Research on disparities in surgical care and outcomes for disadvantaged populations is the focus of a new initiative from the National Institute on Minority Health and Health Disparities.
- Successful approaches, once identified, might be useful across other specialties.
- There is a concern that increased wealth inequality will exacerbate health disparities.
- The Affordable Care Act can improve access, but this is only one cause of disparities.
A new initiative to support research on disparities in surgical care and outcomes for disadvantaged populations was recently launched by the National Institute on Minority Health and Health Disparities. The initiative will provide grant opportunities on surgical disparities research.
The research will focus on the following five priorities, which were identified at the May 2015 Inaugural National Institutes of Health (NIH)-American College of Surgeons (ACS) Symposium on Surgical Disparities Research Symposium.1
- Improving patient-clinician communication by helping clinicians deliver culturally dexterous, competent care and measuring its effect on the elimination of disparities.
- Fostering engagement and community outreach by using technology to optimize patient education, health literacy, and shared decision-making in a culturally relevant way; disseminating these technologies; and evaluating their effects on reducing surgical disparities.
- Improving care at facilities with a higher proportion of minority surgical and trauma patients.
- Evaluating the longer-term effect of acute interventions and rehabilitation support within the critical period of injury or illness on functional outcomes and patient-defined perceptions of quality of care.
- Improving patient-centeredness by identifying expectations for postoperative and post-injury recovery.
“We cannot afford to be the wealthiest nation of all time, with all of the advantages we have, and continue to have widening healthcare disparities. And it hasn’t gotten better — it’s gotten worse,” says L.D. Britt, MD, MPH, FACS, professor at Eastern Virginia Medical School and chair of the ACS Committee on Health Care Disparities.
Britt believes that in order to make some real progress, the combined resources of ACS and the NIH are necessary. “If we can’t put a dent in diminishing healthcare disparities, then no one can do it. And I feel strongly we can do it,” says Britt.
The problem is multifaceted: patients need to be able to access their providers, providers need guidelines on how to diminish disparities, and the public has to be educated. “We spend more on healthcare than any other nation. But the challenge we’ve had a consistent problem with is healthcare disparities,” says Britt.
Britt expects the initiative will result in some good models, which can then be used across other medical specialties. “If it works in surgery, maybe it can work in medicine,” he says. “There’s no specialty where disparities have not been a problem.”
Britt emphasizes that disparities in healthcare outcomes are ethically unacceptable. “We can accept that some people are wealthy and some are not,” he says. “But we should never accept disparities when it comes to clean air, water, education and healthcare.”
Disparities are a serious concern in cancer care, according to Simon J. Craddock Lee, PhD, MPH, assistant professor of clinical sciences at Harold C. Simmons Comprehensive Cancer Center at University of Texas Southwestern Medical Center in Dallas. “Disparities in lung cancer don’t seem to be related to higher rates of smoking or limited access to healthcare,” he notes. The presence of comorbidities decreased likelihood of surgery in African-American lung cancer patients but not in a comparable set of white patients, found a 2010 study.2
“This raised questions about presumptions that physicians may make about African-American patients that they do not make about white patients,” says Lee.
The other contributing factor was usual source of care. “This raises questions about access to healthcare, insurance, as well as other structural barriers to care in African-American communities,” says Lee. Lee’s own study sought to understand lung cancer decision-making among patients treated for in a county safety-net system.3
“I found many patients and their caregivers lacked an understanding of their diagnosis and prognosis,” says Lee. For example, some expressed relief when they were told they were not going to need surgery — but did not understand that the physician recommendation was because their cancers was not resectable. Instead, they were relieved because they had an uncorrected assumption that surgery could cause the cancer to spread.
“From an ethical perspective, this raises questions about how physicians approach patient autonomy, and ultimately, informed consent,” says Lee.
In Lee’s experience, low-income and minority patients do not distrust health systems or physicians. “Rather, low-income and minority patients have enormous respect for their doctors, and don’t like to question them lest they appear to challenge their authority,” says Lee. The problem arises, says Lee, when clinicians mistake that respect and passiveness as lack of engagement.
“Many physicians then don’t always engage to explain more about their presenting disease, possible treatment paths, and likely prognosis,” he says.
It is important to recognize that disparities in surgical outcomes are part of a larger problem of health disparities in general, says Robert Perlman, MD, PhD, professor emeritus in the Department of Pharmacological and Physiological Sciences at the University of Chicago.
“We should appreciate that racial and ethnic disparities in health are intimately connected to socioeconomic disparities,” Perlman adds. “These are complex and difficult problems.”
