Healthcare Inequity and Critical Care Medicine

2013 - 4 August - Managing Post-Intensive Care Syndrome in the ICU
Gregory E. Kerr, MD, MBA, FCCM
There is profound disparity in health based on race, ethnicity, gender, socioeconomic backgrounds and geographic origin, and delivery of healthcare to those disparate groups varies widely.
In 2003, the Institute of Medicine published Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, which informed the medical community that a profound disparity in health was based on race, ethnicity, gender, socioeconomic backgrounds and geographic origin, and that the delivery of healthcare to those disparate groups varied widely.(1) At the time, the issue was not commonly addressed, yet it soon became important as the United States started to discuss universal healthcare coverage for its citizens.

The Race Factor
The specialty of critical care has been slow to look at healthcare disparities. Primary care medicine has noted that pain management varies across racial and socioeconomic lines.(2) Numerous studies have revealed that cardiovascular diseases are a greater burden on Hispanics and African Americans than on the white population due to genetics, limited access to healthcare and variations in management.(3) Although pain management and cardiac care are subelements of critical care, the specialty itself has done relatively little to evaluate the significance of healthcare disparity among the critically ill.
Disparities in health and/or healthcare delivery emanate from multiple factors. First, genetic or inherent individual issues create health disparities no matter how well healthcare is delivered. A perfect example would be sickle cell anemia and its presence among the African American population. Second, socioeconomic influences in a community, cultural mores and ways of life have a huge impact on how medical issues are prevented or managed. More than 1.25 million Americans carry the hepatitis B virus and over half of those infected are Asian.(4) This disease could probably have a lower prevalence if the Asian American population was aware of existing methods for prevention. Third, access to healthcare has been a long-standing issue in the United States. Barriers to access have historically been financial, geographical and/or cultural/linguistic in nature. The Affordable Care Act includes elements that seek to improve access,(5) but the sudden influx of insured citizens and minimal change in the number of healthcare providers actually may limit access (i.e., insufficient number of providers relative to the new demand).(6) Finally, even when healthcare is available, the quality and options vary widely across the country and can vary even within a small community.

Healthcare Disparities
When trying to grasp the differences in healthcare delivery, it is important to distinguish the “macro” view (current state of the U.S. economy and healthcare system) from the “micro” view (local community issues). At the macro level, the presence and accessibility of hospitals (or lack thereof), and the type and quality of the hospitals vary tremendously. It has been well documented that minority patients are more likely to go to hospitals of “lower quality.”(7) On the micro level are issues that pertain to patients, physicians and institutional relationships. Patient perceptions and interactions with the healthcare system must be understood, along with physician perceptions and delivery of care.

Patients prefer to be managed by healthcare providers who are like them. In recent years, African Americans have comprised only 4% of the physician workforce,(8)  yet 20% of African American patients report that they are cared for by an African American physician.(9) Data from the Commonwealth Fund suggest that geographical proximity only partially explains the draw towards physicians of the same race.(10) Culture and the perception that communication is easier also play important roles. Simply placing a physician of any race in close proximity to an underserved population is not enough to fulfill the needs of the community; there appears to be a demand for healthcare providers of the same race and/or ethnicity.

A recent survey revealed that Asian Americans tended to experience more communication problems with their doctors (most of whom were white) than their white counterparts. In fact, Asian Americans felt that they were less involved than white patients in decisions about care.(11) Other studies revealed that patients are better able to communicate with physicians who are like them and thus more likely to feel comfortable with their care.(12)

Because of the small number and percentage of underrepresented minority physicians graduating from medical school, the accessibility of these physicians will continue to be challenging. Under-represented minorities make up 22.1% of the U.S. population,(13) but only 6.2% of the students graduate from medical school.8 Future U.S. Supreme Court decisions on school admission practices may have a negative impact on these statistics. Although Asian Americans are well represented in medical schools, large swaths of Asian American communities throughout the country are still underserved by well-trained physicians.(14)

Another disconcerting factor is the falloff of all so-called minority students at every step of the academic ladder after graduation.(15) According to Beale et al, “Beginning in middle school and on through high school and college, minority students face several challenges that decrease their likelihood of matriculation to graduate programs in healthcare, and ultimately healthcare leadership.”(16) Because of this, there are few minority physician-leaders that young people can relate to. Furthermore, this falloff has a negative impact on research into the specific concerns of patients from diverse backgrounds.

