Anesthesiology and Health Equity

This document is an ongoing project under the oversight of the Committee on Professional Diversity. The committee anticipates that it will be reviewed and updated as new insights and perspectives are brought to its attention. 

There is growing evidence of a gap in resources, quality of care, health outcomes, and mortality based on race and socioeconomic status. Much has been written about the factors that cause these disparities, including social determinants, public policy, prevalence of chronic conditions (e.g., diabetes, high blood pressure, heart disease, and pulmonary disease), access to primary care, and under-resourced safety net hospitals. 

ASA believes that lack of access to physician-led anesthesia care is also a critical factor. We have identified the following areas for additional policy development.

1. High quality perioperative care for all populations: High quality perioperative care, including physician-led anesthesia care, is associated with improved patient safety and better health outcomes and is an imperative for patients with pre-existing health conditions. Leadership by anesthesiologists provides higher quality preoperative evaluation, appropriate selection of anesthetic, and adequate monitoring during the surgical period, thereby optimizing patient care. Yet some hospitals, particularly resource constrained safety net hospitals, often seek to provide anesthesia services without physician involvement. The nation’s highest-ranking hospitals utilize physician delivered and physician-led models of anesthesia care delivery. ASA strongly recommends that all patients, regardless of the location of their care, should be assured the involvement of a physician in their anesthetic management to decrease outcome disparities. 
   
   Low-income and minority populations are less likely to have access to primary care, preventive care, and routine chronic care. In many cases, chronic health conditions go undiagnosed or untreated until an urgent medical encounter.² This encounter may occur as part of the anesthesiology pre-operative assessment when patients are scheduled for surgery because of a critical injury or urgent surgical condition. As a result of the pre-operative assessment, anesthesiologists can play a critical role in diagnosing chronic disease and unrecognized health disorders and linking patients to appropriate medical and social resources.¹ ASA strongly recommends that Centers for Medicare and Medicaid Services (CMS) assure appropriate resources for evaluation and management services provided during the pre-operative assessment. 
   
   
2. Maternal care: Low income and minority populations are more likely to suffer from higher rates of maternal and infant mortality because of inadequate prenatal care and chronic conditions. ^3,4 Anesthesiologists work closely with obstetricians in providing the best possible maternal care. The role of the anesthesiologist is essential for patient assessment and in managing sedation, pain, and potential complications that may arise in the post-partum period.⁵ ASA has worked closely with the American College of Obstetrics and Gynecology in the development of evidence-based standards and supports their work to eliminate racial disparities in maternal and infant care. ASA strongly recommends the development of policies that support adequate access to Medicaid coverage in the prenatal period and in the year following delivery.³ 
   
   
3. Access to pain management:  Sickle cell anemia, an inherited disease common among Black people, is known to be a debilitating and painful condition.⁶    Anesthesiologists are specialists in pain management and several academic centers have established sickle cell centers to provide integrated care for this condition.^7,8  Unfortunately, this comprehensive care is not widely available. Undertreated or untreated pain can result in disability, drug dependence, and mortality. ASA recommends policies that support adequate access to Medicare and Medicaid coverage for chronic pain care. 
   
   
4. Access to COVID-19 critical care resources:  The chronic conditions more prevalent in the lower income and minority populations place these groups at higher risk of contracting the COVID-19 virus.⁹ Data from the United States indicate that these high-risk populations are more likely to need a breathing machine, or ventilator, and to die from COVID-19. ^10,11 Anesthesiologists are specialized in critical care medicine, which includes the management of complex conditions like COVID-19. Unfortunately, due to the shortage of critical care resources in many urban hospitals, minority patients may not have access to this high-quality medical care. Without these resources, more minority patients will die of COVID-19 and similar respiratory viruses. ASA recommends policies that ensure adequate payments from the Medicare and Medicaid programs to support critical care physicians and the safety net hospitals in which they practice.  
   
   
5. Pediatric patients: Pediatric patients are at an increased risk of perioperative respiratory adverse events. Due to the anatomy of the airway and the higher prevalence of respiratory infections, children are more likely to encounter serious problems with breathing during general anesthesia. Pediatric anesthesiologists are specialized in the care of children to avoid these complications that can lead to lack of oxygen to the brain or even death. In addition, the COVID-19 pandemic, while affecting children less severely than elderly populations or those with multiple chronic diseases, has placed children at risk of multi-system inflammatory syndrome in children (MIS-C). This complex disease requires the expertise of pediatric intensive care physicians and anesthesiologists. The ASA supports policies for appropriate Medicaid policies to assure access to these specialists. 
   
   
6. Access to health insurance: Significant literature has identified the inability of minority populations to access health insurance as a cause of health inequity.^11,12,13  Uninsured adults are less likely to receive critical health care services including preventive services to address underlying health care conditions such as heart disease, diabetes, and cancer. Minorities account for over half of the uninsured population. ASA supports ensuring access to high-quality health insurance through reforms that expand choice of affordable coverage, increase portability and reduce unnecessary costs. 
   
   
7. Disparities in clinical research: Traditionally, pharmaceutical research has included a disproportionate representation of White patients with under-representation of Blacks, Latinx, Native Americans and other minorities. Variation in drug effectiveness and safety between racial groups and genders are well-documented; this disparity can result in ineffective, delayed, or unsafe treatment for untested populations.¹⁴ ASA commends the recent statement and work of the Foundation for Anesthesia Education and Research to stress the importance of diversity and inclusion in the development of anesthesiology researchers and assuring diversity in study populations. ASA strongly recommends that disparities be addressed in requirements by the NIH and FDA for grant reviews and product approvals, respectively.

³ Taylor J, Novoa C, Hamm K, Phadke S. Eliminating racial disparities in maternal and infant mortality: a comprehensive policy blueprint. Center for American Progress. May 2019. 

⁴ Howell EA. Reducing disparities in severe maternal morbidity and mortality. Clin Obstet Gynecol. 2018;61(2):387-399. 

⁵Abir G, Mhyre J. Maternal mortality and the role of the obstetric anesthesiologist. Best Pract Res Clin Anaesthesiol. 2017;31(1):91-105.

⁶ Adjepong KO, Otegbeye F, Adjepong YA. Perioperative management of sickle cell disease. Mediterr J Hematol Infect Dis. 2018;10(1):e2018032.

⁷ Grady Health. Georgia Comprehensive Sickle Cell Center. Available at: https://www.gradyhealth.org/care-treatment/sickle-cell-disease-center 

⁸ Duke University School of Medicine. Duke Sickle Cell Center. Available at: https://medicine.duke.edu/divisions/hematology/patient-care/duke-sickle-cell-center

⁹ Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): health equity considerations and racial and ethnic minority groups. Updated July 24, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html 

¹⁰ Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and mortality among black patients and white patients with Covid-19. NEJM. 2020;382(26):2534-2543.

¹¹ Artiga S, Corallo B, Pham O. Racial disparities in COVID-19: key findings from available data and analysis. Kaiser Family Foundation. August 2020. Available at https://www.kff.org/racial-equity-and-health-policy/issue-brief/racial-disparities-covid-19-key-findings-available-data-analysis 

¹² National Quality Forum. A roadmap to reduce health and health disparities through measurement. July 2017. 

¹³ Kaiser Family Foundation. Health and health care for blacks in the United States. May 2019. Available at: https://www.kff.org/infographic/health-and-health-care-for-blacks-in-the-united-states

¹⁴ America’s Essential Hospitals. Results of America’s essential hospitals 2018 annual member characteristics survey. May 2020. Available at https://essentialhospitals.org/wp-content/uploads/2020/05/Essential-Data-2020_spreads.pdf