Health disparities in the perioperative setting are a public health and patient safety issue. This letter to the editor is a call for action among the Anesthesia Care Team members.
The recent COVID-19 pandemic has highlighted the health disadvantage of the most vulnerable members of the society.1 The literature about health disparities in the perioperative setting and their impact in patient safety is growing. Different authorities, like the executive branch of government and physicians’ organizations, have raised concern about the negative environment fostered by health disparities in patient experience and outcomes.2-4
The latest National Healthcare Quality and Disparities Report shows that health care disparities are present in the US population, mainly among the poor and uninsured. The report stated, “Blacks and American Indians and Alaska Natives received lower quality care than Whites for 40% of quality measures.” The patient safety measures in which Black adults received worse care than Whites during the 2016–2018 period included postoperative physiologic and metabolic derangements per 1,000 elective surgical hospital discharges, sepsis diagnoses per 1,000 elective-surgery admissions, postoperative pulmonary embolism per 1,000 surgical hospital discharges, and postoperative acute kidney injury requiring dialysis per 1,000 elective surgical hospital discharges.5
While we cannot change the socioeconomic conditions of our individual patients, as members of the anesthesia care team we are charged with delivering equal treatment to our patients.
Health disparities place the vulnerable population at risk during health care interactions. Delayed or inadequate diagnosis, inappropriate coordination of care, fragmented communication, and lack of a safety culture that embraces patient individuality and promotes family engagement fosters an unsafe environment.6
Global equity in health delivery should be our goal, and we want to provide possible solutions to the problem in the perioperative environment. Some researchers believe that unequal health treatment can be attributed to the hospital in which the patient receives care while others favor individual-provider factors as the source of disparities.7,8 The American Society of Anesthesiologists, the American Association of Nurse Anesthesiology, the American Academy of Anesthesiologist Assistants, and the American Board of Anesthesiology have published statements acknowledging racial and ethnic disparities in anesthesia care and promoting health equity.9,10 Health care providers do not exist in isolation. Clinicians are part of a community and some of their behaviors are products of cultural imprinting. As members of the wider population, providers can unconsciously display the same implicit bias reflected in members of their community.11,12 Bias, implicit bias, and stereotyping are some of the attitudes that need to be mitigated and abolished in order to prevent disparities in health care. Implicit bias is an unconscious, unjustified, negative attitude or feeling towards an individual of a certain group, while explicit bias is a conscious prejudicial evaluation.7,13,14
The latest National Healthcare Quality and Disparities Report advocates for a more diverse workforce in order to promote better access, improve communication, and meet the underserved community needs.5 Researchers have seen higher participation in preventive screenings with physician-patient gender concordance, and enhanced patient experience with patient-physician racial concordance.15,16 Diversity is also needed in the anesthesiology field, where 74% of active anesthesiologists are male, and 65% of residents and fellows are male.17 A change in recruitment and promotion practices could create a more diverse and inclusive workforce in anesthesiology departments.18
It is imperative for anesthesia professionals to be aware of the impact of structural inequities and social determinants of health on clinical outcomes and in patient care. This includes training in cultural competency and cultural humility and supporting promotion of health literacy efforts for our patients. It is also important to promote continuing education about health disparities, inclusion of minorities in research, increase health workers’ diversity, enforce diversity training in medical and nursing schools, and mitigate clinicians’ implicit bias (Table 1).19,20 Perioperative clinicians will be at the forefront of improving care and patient outcomes by expanding our knowledge of health disparities. But the change of behaviors ingrained in society and the aftermath of unequal polices require interventions at individual, health systems, and legislative levels. The behavioral modifications required in the fight against health disparities can be facilitated by applying existing models like the behavioral change wheel and the transtheoretical model of change.21,22 The behavioral change wheel includes education, training, and environmental restructuring among useful interventions.21
Table 1: Suggestions to Mitigate Health Disparities
|Clinician Level||System Level|
A silver lining from the COVID pandemic has been the renewed emphases on health equity, one of the six aims of quality as defined by the Institute of Medicine.23 Health disparities are inherently a public health emergency and a patient safety issue. The discipline of anesthesiology has led the field of patient safety in health care for decades. As such, it is appropriate for our specialty to take on health disparities as a clarion call for our patients in order to continue to safeguard care throughout the perioperative continuum.
Lilibeth Fermín, MD, MPH, is a clinical associate professor of anesthesiology at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Weston, Florida.
Luis E. Tollinche, MD, FASA, is chair of anesthesiology, MetroHealth Medical Center, Cleveland, OH.
Judith L. P. Handley, MD, is a clinical associate professor, Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia/Augusta University.
