Is Equity, Diversity, and Inclusion Important for Perioperative Outcomes 10.2.20

Equity, Diversity and Inclusion &

perioperative outcomes

MPOG Annual Retreat October 2, 2020

Nathalia Jimenez MD. MPH

Associate Professor & Vice Chair Equity Diversity and Inclusion,

Department of Anesthesiology and Pain Medicine ,

University of Washington, Seattle, WA

•I have no conflicts of interest

Objectives

1. Describe key concepts of Equity, Diversity and Inclusion (EDI)

2. Explain what are Social Determinants of Health (SDOH) and its

contribution to perioperative outcomes

3. Discuss strategies to incorporate EDI in perioperative outcomes

research and QI

Outline

(1) Importance of equity, diversity and inclusion (perioperative care/outcomes)

- What are social determinants of health (SDOH)/ examples disparities in

perioperative care

- demographic and socioeconomic factors in the US population

(2) One size does not fit all, how QI/QS efforts can increase disparities

(3) Promoting equitable outcomes

-The role of Quality improvement work & research

-Beyond adjusting, how to interpret disparities between population groups

-We found disparities, now what? moving from documenting to implementing

solutions.

Should we care about diversity?

Paradigm

• All patients are equal

• I treat all my patients the same (equally) , I don't see race/ ethnicity/gender…

• Anesthesia is data driven-we use the same information for all patients (age,

gender, weight, comorbidities, same fasting guidelines…)

anesthesiologists

& Diversity

(equity and

Inclusion)

All patients are NOT the same

We treat patients differently

We strive for equitable care VS equal care

• Age → developmental range (physical, emotional & cognitive )

• gender → PONV, Sugamadex

• Race →

• differential prevalence-comorbid conditions

population groups (i.e. sickle cell disease, cystic fibrosis)

• Genetic associations population groups-

CYP2D6 and ultra-rapid codeine metabolizers

• Anesthesia uses the same information for all patients→ BUT

• We tailor care according to: age, gender, weight,

comorbidities

Implicit Bias & medical care

• Explicit (self-reported) beliefs known to the individual

• Implicit (non-conscious) beliefs not readily apparent to the individual and can differ

from a person’s explicit beliefs

→implicit prejudice, discrimination, and bias can be observed in the absence of intention

to discriminate. ( examples medical literature )

→Implicit attitudes more frequent non-verbal behavior

Sabin et al. Physicians’ Implicit and Explicit Attitudes About Race by MD Race, Ethnicity, and Gender JHCPU. 2009; 20(3): 896–913

Sabin et al. The Influence of Implicit Bias on Treatment Recommendations for 4 Common Pediatric Conditions. American Journal of Public Health | 2012, Vol 102, No. 5

Anesthesia & implicit bias ?

• Non verbal interaction with patients

• Don’t have immediate feedback from patients (prophylactic tx PONV, Pain)

• Quick decisions based limited number of variables

Disparities in Anesthesia care

example 1.

• Antiemetic Prophylaxis as a Marker of Healthcare Disparities in the

National Anesthesia Clinical Outcomes Registry (Andreae et al)

• Main finding: association between socioeconomic markers and anti-emetic

prophylaxis (ondansetron and dexamethasone).

• Medicaid patients less likely to receive anti-emetic OR 0.85 [0.81, 0.89]

• Methods:

• Use of large dataset (NACOR) 173,133 cases.

• Outcome anti-emetic prophylaxis → surrogate marker for anesthesia quality

(availability, applicability, cost)

• Predictor socioeconomic indicators: Insurance and income (Beyond race)

Anesth Analg. 2018 February ; 126(2): 588–599.

What are Social determinants of health

SDOH

Economic Stability

Employment

Food Insecurity √

Housing Instability √

Poverty √

Education √

Early Childhood Education and Development

Enrollment in Higher Education

High School Graduation

Language and Literacy √

social and Community Context

Civic Participation

Discrimination

Incarceration

Social Cohesion – Family support √

Health and Health Care

Access to Health Care √

Access to Primary Care √

Health Literacy √

Neighborhood and Built Environment

Access to Foods that Support Healthy Eating

Patterns

Crime and Violence

Environmental Conditions

Quality of Housing √

Adapted from CDC model

Poverty

• 38.1 million people lived in Poverty USA. poverty rate 11.8% (2018)

• Distribution unequal

Higher among females Higher among children

Poverty

poverty line—for an individual was $12,784 yr

Higher among NA/AA/Hispanic

Poverty: Percent of US children <17 years

living in poverty

Office of Disease prevention and Health Promotion-

Heathy People 2020

Anesthesia

-Food insecurity

-Obesity/failure to

thrive

-poor TX adherence

-Calls (phone

minutes)

Year 2019, a family of two adults and two children fell in the

“poverty” category if their annual income fell below

$25,926/yr.

18% US

WA 10%

Demographic changes in the U.S

Race and ethnicity U.S population

• is increasingly more diverse.

• The biggest change is among Children

Disparities in anesthesia care

example 2.

• Race, Postoperative Complications, and Death in Apparently Healthy Children

(Olubukola et al)

• Main finding: AA children compared to White children had higher 30 DPOP

mortality OR 3.43 (95% CI: 1.73–6.79), post-operative complications : 1.18 (95%

CI: 1.13–1.23) and serious adverse events (OR 1.07; 95% CI: 1.01–1.14).

• Methods:

• NSQIP-Pediatrics (2012–2017) 172,549 patients.

• Serious adverse events in healthy children (excluded ASA3+)

• Adjusting age, sex, age, RVU (complexity of procedure), year of procedure, case urgency and

operating time.

