequities in health care and improve care for all. While we still have a long way to go, we have at least started. If we succeed, then we hope that future Mr. Xs will not face the same disparities.