Understanding the Struggle of Patient Access to Perioperative Medical Care

By: Adam J. Milam, MD, PhD, MHS
Faculty Associate
Department of Mental Health
Johns Hopkins Bloomberg School of Public Health

Two patients, Mr. Clark and Mr. Smith, arrive at the same hospital for coronary artery bypass surgery for three vessel coronary disease. The patients are of similar age, both ASA physical class four, and have the same comorbidities; Mr. Clark is African American, and Mr. Smith is White. Will these patients receive similar care? Will these patients that are similar except for race, have the same outcomes following their CABG surgery?

There are significant racial and socioeconomic disparities in perioperative health outcomes.^1-3 According to Hoyler and colleagues, African American patients have 13% higher odds of mortality following aortic and mitral valve surgery compared to White patients after adjusting for age, sex, presenting comorbidities, year and state of procedure, type of surgery, urgency of the surgery, and hospital volume; uninsured patients have 21% higher odds of mortality following the same surgeries compared to insured patients.² My mentor always said, “you can always find a study to support your statement” so this study alone may not be convincing that there are racial/ethnic disparities in perioperative health outcomes. However, the four systematic reviews (three of which are also meta-analyses) that have all identified racial/ethnic and socioeconomic disparities in care and outcomes during the perioperative period for total knee arthroplasty, trauma care, and coronary artery bypass surgery may be more convincing.^4-7 These systematic reviews generally show a decrease in morbidity and mortality following surgery over time, but a persistent disparity in outcomes by race/ethnicity and socioeconomic status.

There is a myriad of complex factors that lead to unequal treatment and disparities in outcomes by race/ethnicity and socioeconomic status. The social determinants of health, defined by the Centers for Disease Control and Prevention as conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks account for a significant portion of disparities in outcomes. The social determinants of health include access to (or lack of) transportation, exposure to violence/crime, and access to emerging technologies. For example, poor people, minorities, and rural populations have less access to primary care. These same communities are also more likely to undergo surgery at lower volume centers with worse perioperative outcomes.⁸ If you apply the concept of intersectionality, a metaphor for understanding the ways that multiple forms of inequality and disadvantage sometimes compounds themselves, coined by Professor Kimberle Crenshaw, things are more troubling. To put this into context, if you are poor, African American, and live in a rural community, a study showed that access to quality bariatric surgery is almost impossible.⁹ These social determinants of health (and other upstream factors) will likely take generations to address; this can be advanced with good public health policy and advocacy by physicians. In fact, the American Medical Association’s Declaration of Professional Responsibility states that physicians should advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.

What if you have access to healthcare and a quality hospital, are there healthcare disparities or racial/ethnic differences in perioperative health outcomes? Based on the literature, the answer is yes! Despite access to a tertiary medical center, the odds of being referred to a cardiothoracic surgeon for aortic valve disease was 54% lower in African American patients compared with White patients, after adjusting for age, gender, aortic calcification, velocities across the aortic valve, and comorbidities.¹⁰ Another example…even after referral to a thoracic surgeon, there are racial differences in resection rates for lung masses.¹¹

Additionally, there are differences in patient-physician communication by age and race that may influence perioperative outcomes. In a study of patients with newly diagnosed breast cancer, physicians provided more biomedical information to younger patients, White patients, and patients with more education.¹² Additionally, more empathy and relationship building were provided to White, younger, and more educated patients, highlighting the role of implicit biases in healthcare disparities. Let me be clear, we all have biases; we need to understand and recognize these biases, so we provide the best care to all of our patients.

There are also clear differences in patient management by race/ethnicity and socioeconomic status. In a study of patients with long bone fractures presenting to the emergency department, nonwhite patients were less likely to receive outpatient opioid prescriptions. More troubling, African American patients that actually received opioids for long bone fractures were less likely to receive a prescription for naloxone.¹³ There are other factors that explain racial, geographic, and socioeconomic disparities in perioperative health outcomes including explicit biases, mistrust of the healthcare system, cultural differences, and patient behaviors.

Things are not all bad! In the presence of equal access and equal treatment we can close the gap in health disparities. This has been found for patients enrolled in cancer trials. Rural-urban disparities disappeared with equal access to cancer care.¹⁴ Also, a recent study examining cardiac surgery outcomes in Maryland found that African American patients had a lower risk of perioperative morbidity and mortality.¹⁵ The authors suggested that the payer system for Maryland, which is an all-payer model intended to equitably distribute health care costs across hospitals and enhance access, combined with the high-quality hospitals in the state was responsible for closing the gap in perioperative outcomes.

In addition to improving access, diversifying the medical workforce is another strategy for addressing healthcare disparities and disparities in perioperative health outcomes. There is evidence that increasing provider diversity can improve patient care, patient satisfaction, and reduce healthcare disparities.¹⁶ Fortunately, we have examples of strategies to effectively improve diversity without sacrificing quality.¹⁷

Health and healthcare disparities also exist for other segments of the population. While racial and ethnic disparities are the most well-studied, there are also disparities among women, older adults, the disabled, as well as sexual and gender minorities. Many of the solutions are the same – addressing biases, effective communication, and advocating for diversity in the field.

Back to our patients, Mr. Clark and Mr. Smith, both undergoing cardiac surgery at the same hospital. Mr. Clark, our African American patient was less likely to have access to a primary care physician, less likely to have access to a cardiologist, less likely to be referred to a cardiothoracic surgeon, and more likely to encounter barriers to communication during his initial consultation with the surgeon. Despite Mr. Clark overcoming all of these obstacles, there are likely to be differences in morbidity following his surgery simply based on his race. This is a difficult pill to swallow! There are well-established disparities in perioperative health care. While some of these disparities are improving, we have a long way to go! We have an obligation to help address these disparities and I look forward to working with the American Osteopathic College of Anesthesiologists and other national societies to identify and implement strategies to eradicate perioperative health disparities.

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Dr. Milam is a Cardiothoracic Anesthesiology Fellow at Cleveland Clinic. Dr. Milam completed his residency in Anesthesiology at Cedars-Sinai Medical Center in Los Angeles, CA. He graduated from Wayne State University School of Medicine in Detroit, MI. Prior to medical school, he attended Johns Hopkins University where he graduated with a Bachelor of Arts in Public Health (BA, 2008). He also holds a Masters in Health Science (MHS, 2009) as well as a Doctorate in Public Health from the Department of Mental Health at Johns Hopkins Bloomberg School of Public Health (JHSPH, 2012). His research is rooted in practices, policies, and interventions to address health disparities and health inequities.