CriticalCareCares: Health Disparities in the ICU – Here’s What You Need to Know

So what can we do? The challenges and barriers to healthcare equality are daunting. As a single provider, it can be difficult to decide where to begin and in what capacity. But everyone can play a valuable role from students to nurses to residents, attendings, and administrators. The Institute of Medicine, the American Medical Association, and the CDC are just a few organizations that have been working to remove systemic bias, eliminate inequities, and alleviate barriers to care. Here are five ways that you can help work towards healthcare justice in your own practice. 

1) Educate and empower your patients and their families

One of the most effective and immediate ways to reduce disparities is to speak to and educate your patients. In the ICU, I have discovered that poor and disadvantaged patients and their families have less knowledge of their clinical course and their options, might not know what questions to ask or what to expect, and have a greater mistrust of the healthcare system in general. We have to take time to understand what they know, what is their perspective and why they think this way, and how they want to proceed. If necessary, we should use interpreter services as often as possible. We must work on building and maintaining trust and on providing them with resources on hospice and end-of-life care when appropriate. Finally, if they wish, we should incorporate community leaders they trust (religious leaders, primary care providers, etc.) to help them understand the course of disease and their prognosis. 

2) Incorporate health disparities discussions in rounds

The Choosing Wisely Campaign recommends specific ICU practices to curtail waste and patient harm. This includes ceasing the orders of diagnostic tests (like morning labs and chest x-rays) unless one is asking a specific clinical question. Being prudent in what tests or procedures we perform is essential if we want to reduce health disparities because the costs can quickly add up. In fact, medical admissions are one of the leading causes of bankruptcies in America. And if you are already on the precipice of falling behind on your bills when you are admitted to the hospital, it won’t take much to send you over the edge. Since many decisions are made during rounds, a cost-benefit analysis of what is necessary versus what is extra must be made with a diverse and multidisciplinary team. This is the perfect time to get social workers involved, to consider the context of the patient’s life, and to educate trainees and staff about the need to reduce health disparities.

3) Conduct research and monitor progress towards eliminating health disparities

When it comes to making change at any level, tracking your progress is critical. If we want many little changes to culminate into grand, societal change then we must keep detailed demographic statistics about who we admit to the ICU, who we reject, and why. We need to take into account which patients are boarding in the emergency department and for how long. We also have to consider the length of a patient’s ICU stay and ensure that it is strictly due to medical necessity and not because of a patient’s VIP status or due to lack of understanding or misgivings about the role of life support versus comfort care.

4) Recruit and hire diverse staff and providers

In the last year, it has been heartening to see the outpouring of support for social medicine initiatives in healthcare institutions, journal articles, and on social media. But now it is time to turn the talk into action. It has been well documented that patients of color rated providers that looked like them to be more superior at listening, treating them with respect, communicating, providing better care, and involving them in decision making. Currently, the United States is on pace to become predominantly people of color in 25 years. In order to ensure satisfaction and quality of care of patients, we have to build a stronger pipeline for educating, recruiting, and hiring providers of color. It is not the lack of ability that many students of color do not pursue careers in medicine, but more often the lack of opportunity, mentorship, and outreach. If we are serious about meeting the requirements of a 21st century patient population, then we need to prove our commitment.

5) Make your voice heard at the administrative or political level

A January 2021 NPR article highlighted the problems faced by the Martin Luther King Jr. Hospital in South LA, which serves a predominantly Latino and Black population and has the fewest number of hospital beds per 100,000 people in LA County. In a good year, the emergency department loses ten million dollars each year. But in 2020, an emergency department with the resources to treat 40,000 patients a year had to care for 110,000 instead. At the height of the pandemic in California, over 66% of the patients in the hospital were COVID-19 patients, two to three times that of other major hospitals in LA. Why? Because so many patients are on public health insurance, which pays only a fraction of what private insurance pays. And unfortunately, underfunded hospitals tend to be understaffed as well, because the money to train and retain providers is not available.

Dr. Elaine Batchlor, the CEO of MLK Hospital explained the paradox of the problem facing her community: “We’re getting paid adequately to amputate someone’s leg. But we’re not getting paid adequately to prevent that leg from being amputated.” This is unacceptable. We have a broken healthcare system that has misplaced its priorities, perverted its incentives, and is only exacerbating health disparities. As healthcare providers, we have to lobby political leaders, businesses, and hospital administrators to institute policies, craft legislation, and delegate funding to help support safety net hospitals, which are sometimes minority hospitals that are chronically underfunded and understaffed.