2017

Demographic

characteristics of uninsured

in the United States

Insurance coverage by demographic characteristics

US census Data

Disparities in Anesthesia care

example 3.

• A Cross-Sectional Analysis of Community Water Fluoridation (CWF) and Prevalence

of Pediatric Dental Surgery Among Medicaid Enrollees (Lee et al)

• Main finding: Access to CWF is associated with lower caries-related visits and Dental surgery

• Methods:

• Use of large dataset (Medicaid claims data) 436 counties within 5 states per year (872 county-

year observations)

• Outcome Dental surgery under general anesthesia (Cost, resources , exposure GA pediatrics )

• Predictor public health intervention water fluoridation at the county level (regional variation)

JAMA Network Open. 2020;3(8):e205882..

Refugees and immigrants:

A refugee is someone who has been forced to

flee his or her country because of persecution,

war or violence.

SDOH

-LEP

-Health literacy

Anesthesia

-prior traumatic events

-coping

-anxiety

Immigrants and

refugees

Limited English

Proficiency (LEP)

Health literacy

• nearly 5 million English language learners in U.S. public schools in

fall 2015

• represent 9.5% of U.S. public school enrollees, 8.1% in 2000.

• ~ 3/4 of students with LEP in U.S. public schools (77%) spoke

Spanish as their primary language at home in 2015

<3%

3-<6 %

6-<10 %

>10%

PEW research center/ National Center for Education Statistics

Disparities in anesthesia care

example 4.

Postoperative Pain Management in Children, Parental English Proficiency,

and Access to Interpretation (Jimenez et al)

Methods:

- Small clinical dataset 474 patients ( 1 year data)

- Matching by age group, surgical procedure, and admission date.

- Assessment of intervention

- Clinical and administrative dataset ( billing data interpreter services)

Main finding: Children of LEP parents had fewer pain assessments, were less likely to receive opioid

analgesics compared with children of EP parents. More frequent use of professional interpreters mitigate

differences.

Hosp Pediatr. 2014 Jan; 4(1): 23–30.

EDI Research and Quality Improvement

Quality improvement (QI) approaches are appealing for addressing

disparities

• QI strategies target modifiable aspects of care delivery

• Address multiple aspects of care in a systematic fashion

• Tailor care over time based on data monitoring.

• Policy supported IOM→ equity is a core domain of health care quality

• AHRQ formalized this link (quality equity) annual quality & disparity

reports

https://www.ahrq.gov/research/findings/nhqrdr/nhqdr18/index.html

• Supported by legislation: ACA requires collection of race/ethnicity data &

reporting of quality performance measures stratified by race/ethnicity

Potential effects of QI interventions on health disparities.

K. Casey Lion, and Jean L. Raphael Pediatrics

2015;135:354-361

QI interventions may not improve disparities

In some cases, disparities may worsen

• greater uptake or effectiveness of the intervention in the population with better

outcomes at baseline.

• Standardized clinical pathways (do not account for differences in populations)

• benchmarking (avoidance of higher risk patients)

• performance incentives (avoidance of patients barriers for adherence treatment)

• public reporting

• provider reminder systems, and decision aids. (difficult heterogeneity)

Addressing Disparities

example 5.

Reduction of Peripartum Racial and Ethnic Disparities-A Conceptual Framework and

Maternal Safety Consensus Bundle. (Council on Patient Safety in Women’s Health Care-Toledo P)

Obstetrics & Gynecology 2018 – V 131 - 5 - p 770-782

https://safehealthcareforeverywoman.org/patient-safety-bundles/reduction-of-

peripartum-racialethnic-disparities/

• Multidisciplinary group

• Commitment to address racial & ethnic disparities

• Bundle created within framework of SDOH

• Systematic approach support systems in addressing disparities

• Readiness

• Recognition

• response

• Reporting –systems learning

Disparities Research

especial consideration

Research methods should adapt to population characteristics and

sociocultural environments i.e. IRB (confidentiality, data management)

Cultural/linguistic considerations challenge the use of mainstream

interpretations of standard evaluation techniques. (i.e. Scales)

do no harm to the populations involved. i.e. Research subject protection

issues and poss. of biases can lead to misinterpretation of results

Disparities Research

difficulties

• Clinical trials, longitudinal cohort studies →

• Recruitment (lack of trust in the system)

• Cost (i.e. Interpretation and translation of materials)

• Adherence (follow up- migrant workers, high mobility populations)

• Existing data →

• No data (before ACA, no data on race/ethnicity except for Medicaid/Medicare)

• Inadequate data race/ethnicity (assigned vs self- reported);

• Data based in obsolete constructs gender (binary)

Recommendations from the National Institute on

Minority Health and Health Disparities (NIMHD)

• formative

• needs assessments (informed by key stakeholders)→

• research relevant to the community and context

• draw upon the assets of the population

• Process: instruments, policies, timing, training, data collection, reliability of the

practices, and adherence to the design

• design and methodology

• Etiologic research should assess exposures and outcomes at multiple levels

• Interventional: multilevel interventions

• summative (outcomes, impacts, and cost)

Am J Public Health 2019 ;109(S1):S34-S40.

Summary

1.Social Determinants of Health (SDOH) contribute to perioperative outcomes

2. equity is a core domain of health care quality

3. Data, Data → to address disparities we need to measure & monitor them

4. QI interventions may reduce disparities if appropriately implemented

5. Disparities research is needed and can be done if it is rooted in the needs and

strengths of vulnerable populations

Questions?

Nathalia Jimenez

njimen@uw.edu