Health Inequity: Too Expensive for Anyone and Everyone

Adaora M. Chima, MBBS, MPH

Health inequity and health disparity are phrases that have grown in medical, scientific and secular use in recent years. Although often used interchangeably, these pervasive issues are distinct but interwoven complex phenomena that have a ripple effect on every single member of societies where they are allowed to exist. Not unique to the US, these problems touch all facets of medical care including perioperative care. The session, co-sponsored by the Association of University Anesthesiologists, “Social Determinants of Perioperative Outcomes: How Anesthesiologists can Transform Care for Vulnerable Patient Populations,” held on Saturday, April 15 at the IARS 2023 Annual Meeting, delved into these complex issues and identified opportunities for anesthesiologists to engage in mitigating this problem, even beyond the perioperative arena.

The session was moderated by Solmaz Manuel, MD, Associate Clinical Professor of Anesthesia and Perioperative Care at University of California, San Francisco (UCSF).

Following introductions by the moderator, the first speaker, Odinakachukwu Ehie, MD, FASA, Associate Professor of Anesthesia and Vice Chair of Diversity, Equity and Inclusion at UCSF, opened up the discussion with a description of the complexity of social determinants of health outlined in conceptual frameworks. She invited the audience to think about the impact of extensive and complex issues that influence a patient’s ability to maintain good health and wellbeing. These issues span personal factors such as education, housing, finances, health literacy; health provider factors such as unconscious bias, knowledge and skills; and health infrastructure including geographic access. The effect of inequities on health disparities, which refers to the negative health outcomes that disproportionately affect disadvantaged groups, is so extensive that in addition to the morbidity and mortality, the financial cost is enormous.

It is estimated that for the years 2003-2006, the direct and indirect costs of health inequity were $230 billion and ~$1 trillion dollars, respectively. Deloitte actuarial estimates of today’s annual costs are as high as $320 billion, projected to reach $1 trillion by 2040. This cost is indirectly borne by society at large thus no one is unaffected by the effects of health inequity. What can anesthesiologists do to help? Dr. Ehie says they can promote a diverse workforce as the presence of concordant providers positively impacts health equity, promote patient-centered care using multidisciplinary teams to identify and address unique problems like challenging financial, housing or social support situations that could be relevant to health management. Additionally, she recommended educating oneself on health policies and their ramifications for social determinants of health and building task forces to advocate for policy change on state and national levels as effective interventions within the reach of the anesthesiology clinician. Anesthesiologists can also advocate for acquisition of extensive data and research on social determinants of health that could impact patients following hospital discharge. She concluded by challenging the audience to examine intentional and subconscious biases around them, and their impact on care.

Next, Allison Lee, MD, MS, Obstetric Anesthesiologist, Associate Professor and Officer of Diversity, Equity and Inclusion at Columbia University, discussed current challenges and strides towards providing equitable maternal care. She provided startlingly worsening statistics on maternal morbidity and mortality, which increased from 20.1 deaths/100,000 live births in 2019 to 23.8 in 2020, 80% of which have been determined to be preventable. Mental health is alarmingly responsible for 22.7% and the mortality rate is threefold higher in Black women than White. There are even shocking disparities within smaller geographic areas such as New York State which has a threefold higher rate of Black maternal mortality while New York City is eightfold more.

Dr. Lee called attention to studies showing differential care in obstetric anesthesia delivery with Black women more likely to undergo cesarean sections under general anesthesia than their White counterparts. Blood patches for postdural puncture headaches were less likely to be performed in non-White patients and when they did occur, were performed a median of a day later compared to White patients. There were also differences in frequency of pain evaluation and postoperative opioid prescription, both less in Black laboring women.

She reminded the audience that structural racism has a profound impact on health outcomes with historical examples like the GI bill which excluded minority servicemen/women and redlining, an outcome of government home insurance programs established >80 years ago, which continues to impact health outcomes of racial minorities to date.

Recent strides to address these disparities include Medicaid extensions to 1 year postpartum and the introduction of the Black Maternal Health Momnibus Act of 2021, which seeks to improve social determinants of maternal health especially in racial/ethnic minorities, veterans, and vulnerable groups.

Dr. Lee encouraged the anesthesiology community to follow evidence-based guidelines targeting disparity that have been provided by organizations such as the Society for Obstetric Anesthesia and Perinatology (SOAP):

• Educate yourself and others on racial myths regarding pain, aging and other misrepresentations.
• Promote the use of language concordant materials in communicating with and educating patients on obstetric-related procedures.
• Advocate for training on mental health screening in patients.

She challenged the audience and the anesthesia community at large to participate in implicit association tests and reflect on the findings.

The final presenter, Olubukola Nafiu, MD, MS, Associate Professor of Pediatrics and Anesthesiology at Nationwide Children’s Hospital and Executive Section Editor of the Healthcare Disparities section of Anesthesia & Analgesia, began his talk with a caveat that discussions around racial disparity often cause discomfort. Rightly so, he advised that racial disparity is a systemic problem that cannot be ignored under the guise of being personally “color blind” or “not racist.” He emphasized the difference between health inequity and disparity as unjust limitations or obstacles preventing an individual from obtaining adequate healthcare versus the higher burden of negative outcomes as a result.

Dr. Nafiu shared more alarming disparity-related mortality statistics in the US, explaining that although clinical errors can result in individual mortality, inaccurate or biased research can cause mortality on an exponential scale. He stressed that it is imperative that accurate research on marginalized and minority populations is supported and encouraged. Some highlighted challenges to health disparity research include a paucity of minority investigators, limited funding, and resistance to publishing disparity studies that don’t include solutions. He encouraged researchers to examine the difference between surface and fundamental causes of health disparities. In response to a question regarding the inclusion of race in statistical models, he counseled on the importance of accounting for potentially race-related modifying factors, in order to avoid fallacious research questions or deductions based on race.

Health disparity is a significant contributor to morbidity and mortality of minority populations in the US. Many opportunities within and beyond the perioperative sphere for anesthesiologists exist to move the needle of health and wellbeing towards equity for everyone regardless of race.