Healthcare Equality?
In a landmark study by Schulman et al, primary care physicians attending a national meeting were asked to look at videos of African American and white actors of both genders reciting the same exact script, which had them complaining of symptoms consistent with acute myocardial ischemia. Physicians were asked questions on how they would manage the patients. Results showed that the African American women actors were significantly less likely to receive invasive interventions relative to the other actors; African American men were right behind them.(17)
Study results highlight the perception among healthcare providers that they deliver equal care to all patients; when in fact, the care provided is not necessarily equal. And even though there is a desire to deliver equal care, the execution seems to be affected by an unconscious bias or “implicit bias.”18 Despite our wishes to deliver equal care to all patients, most of us have biases that affect how we think, how we perform and how we ultimately manage patient care.

Managing Disparities
Corporate and academic centers are consciously addressing all the issues of unconscious bias and more. The Implicit Association Test is administered to help institutions better understand the pervasive unconscious.(19) The American Association of Medical Colleges, recognizing the need to address healthcare disparities, has asked that medical schools aggressively educate medical students not only on the concerns related to unconscious bias but to increase cultural competence.(20)

Because racial disparities in healthcare utilization and outcomes are well documented, the federal government created Healthy People 2010, a set of published health objectives, which includes the elimination of healthcare disparities.(21) The American Medical Association joined with the
National Medical Association and National Hispanic Association to create a consortium to actively address these disparities. Over 70 medical specialties and healthcare-related organizations – including the Society of Critical Care Medicine – state societies, and representatives from private industry joined the consortium, now known as the Commission to End Health Care Disparities.(22)

So how much do the folks who work in critical care medicine understand about the disparity of care rendered in intensive care units (ICU) throughout the country? As noted earlier, studies have looked at disparities in the management of pain and cardiovascular diseases, and no doubt these could be extrapolated to the critically ill. One body of work has looked at end-of-life care and patients with acute respiratory distress syndrome. However, the specialty has yet to firmly establish that healthcare disparities exist among the critically ill, and thus has not laid out a map that would help diminish the inequities. In fact, the specialty could look at pain management in the critically ill and the differences in management and outcome across the spectrum of diseases. Do ICUs that predominantly treat minorities apply lung-protective strategies, ventilator-associated pneumonia bundles, and sedation holidays to the same degree as their sister hospitals? What are the differences in factors such as ICU length of stay or mortality rates across various disease states?

The Future of Our Specialty
 In addition to addressing these issues, we also should be attune to the racial, ethnic and gender breakdown of our critical care practitioners as well as similar demographics within the Society of Critical Care Medicine (SCCM). Medical students of diverse backgrounds should be encouraged to pursue careers in critical care. As members of SCCM, we must be sure to reach out and engage with minority practitioners, as the organization assumes the same responsibilities. These efforts will help in the fight to minimize and eliminate healthcare disparities. By staying attune to these issues within society and within our own organization, we are closer to achieving SCCM’s mission of improving critical care.
 
