At the Anesthesiology Annual Meeting held this past week in Philadelphia, some research stood out for the wrong reasons. Among the presentations on forward-facing topics like the practicalities of space anesthesiology and the impact of AI on the profession were three separate studies dealing with a long-standing issue: racial disparity in US health care.
The National Institutes of Health defines ‘health disparities’ as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.” The term ‘disparities’ is often used to reflect racial or ethnic differences, but disparities can exist across many dimensions, including gender, sexual orientation, age, disability status, socioeconomic status, and geographic location.
While all of these factors influence an individual’s ability to achieve optimal health, the focus here is on the impact of race on healthcare. A 2022 study described the issue of racial differences in American health outcomes as “profound and persistent.” It pointed to 2018 – that’s pre-COVID-19 pandemic – data from the Centers for Disease Control and Prevention (CDC) showing that the life expectancy for the African American population was 74.7 years compared to 78.6 years for the white population.
The studies presented at this year’s Anesthesiology conference confirm that racial disparity in healthcare is still an issue. Presented below in no particular order, the studies explore how race and ethnicity impact three important areas: access to lifesaving transport following serious injury, the delivery of effective pain relief following major surgery, and the risk of death following coronary artery bypass graft (CABG) surgery.
Access to lifesaving medical transport
Patients with serious injuries who require urgent surgery or admission to the intensive care unit (ICU) should be taken to a hospital that provides the highest level of trauma care. The decision to transport a patient to the hospital via medical helicopter – also known as air ambulance – is usually based on information received about the patient during the 911 call.
“Severely injured patients are more likely to survive if they get the right care within the ‘golden hour,’ the critical first hour after the trauma,” said Dr Christian Mpody, an anesthesiology resident at the Montefiore Medical Center in New York and lead author of the study. “The reality is that current efforts to expand helicopter ambulance programs have yet to result in equitable care for patients of different races and ethnicities.”
Mpody and his fellow researchers assessed hospital transport records for 307,589 adults and 42,812 children with a life-threatening injury requiring surgery or ICU admission between 2017 and 2022. Patients injured within 15 miles (24 km) of the receiving hospital were excluded to ensure only records for patients needing helicopter transport were assessed.
Overall, transport via helicopter was associated with a statistically significant higher survival rate: 82.4% of patients delivered to the hospital by helicopter survived compared with 80.6% transported by ground ambulance. But, the researchers also found that, overall, race and ethnicity had a statistically significant impact:
- Compared to Black adults, white adults were twice as likely to be air transported: 25.4% vs 12.6% (and vs 13.5% Asian adults, 15.9% Hispanic adults).
- 33.6% of children who were air transported were white vs 20% Black children, 22.4% Asian children, and 24% Hispanic children.
“We need to keep collecting and analyzing data to better understand and fix disparities in trauma care,” Mpody said. “By doing this, we can identify service gaps and develop targeted solutions. When it comes to disparities, we need to do the opposite of ‘see no evil, hear no evil, speak no evil’ – we must see it, hear it, and speak out to fix it.”
Source: American Society of Anesthesiologists (ASA) via Newswise
Effective pain relief following complex surgery
Multimodal analgesia involves using combinations of drugs that work together to achieve effective pain relief while minimizing side effects typically associated with giving a higher dose of a single medication, such as an opioid. Using a multimodal approach to analgesia is particularly effective following complex surgeries such as lung or abdominal cancer surgery and hernia repair.
“We know that multimodal analgesia provides more effective pain management with less need for opioids, which are highly addictive,” said Dr Niloufar Masoudi, lead author of the study and an anesthesiologist and research assistant at Johns Hopkins University in Baltimore, Maryland. “It should be standard practice, especially in high-risk surgical patients. We strive to provide patients [with] the most effective pain control while using fewer opioids. Although the optimal number of drug combinations for multimodal analgesia is unknown, using four different types of pain medication vs two or three may better help to achieve this goal. However, more research is needed.”
