Health equity has been elusive in the field of medicine for centuries. We are all aware of the impact of the social determinants on health equity (see other articles in this Monitor supplement). These social determinants of health are based on the environmental conditions where people are born, live, learn, age, work, and age (Figure 1). For example, cardiologists have identified that patients from a lower socioeconomic status (SES) undergoing coronary artery bypass grafting surgery have increased morbidity and mortality compared to those from a higher SES. Pediatricians noted that higher parental education is associate with lower childhood mortality compared to those with a lower parental education level. A survey of U.S. adults found that those identifying themselves as sexual preference minorities were more likely to get delayed or did not receive care regardless of cost compared to heterosexuals. As a specialty, anesthesiologists have researched several aspects of health disparities, including access to care and quality of care delivered.
Access to care
Examples of health care disparities due to access to care have been found in the field of anesthesiology. This has been most apparent in chronic pain management, access to epidural analgesia for childbirth, and neuraxial anesthesia for cesarean delivery.
Spinal cord stimulation (SCS) has been found to be advantageous in chronic pain management. In particular, chronic low back pain is one of the syndromes that has benefited from the implantation of these neuromodulary devices. Approximately, 50,000 SCS devices are implanted annually. However, an analysis of Medicare patients who were diagnosed with post-laminectomy syndrome or chronic pain revealed that Black, Asian, Hispanic, and Native North American patients were significantly less likely to receive a spinal cord stimulator compared to White patients. Those patients who are insured by both Medicaid and Medicare (dual-eligible), compared to patients insured only by Medicare, were less likely to receive a spinal cord stimulator.
Obstetrical analgesia/anesthesia has similarly revealed disparities in access to neuraxial techniques for certain groups. An analysis of a perinatal database revealed that White/Hispanics and Black patients were less likely to receive a labor epidural than White patients. In fact, when including insurance type in the analysis, Black patients with private insurance received epidural analgesia at the same rate as White, uninsured patients, which was significantly less frequent than White patients with private insurance. Another study found that, compared to White patients, Black patients were twice as likely to get a general anesthetic versus a neuraxial anesthesia for Cesarean delivery. Some investigations into these disparities have focused on preprocedural issues such as misconceptions, inadequate knowledge/counseling, and use of midwives.
Quality of care
Using data collected through the National Anesthesia Clinical Outcomes Registry (NACOR), it was found that patients living in lower socioeconomic locations were more likely to have an intraoperative cardiac arrest, unplanned intensive care unit (ICU) admission, and intraoperative mortality than those patients in higher socioeconomic status. In addition, patients from lower socioeconomic backgrounds were less likely to have prophylactic anti-emetics administered.
Racial disparities have also been noted in the ICU. The Acute Respiratory Distress Syndrome Clinical Network trial showed that Hispanic patients had a higher mortality rate after acute lung injury and fewer ventilator-free days than White patients. Maternal mortality has been noted to be higher among Black patients than White patients, and uncontrolled hemorrhage has been found to be more common among Native Americans, Asians, and Pacific Islanders.
ASA and CPOM involvement in health equity quality screening and measurement
When considering health equity, it is important to recognize the influence of the Centers for Medicare & Medicaid Services (CMS) when considering any health care reform. CMS is the largest provider of health care in the U.S., driving policy and payment reform and setting standards that influence not only providers but all health care institutions. CMS is prioritizing health equity for the next decade. This is consistent with Executive Order 13985, “Advancing Racial Equity and Support for Underserved Communities Through the Federal Government,” which was signed by President Biden in January 2021. These actions represent very powerful drivers of health care changes that will influence all of us and our specialty.
The CMS Framework for Health Equity outlines five major priorities for advancing health equity in the U.S.17 These are relevant as we begin to address ways to advance anesthesiologists as leaders in overcoming health care disparity (Figure 2).
The first CMS priority is to enhance data collection, and this will begin in 2023 with the introduction of two new measures: Social Drivers of Health (SDOH). The first SDOH measure requires hospitals to attest that they screen inpatients for social drivers of health. The second measure reports the number of patients who screen positive in five distinct areas: food insecurity, housing instability, transportation problems, utility difficulties, and interpersonal safety, which are derived directly from the CMS Accountable Health Communities Model. More opportunities will emerge as CMS introduces new health care equity measures.