 
References:
 1. Smedley BE, Stith AY, Nelson AR, eds. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. http://www.iom.edu/Reports/2002/Unequal-Treatment-Confronting-Racial-and-Ethnic-Disparities-in-Health-Care.aspx. Published March 20, 2002. Accessed May 3, 2013.
 2. Green C, Anderson KO, Baker TA, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med. 2003;4(3):277-294.
 3. Bonow RO, Grant AO, Jacobs AK. The cardiovascular state of the union: confronting healthcare disparities. Circulation. 2005;111(10):1205-1207.
 4. Hepatitis and Asian Americans. The Office of Minority Health website. http://www.minorityhealth.hhs.gov/templates/content.aspx?id=6495. Accessed May 3, 2013.
 5. Understanding the reforms. The Whitehouse.gov website. http://www.whitehouse.gov/healthreform/healthcare-overview#healthcare-menu. Accessed May 3, 2013.
 6. Affordable Care Act brings influx of patients. Medical Economics. July 25, 2012. http://medicaleconomics.modernmedicine.com/medical-economics/news/modernmedicine/modern-medicine-feature-articles/affordable-care-act-brings-in. Accessed May 3, 2013.
 7. Skinner J, Chandra A, Staiger D, Lee J, McClellan M. Mortality after acute myocardial infarction in hospitals that disproportionately treat black patients. Circulation. 2005;112(17):2634-2641.
 8. America needs a more diverse physician workforce. AspiringDocs.org website. https://www.aamc.org/download/87306/data/. Published March 16, 2006. Accessed May 3, 2013.
 9. Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Aff (Millwood). 2000;19(4):76-83.
 10. Mead H, Cartwright-Smith L, Jones K, Ramos C, Woods K, Siegel B. Racial and ethnic disparities in U.S. health care: a chartbook. The Commonwealth Fund. http://www.commonwealthfund.org/Publications/Chartbooks/2008/Mar/Racial-and-Ethnic-Disparities-in-U-S--Health-Care--A-Chartbook.aspx. Published March 13, 2008. Accessed May 3, 2013.
 11. Ngo-Metzger Q, Legedza AT, Phillips RS. Asian Americans’ reports of their health care experiences: results of a national survey. J Gen Intern Med. 2004;19(2):111-119.
 12. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282(6):583-589.
 13. U.S. Census Bureau projections show a slower growing, older, more diverse nation a half century from now. United States Census Bureau website. https://www.census.gov/newsroom/releases/archives/population/cb12-243.html. Published December 12, 2012. Accessed May 3, 2013.
 14. Weir RC, Winston T, Yen IH, Caballero J. Primary health-care delivery gaps among medically underserved Asian American and Pacific Islander populations. Public Health Rep. 2009;124(6):831-840.
 15. Fang D, Moy E, Colburn L, Hurkey J. Racial and ethnic disparities in faculty promotion in academic medicine. JAMA. 2000;284(9):1085-1092.
 16. Beal A, Abrams M, Saul J. Healthcare workforce diversity: developing physician leaders. The Commonwealth Fund. http://www.commonwealthfund.org/Publications/Testimonies/2003/Oct/Healthcare-Workforce-Diversity--Developing-Physician-Leaders.aspx . Published October 12, 2003. Accessed May 3, 2013.
17. Nelson JC, and the American Medical Association. Invited testimony of the Sullivan Commission on Diversity in the Healthcare Workforce. http://www.ama-assn.org/resources/doc/mac/testimonyoctober.pdf . Published October 20, 2003. Accessed May 3, 2013.
 17. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physician’s recommendation for cardiac catheterization. N Engl J Med. 1999;340(8):618-626.
 18. Allport GW. The Nature of Human Prejudice. New York, NY: Basic Books; 1979.
 19. Greenwald AG, McGhee DE, Schwartz JL. Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol. 1998;74(6):1464-1480.
 20. Tool for assessing cultural training (TACCT). Association of American Medical Colleges website. https://www.aamc.org/initiatives/tacct/. Accessed May 3, 2013.
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 22. Commission to End Health Care Disparities (CEHCD). American Medical Association website. http://www.ama-assn.org/ama/pub/physician-resources/public-health/eliminating-health-disparities/commission-end-health-care-disparities.page. Accessed May 3, 2013.