The researchers compared the post-surgery pain management received by 2,460 white patients and 482 Black patients in the ICU for the first 24 hours after complex, high-risk surgeries done at one institution between 2016 and 2021. For the study, ‘multimodal analgesia’ was defined as the administration of an opioid plus at least one other form of pain medication, such as a local anesthetic (epidural or pain patch on the skin), nonsteroidal anti-inflammatory drug (NSAID), intravenous ketamine, or oral gabapentin.
Black patients were 29% less likely than white patients to receive multimodal analgesia using a combination of four drugs. And, while almost all the patients surveyed received at least one dose of an intravenous opioid, Black patients were 74% more likely than white patients to receive oral and IV opioids, which isn’t ideal, given their high potential for addiction.
While the researchers ruled out other reasons for the differences they observed – for example, insurance, co-existing health conditions, and age – they say that several factors may have contributed to the disparity: differences in pain reported by the patient, patient preferences for a particular form of analgesic, and practitioner bias for or against forms of analgesia by race.
“Further research needs to be done to understand the specific cause for the differences in multimodal analgesia between Black and white patients so recommendations can be developed,” Masoudi said. “Additionally, research should be conducted in other ethnic groups to assess whether they are impacted by similar disparities. In the meantime, pain specialists need to understand the benefits of multimodal analgesia, recognize the existence of disparities in its use and develop standardized protocols to ensure all patients receive this preferred form of pain management when medically appropriate.”
Source: American Society of Anesthesiologists (ASA) via Newswise
Risk of complications after coronary artery bypass surgery
Coronary artery bypass graft (CABG) surgery is performed to treat a blockage or narrowing of one or more of the arteries that provide the main blood supply to the heart, usually when non-surgical procedures are not an option. In the surgery, a healthy blood vessel from the leg, chest or arm is removed and attached as a bypass around the blockage.
The researchers who undertook the study assessed a national inpatient database for patients undergoing bypass surgery in the US between 2016 and 2021. Of the 1,159,040 patients who had CABG during that time, 75.58% were white, 7.44% were Hispanic, and 6.75% were Black (10.23% were categorized as belonging to other racial groups). Black and Hispanic patients were more likely to be younger than white patients. On average, white patients were 73, while Black and Hispanic patients were 63 and 64 years, respectively. Black and Hispanic patients were also more likely to have heart failure: 10.6% for white patients, 12.2% for Hispanic and 15.4% for Black patients.
“While advances in cardiovascular medicine, such as minimally invasive cardiac procedures and modern mechanical circulatory support devices, have increased life expectancy, our research suggests Black patients are less likely to have access to them,” said Dr Vinicius Moreira, chief anesthesiology resident at Advocate Illinois Masonic Medical Center, Chicago, and the study’s lead author. “For example, we found that compared to white patients, a lower proportion of Black patients had bypass surgery when it was indicated. It is imperative that modern policies focus on improving the screening, diagnosis and treatment of chronic conditions that disproportionately affect the Black population and other minorities.”
The study also found that compared to white patients:
- Black patients were 22% more likely to die in hospital.
- Black patients stayed in the hospital 1.5 days longer (on average, white patients stayed 9.6 days, Hispanic patients stayed 10.7 days, and Black patients stayed 11.8 days).
- Black patients had a 23% higher rate of cardiac arrest.
- Total hospital costs were US$23,000 higher for Black patients and $78,000 higher for Hispanic patients.
“Our large study shows that disparities in cardiovascular health care delivery in the US are ongoing, especially in Black patients,” Moreira said. “We found Black patients who have coronary artery bypass surgery experience higher rates of severe postoperative complications, including death and cardiac arrest. These alarming statistics call for urgent action from governments and health care systems.”
The path to equity in healthcare is a rocky one, as these three independent studies demonstrate. But, Dr Moreira sums up why America needs to continue on that path:
“Although strides have been made in workforce diversity and addressing racial biases in health care technology, the path toward true equity remains long and requires a much more concerted effort.”
Source: American Society of Anesthesiologists (ASA) via Newswise