One important part of this problem has to do with geography. “National disparities in healthcare reflect regional variations in the quality of care,” says Perlman. Populations who have bad health outcomes, whether poor people or African-Americans, disproportionately live in regions of the country where health is generally poor.
Perlman notes that life expectancy in Louisiana, which is home to about 1.5 million African-Americans and has a poverty rate of 23.1%, is 75.71 years. In contrast, in Connecticut, which has 360,000 African-Americans and where 8.6% of the population lives in poverty, life expectancy is 80.82 years.
“These huge differences in life expectancy reflect differences in health generally,” says Perlman. “In cities, too, poor people and members of racial minorities tend to live in communities where health and healthcare is poor.”
As health in the U.S. has improved, health disparities are beginning to decrease, notes Perlman. “That is very good news, indeed. People who currently have poor health outcomes stand to gain the most from improvements in healthcare,” he says.
While the Affordable Care Act is reducing disparities in access to healthcare, this only goes so far. “Disparities in access to healthcare are probably not a major cause of health disparities,” says Perlman.
Neither Medicare in the U.S. nor the National Health Service in the United Kingdom has eliminated health disparities, although they have greatly reduced disparities in access to healthcare. “The problem has more to do with access to the highest quality of healthcare, rather than access to healthcare in general,” explains Perlman.
Perlman believes the stresses that accompany living at the bottom of a socioeconomically hierarchical society are a major factor leading to health disparities. “I’m concerned that increases in income and wealth inequality in the United States will exacerbate the problem of health disparities,” he says.
Perlman says there is little reason to think that the behavior of physicians is a significant cause of health disparities. “Physicians as a group act ethically and do not violate the traditional principles of autonomy, beneficence, non-maleficence, and justice,” says Perlman.
Perlman says there are two ways to reduce health disparities, including disparities in surgical outcomes. “The first is to improve healthcare for everyone, which means especially improving healthcare in regions of the country and in urban communities where care is poor,” he says.
The other goal is reduction of socioeconomic disparities. “This raises huge questions of social justice that need to be debated and discussed by the whole society,” says Perlman.
Peter Angelos, MD, PhD, FACS, Linda Kohler Anderson Professor of Surgery and Surgical Ethics and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, sees the central ethical issue when considering disparities in surgical outcomes based on race and ethnicity as one of justice. “It is unjust to treat patients differently based on race or ethnicity,” says Angelos.
Surgeons, as do all physicians, have a moral responsibility to promote their patient’s best interests. “This is based on the principle of beneficence. Whether one considers it on an institutional level or on an individual physician level, we should do all that we can to give our patients the best possible outcome,” says Angelos.
Biases, whether conscious or unconscious, that result in worse patient outcomes should be identified and rectified, says Angelos. Bioethicists can help by highlighting the issue and continuously raising the question of whether justice is being upheld, he says.
Such an approach will be most effective for conscious biases, he acknowledges. “Perhaps by looking at the clinical encounter between a patient and a surgeon from a perspective different from the involved clinicians, the bioethicist can help to identify those unconscious biases when they are present,” says Angelos.
- Haider AH, Dankwa-Mullan I, Maragh-Bass AC, et al. Setting a national agenda for surgical disparities research recommendations from the National Institutes of Health and American College of Surgeons Summit. JAMA Surgery 2016; DOI: 10.1001/jamasurg.2016.0014.
- Cykert S, Dilworth-Anderson P, Monroe MH, et al. Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer. JAMA 2010; 303:2368–2376.
- Lee SC, Marks EG, Sanders JM, et al. Elucidating patient-perceived role in “decision-making” among African-Americans receiving lung cancer care through a county safety-net system. J Cancer Surviv 2016; 10(1):153-163.
- Peter Angelos, MD, PhD, FACS, Associate Director, MacLean Center for Clinical Medical Ethics, University of Chicago. Email: firstname.lastname@example.org.
- L.D. Britt, MD, MPH, FACS, Eastern Virginia Medical School, Norfolk. Phone: (757) 446-8964. Email: email@example.com.
- Simon J. Craddock Lee, PhD MPH, Assistant Professor of Clinical Sciences, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas. Phone: (214) 648-2410. Fax: (214) 648-3934. Email: SimonCraddock.Lee@UTSouthwestern.edu.
- Robert Perlman, MD, PhD, Professor Emeritus, Department of Pediatrics, University of Chicago. Phone: (773) 702-6428. Email: firstname.lastname@example.org.