Unequal Treatment: How to Move from Detecting to Understanding and Reducing Healthcare Disparities within Otolaryngology
Recently the coronavirus pandemic has illuminated long-standing social, economic, and health inequities in the United States.
Sarah N. Bowe, MD; Karthik Balakrishnan, MD; Uchechukwu C. Megwalu, MD; and Regan W. Bergmark, MD
Recently the coronavirus pandemic has illuminated long-standing social, economic, and health inequities in the United States. Initially less than a dozen states publicly shared data on the racial and ethnic patterns of COVID-19, and what emerged painted an alarming portrait.1 In New York City, deaths from coronavirus adjusted for the size and age of the population disproportionately affected Hispanic and Black people, occurring at a rate of 22.8 per 100,000 and 19.8 per 100,000, respectively, compared with 10.2 per 100,000 for White individuals.2 In Wisconsin’s Milwaukee County, 50% of cases and 81% of fatalities were among Black individuals, yet they only accounted for 25% of the local population.1 As a result, the American Medical Association (AMA) wrote a letter to the then U.S. Department of Health and Human Services Secretary Alex Azar urging all healthcare agencies and institutions to immediately standardize, collect, and release race and ethnicity data. The AMA was not alone in its request—six other top physician organizations signed the letter.3 The Association of American Medical Colleges echoed similar concerns, with David A. Acosta, MD, chief diversity and inclusion officer, noting that “better data on the current pandemic will give us an opportunity to take decisive action to protect vulnerable communities.”4
The aforementioned comments and findings emphasize the critical starting point of health disparities work: detection.5 In 2006 Kilbourne et al. proposed a conceptual framework progressing from detection to understanding, followed by reduction. The first phase involves defining health disparities, identifying vulnerable populations, and developing assessment measures. Health disparities can be defined as “observed clinically and statistically significant differences in health outcomes or healthcare use between socially distinct vulnerable and less vulnerable populations that are not explained by the effects of selection bias.”5 Vulnerable populations include any groups that face discrimination because of underlying differences in social status (e.g., race/ethnicity, sex/gender, age, socioeconomic status, literacy). The selection of measures will vary widely but should broadly include process measures, or differences in healthcare use (e.g., insurance, access to care), and outcome measures, or differences in health status (e.g., disease severity, mortality). Over the past decade, numerous studies have identified healthcare disparities within our specialty, yet few have progressed beyond detection to understanding.6
In order to achieve understanding, it is important to recognize the complexity of factors that contribute to healthcare disparities, which can be very context dependent. Thus, while some collective information on health disparities can be shared, there is also a critical need to perform analysis on a more individualized basis, including unique patient, provider, and healthcare system factors. The detailed information that is obtained during the understanding phase can be used to drive the development and implementation of interventions that will ultimately lead to the reduction of healthcare disparities. Following are shared experiences and perspectives from notable leaders within otolaryngology as they work on understanding healthcare disparities within their own patient populations.
Karthik Balakrishnan, MD, MPH
Humans understand the world by categorizing experiences to form cognitive associations.7 We apply these associations to understand subsequent experiences and interpersonal interactions. The result is often inappropriate generalization from specific experiences, or bias, to which clinicians are particularly vulnerable due to the high cognitive demands of our profession.7 Because these biases are the result of the interaction of individuals and the societies in which they live, they also manifest on the societal level as privilege and disadvantage.8
In healthcare, bias, privilege, and disadvantage directly affect health outcomes through every aspect of patient-provider interaction, medical decision-making, patient experience, and treatment adherence.9 Meanwhile multiple studies have demonstrated improved patient-provider interaction metrics when the patient-provider dyad is concordant for race or gender.10
To counter these biases and move toward justice in healthcare, we must reduce both the effects of our personal biases and the systemic privileges and disadvantages experienced by our patients. Awareness of our biases is a critical first step, followed by a mindful approach to altering our cognitive associations.11 Meanwhile, as a specialty and a profession, we must confront biases in how we select, train, and promote colleagues, in order to reduce privilege and disadvantage in who enters and thrives in our specialty. This in turn will increase diversity among clinicians in otolaryngology, conferring downsteam benefits to our patients.12-13
Uchechukwu C. Megwalu, MD
Sociodemographic disparities are becoming increasingly apparent in head and neck cancer (HNC). In addition to tumor-specific and treatment factors, nonclinical factors—such as race, gender, and socioeconomic status—are known to significantly impact patient outcomes. Of these, race/ethnicity and insurance status have been the most studied. Significant racial disparities exist in HNC outcomes.14-18 Black patients present with more advanced tumors, are less likely to receive appropriate treatment, and have worse survival outcomes than other racial groups, even after adjusting for disease stage and other clinically important factors.15, 16, 19-23 Significant insurance status disparities have also been demonstrated in HNC outcomes. Uninsured and Medicaid patients have worse outcomes compared with commercially insured patients.24-27
Understanding the drivers of sociodemographic disparities is critical for designing and testing interventions aimed at reducing disparities. Some of the racial/ethnic and insurance status differences in outcomes may be explained by differential access to high-quality care. Several studies have shown that certain racial/ethnic populations are more likely than non-Hispanic Whites to receive care in low-quality hospitals.28-31 These racial/ethnic disparities may also be mediated by insurance status. Uninsured and Medicaid patients are also more likely to be treated in low-quality hospitals than commercially insured patients.28, 31 However the role of insurance status and hospital quality as drivers of HNC disparities has not been previously studied. Further investigation of these potential drivers is important, especially as these are actionable targets for interventions addressing HNC disparities.
Regan W. Bergmark, MD
The COVID-19 pandemic will exacerbate health disparities for diseases of the head and neck and more broadly through multiple mechanisms.32-34 First, the delays in care suffered by patients throughout the United States due to the pandemic are expected to most severely affect patients who are already at risk of having delayed care, including racial and ethnic minority patients and uninsured and Medicaid patients. Second, job loss is leading to loss of insurance or transitions to insurance programs with less coverage. These changes are expected to lead to worsening discontinuity of care as patients need to delay care or switch healthcare systems. Job loss additionally reduces personal or family resources, making healthcare costs more financially toxic. Third, hospital closures are expected—particularly in rural areas—due to the economic effects of the pandemic, reducing potential points of access. Fourth, the impact of the pandemic on education raises a longer-term risk to the diversity of our workforce.
A population health approach to diseases of the head and neck and leadership from otolaryngologists across the country can help mitigate these effects. Wait times for virtual appointments, in-person appointments, and surgical procedures should be determined based on clinical urgency and analyzed based on race/ethnicity and insurance status to try to ensure equity in real time.32-34 Partnering with community centers and primary care clinics in underserved areas can potentially expedite referrals from these communities. For the long term our specialty should be deeply involved in national discussions on financial incentives in the U.S. healthcare system. For lasting and deep change, insurance coverage should be expanded, and addressing and reducing healthcare disparities should be financially rewarded.35
Acknowledgment: The content of this article was discussed in detail during the AAO-HNSF 2020 Virtual Annual Meeting & OTO Experience Panel Presentation “Unequal Treatment: How HealthCare Disparities Negatively Impact Our Otolaryngology Patients” and was sponsored by both the AAO-HNS Diversity and Inclusion Committee and the AAO-HNS Patient Safety and Quality Improvement Committee.
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