Amy Lu , MD, MPH, is a clinical associate professor, vice chair Quality, Safety and Improvement, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine.
Luis E. Tollinche, MD, served as a paid consultant and in an advisory role for Merck & Co. Pharmaceutical Company and is a grant recipient through the Merck Investigator Studies Program to fund a clinical trial at MSKCC (NCT03808077). Lilibeth Fermín, MD, Judith Handley, MD, and Amy Lu, MD, have no conflicts of interest.
- Tai DBG, Shah A, Doubeni CA, et al. The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States. Clin Infect Dis. 2021;72:703–706.
- Agency for Healthcare Research and Quality. 2019 National healthcare quality and disparities report executive summary. 2020. www.ahrq.gov/research/findings/nhqrdr/index.html. Accessed April 16, 2022.
- The White House. Fact Sheet: Biden-Harris administration announces initial actions to address the black maternal health crisis. 2021. https://www.whitehouse.gov/briefing-room/statements-releases/2022/04/13/fact-sheet-biden-harris-administration-announces-additional-actions-in-response-to-vice-president-harriss-call-to-action-on-maternal-health/. Accessed April 19, 2022.
- Peterson MD, Wright C. Anesthesiology and health equity: an ongoing ASA priority. ASA Monit. 2020;84:49–50. doi:10.1097/01.asm.0000724116.75355.fa. Accessed April 19, 2022.
- Agency for Healthcare Research and Quality. 2019 national healthcare quality and disparities report. Rockville, MD; 2020. doi:20(21)-0045-EF. Accessed April 19, 2022.
- Vincent C, Amalberti R. Safer healthcare. (Springer, ed.). Cham: Springer International Publishing; 2016. 29465922. Accessed April 19, 2022.
- Lee A, Landau R. Racial and ethnic disparities uncovered in the 2020 MBRRACE-UK report—global implications and future agenda. Anaesth Crit Care Pain Med. 2021;40. 33781989. Accessed April 19, 2022.
- Okoroh JS, Uribe EF, Weingart S. Racial and ethnic disparities in patient safety. J Patient Saf. 2017;13:153–161. 251197819. Accessed April 19, 2022.
- American Society of Anesthesiologists Committee on Professional Diversity. Anesthesiology and Health Equity. September 15. https://www.asahq.org/about-asa/newsroom/news-releases/2020/09/anesthesiology-and-health-equity. Accessed April 25, 2022.
- American Association of Nurse Anesthetists. The CRNA’s role in addressing racial and ethnic disparities in anesthesia care. Position statement, policy and practice considerations. https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/professional-practice-manual/2021-disparities-position-statement-final-_bod.pdf?sfvrsn=f45c2514_19. Accessed July 8, 2021.
- Fitzgerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18. 28249596. Accessed April 19, 2022.
- Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105:e60–e76. 26469668. Accessed April 19, 2022.
- Lichter DT. Immigration and the new racial diversity in rural America. Rural Sociol. 2012;77:3–35. 26478602. Accessed April 19, 2022.
- Buchmueller T, Levy H. The ACA’s impact on racial and ethnic disparities in health insurance coverage and access to care. Heal Aff. 2020;39:395–402. 32119625. Accessed April 19, 2022.
- Malhotra J, Rotter D, Tsui J, Llanos AAM, Balasubramanian BA, Demissie K. Impact of patient–provider race, ethnicity, and gender concordance on cancer screening: findings from Medical Expenditure Panel Survey. Cancer Epidemiol Biomarkers Prev. 2017;26:1804–1811. 29021217. Accessed April 19, 2022.
- Takeshita J, Wang S, Loren AW, et al. Association of racial/ethnic and gender concordance between patients and physicians with patient experience ratings. JAMA Netw Open. 2020;3:e2024583. 33165609. Accessed April 19, 2022.
- AAMC. Active physicians by sex and specialty, 2017. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-sex-and-specialty-2017. Accessed April 19, 2022.
- Hopf HW, Dew LI. Diversity: value, barriers, and solutions. ASA Monit. 2020;(July):28–29. https://doi.org/10.1097/01.M99.0000688664.11872.05. Accessed April 19, 2022.
- Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J. 2011;15:71-78. 21841929. Accessed April 19, 2022.
- Chin MH. Advancing health equity in patient safety: a reckoning, challenge and opportunity. BMJ Qual Saf. 2021;30:356-361. 33376125. Accessed April 19, 2022.
- Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42. 21513547. Accessed April 19, 2022.
- Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Heal Promot. 1997;12:38–48. 10170434. Accessed April 19, 2022.
- Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press; 2001.