By James C. Etheridge, MD, and Christy E. Cauley, MD, MPH
The COVID-19 pandemic threatens to worsen existing disparities in the delivery of surgical care. Millions of elective operations have been postponed or cancelled as resources are taxed and safety concerns mount.¹ This unprecedented backlog of operations has forced surgeons, hospitals, and healthcare systems to make many difficult decisions.² Approaches to case prioritization and scheduling profoundly impact the ability of disadvantaged individuals to access surgical care. Such decisions can have far-reaching effects on health equity. We spoke with Dr. Zara Cooper, an acute care surgeon and Kessler Director for the Center for Surgery and Public Health at Brigham and Women’s Hospital, about a new initiative to reduce disparities in access to surgical care.
Even before the pandemic, disparities in surgical care were well-known. As Dr. Cooper noted, “Inequality has been documented in almost every area of surgery, whether it’s plastic surgery, general surgery, trauma surgery, transplant surgery, colorectal surgery, breast surgery, cardiothoracic surgery — the list goes on and on.” The American College of Surgeons recognizes access as the lynchpin for improving health equity.³ Indeed, several studies demonstrate that surgical outcome disparities are reduced or even eliminated when access disparities are addressed.⁴ ⁵ ⁶
“Inequality has been documented in almost every area of surgery, whether it’s plastic surgery, general surgery, trauma surgery, transplant surgery, colorectal surgery, breast surgery, cardiothoracic surgery — the list goes on and on.”
The pandemic has underscored existing inequalities in healthcare.⁷ Early on, Brigham and Women’s Hospital appreciated the need to address equity concerns in the COVID-19 response. “Our leadership recognized that there was an absence of equity built into our incident command structure, so I was asked to be an equity representative,” Dr. Cooper recalled. Working with a diverse multidisciplinary team, Dr. Cooper helped to develop and implement the data infrastructure for monitoring equity in Brigham and Women’s resource allocation and access to care.⁸ This infrastructure allowed them to track “how many tests we were providing, how many patients were coming through the Emergency Department, and who they were. Demographics were broken down by race, ethnicity, and English proficiency.” As a result, the hospital system was able to evaluate changes in their patient population as the first wave mounted and operating rooms closed to elective surgery. “Brigham and Women’s is not a safety net hospital. Our patients tend to be disproportionately white, well-educated, and insured.” The shifting demographic distribution revealed by the dashboard was striking.
As the hospital prepared to resume elective operations after the first wave, Brigham and Women’s repurposed their data infrastructure to inform surgical scheduling decisions. By providing clear metrics, this equity dashboard proved to be a powerful tool for reducing inequalities in access to surgical care. “We were considering not only the surgeries that were performed, but we were looking at our depot. So who are those patients that were put on hold because of the pandemic? Which elective cases were canceled?” Access to this data helped surgical leaders make policy decisions and ensure disadvantaged patients were not disproportionately affected by delays and cancellations.
However, acting on insights from the equity dashboard is not without challenges. Addressing the gaps identified by the dashboard often requires structural changes. Examples of these changes include adjusting compensation or payment models, changing clinic or operating room hours, and using virtual care to reduce costs for patients.
Overall, the equity dashboard has been well-received. “Sunlight is the best disinfectant,” Dr. Cooper reflected. “As surgeons and scientists, we are data driven: we need to see numbers and we need to measure improvement.” Those numbers were eye-opening for hospital and departmental leadership. “Many were surprised by the lack of diversity in our surgical patient population, because that’s not necessarily what we experience day to day.”
“We have to be mindful that those environmental factors, those social factors, those economic factors that were making it hard for a segment of our population before the pandemic, those burdens have only increased.”
Moving forward, Dr. Cooper believes the equity dashboard will continue to drive change after the pandemic. “It really underscored some major gaps in our patient population. It has spurred us to think as a department and as a hospital: how can we truly be more responsive to the needs of our community? How can our patient base be more representative of our neighbors?” Attention to these disparities will become more crucial in the wake of the pandemic. “We have to be mindful that those environmental factors, those social factors, those economic factors that were making it hard for a segment of our population before the pandemic, those burdens have only increased.”
- COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020 Oct;107(11):1440–1449.
- Brindle ME, Doherty G, Lillemoe K, Gawande A. Approaching Surgical Triage During the COVID-19 Pandemic. Ann Surg. 2020;272(2):e40-e42.
- American College of Surgeons. Statement on optimal access. Available from: http://bulletin.facs.org/2013/04/statement-on-optimal-acces. 2013. Accessed December 7, 2020.
- Robinson CN, Balentine CJ, Marshall CL, et al. Ethnic disparities are reduced in VA colon cancer patients. Am J Surg 2010; 200:636–639.
- Hofmann LJ, Lee S, Waddell B, Davis KG. Effect of race on colon cancer treatment and outcomes in the Department of Defense healthcare system. Dis Colon Rectum 2010;53:9–15.
- Banez LL, Terris MK, Aronson WJ, et al. Race and time from diagnosis to radical prostatectomy: does equal access mean equal timely access to the operating room? Results from the SEARCH database. Cancer Epidemiol Biomarkers Prev 2009;18:1208–1212.
- Kim EJ, Marrast L, Conigliaro J. COVID-19: Magnifying the Effect of Health Disparities. J Gen Intern Med. 2020 Aug;35(8):2441–2442.
- Sivashanker K, Duong T, Ford S, Clark C, Eappen S. A data-driven approach to addressing racial disparities in health care outcomes. Harvard Business Review. July 21, 2020.
James C. Etheridge, MD, is a Safe Surgery/Safe Systems Research Fellow at Ariadne Labs. He is a general surgery resident at Brigham and Women’s Hospital and a MPH candidate at the Harvard T.H. Chan School of Public Health.
Christy E. Cauley, MD, MPH, is a faculty member in the Safe Surgery Program at Ariadne Labs. She is a staff surgeon at Massachusetts General Hospital and Harvard Medical School in the Division of General Surgery with subspecialty training in Colon & Rectal Surgery.
Illustration by Julia August / iStock