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

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Picture of Bassam Zahid, MD
Bassam Zahid, MD
EM PGY-3. Rising ACCM fellow. Interested in international critical care, artificial intelligence, and all things motivation and productivity. I host a podcast called Doctor Hustle (www.doctorhustle.com), which explores creativity, leadership, and entrepreneurship in the healthcare community. You can learn more about me and my work at my website (www.bassamzahid.com).

The Pre-brief

More than half a million people have died from COVID-19 in the United States. The virus and its consequences have shuttered businesses, separated us from friends and family, and stalled vacations, birthdays, and weddings. The pandemic has also exposed the socioeconomic disparities that led a large number of essential workers, made up of predominantly people of color, to contract and spread the virus in their communities. In turn, this led to large numbers of Black and Latino patients being hospitalized and, unfortunately, succumbing to the disease. According to the COVID Tracking Project, African Americans have died at 1.4 times the rate of white people and Latinos at 1.2 times.

Source: https://covidtracking.com/race

However, this is not breaking news to communities of color who have come to expect these statistics. Our society and the healthcare system are built on interpersonal, institutional, and structural biases that have manifested themselves in a variety of ways, both explicitly and implicitly. Factors contributing to healthcare disparities include race, gender, and sexual orientation, access to and delivery of healthcare, patient education and finances, and social and cultural differences. These disparities have been noted for nearly every major disease.

Unfortunately, patients with critical illness or in the ICU are not immune to the effects of healthcare inequities. In the entire continuum of acute critical illness, health disparities have been observed from individual susceptibility to clinical presentation to medical treatment to final outcomes. In one study, researchers noted that even after controlling for hospital and insurance plans, patients of color were admitted to ICUs less often than white patients with the same diagnosis.

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3873606/

Across the board, African-American patients receive less intensive treatment overall. They have fewer blood transfusions, orthopedic procedures, cardiovascular procedures, lung resections due to cancer, and organ transplantations. This occurs despite the fact that patients of color have higher rates of comorbid conditions like diabetes, asthma, chronic renal failure, HIV, obesity, and hypertension. Black patients have the highest incidence of critical illnesses and are more likely to die from out-of-hospital cardiac arrests and sepsis.

When it comes to end-of-life care, a purview of expertise that resuscitationists and intensivists pride themselves in, we are failing people of color. Black people are more likely to require intensive care, use advanced life support, receive CPR, have higher end-of-life spending, and die in the hospital. They are less likely to have comfort-driven care, use hospice, have advanced directives or living wills, and have DNR orders.

The discrepancies in healthcare extend to quality of care delivered in minority hospitals as well as access to critical care. A 2020 study by Danziger et al, compared non-minority and minority hospitals (defined as a minority census > 25% in the ICU). Over a ten year period from 2006 to 2016, researchers analyzed temporal trends in ICU mortality, length of stay, and delay until ICU admission. In all three categories, non-minority hospitals steadily improved with decreasing deaths, faster discharges, and faster admissions. Minority hospitals remained stagnant in all three.

Another 2020 study by Kanter et al, explored how ICU bed availability (defined as number of beds per 10,000 hospital service area residents aged 50 or older) was related to community income. As expected, they discovered that ICU beds are more available in wealthier communities. The major surprise was that 49% of the low-income communities (< $35,000) had zero ICU beds. Rural communities had markedly less beds available than dense, urban areas, but income disparities still persisted in cities.

Source: https://pubmed.ncbi.nlm.nih.gov/32744946/

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.

Every day, I take a look at the latest COVID-19 numbers and hope that we are finally turning the corner so that life can get back to normal. But the pandemic has laid bare important truths that we cannot and should not ignore. We have stark socioeconomic disparities, a politically divided country, an unchecked environmental crisis, and rampant healthcare inequality. We cannot quickly solve all the problems that exist, but we must do our part to pull our communities together. For us, this means learning, teaching, and fighting to solve the injustices in our own schools, clinics, and hospitals. I recommend that everyone continue their education in understanding the causes and solutions to healthcare disparities. Start with the links below. Do your own literature review. Ask your department what initiatives are being instituted to address these issues. Encourage your trainees to give presentations and conduct research on social medicine. Don’t forget to contact your political leaders. As healthcare providers, our voice has weight, now more than ever. But in our 24/7 media cycle, who knows how long it will last. We cannot delay. The time is now.