New CMS measures focusing on inpatients and individual physician level health equity data are more challenging to collect. For multiple reasons, the current structure of the Merit-Based Incentive Payment System (MIPS) and quality reporting may not reveal disparities. Physicians, including anesthesiologists and their practices, choose which measures to report. These measures often reflect workflows, ease of use, and historical reporting patterns. Furthermore, only 70% of total cases must be reported for MIPS participation, and patient demographic data are not required for reporting a measure. Also, assessing and/or testing for disparities among quality measures is not common. However, the new reporting requirements by CMS on social drivers of health will provide anesthesiologists with the opportunity to partner with their own institutions and explore the presence of social drivers of health in their patient panels. There will be an opportunity to use hospital population data that includes health equity in the foundational data subsets as CMS moves to encourage the development of more MIPS value pathways, or MVPs.
NACOR collects data on anesthesia measures with the Anesthesia Quality Institute. The ASA Committee on Performance and Outcomes Measurement (CPOM) led the initial evaluation of ASA quality measures of two measures for racial health care disparities using NACOR data, specifically MIPS 404 (Anesthesiology Smoking Abstinence Measure) and AQI 56 (Use of Neuraxial Techniques and/or Peripheral Nerve Blocks for Total Knee Arthroplasty). Using patients’ ZIP codes, preliminary findings indicated that disparities exist, although more complete patient records and research are needed before definitively confirming disparities. Specifically, variation in measure performance was at the group/practice level and not related to or statistically significant with racial distribution in select metropolitan areas. This type of analysis will be critical to guide anesthesiologists in the emerging field of health equity quality measures. We look forward to reporting the final analysis of these quality measures in a future committee report.
“The ASA Committee on Performance and Outcomes Measurement (CPOM) is leading the way in the development of an anesthesiology health equity measure.”
Health equity interventions
Although CMS has laid the groundwork to require health equity patient data collection, the bigger question beyond data analysis will be: how can we, as anesthesiologists, impact disparities and promote equity when we are not “in control” of which patients we provide care to, especially in comparison to primary care physicians or our surgical/procedural colleagues? Interestingly, there is increasing evidence of interventions that we can include to help in this realm.
A first step is to recognize that health disparities and inequity exist, but do not necessarily reflect that we are racist, sexist, ageist, etc. Instead, they reflect systems (both within and external to health care) that have developed over time that have contributed to health disparities.
Once we accept the presence of health disparities within our system, we should identify within our specialty where opportunities exist to improve. For example, the results of a study examining racial disparities in surgical outcomes were studied after the implementation of an Enhanced Recovery after Surgery (ERAS) protocol for patients with colorectal cancer. The authors found that patients enrolled in the ERAS protocol had reduced length of stay (LOS) compared to historical non-ERAS controls. Additionally, disparities between Black and White patients with respect to LOS were reduced in the ERAS group, and there were no differences in readmissions or mortality between Black and White patients.
It has been described that Hispanic obstetrical patients are less likely to choose epidural labor analgesia than non-Hispanic women. A randomized, controlled trial was aimed at increasing education (in English and Spanish) concerning epidural placement to Hispanic and non-Hispanic patients on the labor suite. The primary endpoint was use of epidural labor analgesia. Hispanic women randomized to the intervention group (education) were more likely to choose epidural placement compared to the control group.
Both of these interventions are well within the clinical practice of anesthesiologists and demonstrate tangible results that could help to reduce health disparities. Leveraging data (e.g., through electronic health records) to identify if and where outcomes disparities exist can be used to implement initiatives as outlined above. These are just a few examples of ways anesthesiologists can improve health equity.
The workforce and well-being
Beyond local clinical interventions, we should also strive to implement initiatives that address diversity within the workforce, which can also help contribute to reducing disparities. For example, it has been shown that a more diverse workforce improves outcomes, including patient satisfaction and financial performance. Creating opportunities to recruit, retain, and promote a more diverse workforce can also be a key contributor to addressing disparities. Several interventions have been described, mainly in addressing the underrepresentation of women in leadership positions (including in anesthesiology). They provide a blueprint as to how we can improve diversity within our leadership and our specialty at large to better reflect the patient populations we serve. CMS has also recognized the importance and influence of the workforce in their Framework for Health Equity blueprint. Priority # 3 directly addresses the workforce struggles – “Build Capacity of Health Care Organizations and the Workforce to Reduce Health and Health Care Disparities.” Hopefully, this will lead to more focus and support for our workforce on a national level. Interventions at a provider, departmental, and institutional level can be led by anesthesiologists to help address health disparities
Improving health equity and reducing disparities may seem monumental, and it is. But there are opportunities for anesthesiologists to lead efforts in this area, similar to our efforts that have led to improvements in patient safety.