The Debrief

  • In the entire continuum of acute critical illness, health disparities have been observed from individual susceptibility to clinical presentation to medical treatment to final outcomes.
  • Factors contributing to healthcare disparities include race, gender, and sexual orientation, access to and delivery of healthcare, patient education and finances, and social and cultural differences. These disparities have been noted for nearly every major disease.
  • In order to work towards healthcare justice, we must educate and empower our patients, make healthcare disparities discussions a part of rounds, conduct research and monitor progress on healthcare inequities, hire diverse staff and providers, and make our voices heard to administrators and politicians.

References

  1. Soto GJ, Martin GS, Gong MN. Healthcare disparities in critical illness. Crit Care Med. 2013;41(12):2784-2793. doi:10.1097/CCM.0b013e3182a84a43 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3873606/
  2. Danziger J, Ángel Armengol de la Hoz M, Li W, Komorowski M, Deliberato RO, Rush BNM, Mukamal KJ, Celi L, Badawi O. Temporal Trends in Critical Care Outcomes in U.S. Minority-Serving Hospitals. Am J Respir Crit Care Med. 2020 Mar 15;201(6):681-687. doi: 10.1164/rccm.201903-0623OC. PMID: 31948262; PMCID: PMC7263391.
  3. Kanter GP, Segal AG, Groeneveld PW. Income Disparities In Access To Critical Care Services. Health Aff (Millwood). 2020 Aug;39(8):1362-1367. doi: 10.1377/hlthaff.2020.00581. PMID: 32744946.
  4. Chertoff J. Racial disparities in critical care: experience from the USA. Lancet Respir Med. 2017 Feb;5(2):e11-e12. doi: 10.1016/S2213-2600(17)30009-7. PMID: 28145235.
  5. Martin G.S. (2006) Healthcare Disparities in Critically Ill Patients. In: Vincent JL. (eds) Yearbook of Intensive Care and Emergency Medicine. Yearbook of Intensive Care and Emergency Medicine, vol 2006. Springer, Berlin, Heidelberg. https://doi.org/10.1007/3-540-33396-7_74
  6. Muni S, Engelberg RA, Treece PD, Dotolo D, Curtis JR. The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest 2011; 139: 1025–33. 
  7. Barnato AE, Anthony DL, Skinner J, Gallagher PM, Fisher ES. Racial and ethnic differences in preferences for end-of-life treatment. J Gen Intern Med 2009; 24: 695–701. 
  8. Dobkin C, Finkelstein A, Kluender R, Notowidigdo MJ. Myth and Measurement – The Case of Medical Bankruptcies. N Engl J Med. 2018;378(12):1076-1078. doi:10.1056/NEJMp1716604
  9. Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Aff (Millwood). 2000 Jul-Aug;19(4):76-83. doi: 10.1377/hlthaff.19.4.76. PMID: 10916962.
  10. Saha S, Arbelaez JJ, Cooper LA. Patient-physician relationships and racial disparities in the quality of health care. Am J Public Health. 2003;93(10):1713-1719. doi:10.2105/ajph.93.10.1713
  11. Fadel, L. “‘The Separate and Unqeual Health System’ Highlighted by COVID-19”. NPR. https://www.npr.org/2021/01/21/959091838/the-separate-and-unequal-health-system-highlighted-by-covid-19
  12. COVID Racial Data Tracking Project: https://covidtracking.com/race
  13. CDC Health Disparities and Inequalities Report: https://www.cdc.gov/minorityhealth/CHDIReport.html
  14. Healthypeople.gov: Disparities https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities

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