• economics
• ethics
• outcomes

Disparities in healthcare have long been recognized as a major public health problem. It is therefore not surprising that this topic has gained increasing attention among the anesthesiology community in recent years as evidence surfaces that differences in access and treatment are prominent in the perioperative period.1 This is especially problematic when disparities in care are associated with worse outcomes among selected patient populations, raising serious ethical questions and concerns.

It is in this context, the publication by La et al2 in this edition of Regional Anesthesia and Pain Medicine adds valuable information to our knowledge and points to the potential role that perioperative physicians and anesthesiologists might play in the public health arena: a role not traditionally embraced by our specialty. The authors of the article entitled ‘Hospital safety net burden is associated with increased inpatient mortality and postoperative morbidity after total hip arthroplasty:a retrospective multistate review, 2007–2014’ sought to investigate the impact of different levels of safety-net burden of hospitals in four different states on the outcomes of mortality, complications and length of stay. They defined the level of safety-net burden as the proportion of cases that a hospital performed on patients insured by Medicare and cases the institution was not paid for. After stratifying hospitals as carrying a high (>30.45%), medium (16.84%–30.45%) or low (0%–16.83%) safety-net burden, the authors concluded after conducting extensive primary and sensitivity analyses that indeed an increasing safety-net burden was associated with up to 38% higher odds for mortality and adverse outcomes.

They concluded that policy measures are necessary to address problems arising from inequities, unwanted variability and disparities in care that ultimately are associated with worse outcomes.

Despite limitations associated with the analysis of secondary, administrative data, which the authors discussed at length, these data carry an important message.

In the recent literature, similar correlations were found for numerous surgical and medical disciplines.3 4 On multiple levels, these are troubling revelations. Safety-net hospitals provide services to the underserved and form an integral part of a functioning public health infrastructure. Specifically, they treat a disproportionate number of patients who belong to minorities, socioeconomically disadvantaged groups and those with advanced diseases.2 4 Despite the important role they occupy within the system, safety-net hospitals are at a financial disadvantage as reimbursement is limited. At the same time, they are forced to absorb higher rates of costly complications and readmissions prevalent among the populations they serve. Finally, outcome-related reimbursement penalties affect hospitals with a high safety-net burden at higher rates.

Although these are disturbing data, an anesthesiologist looking at this article and its conclusions might wonder how they might relate to him or her. After all, what influence do we as a specialty have on the proportion of Medicare cases performed at a hospital?

However, this view ignores a reality that has over the last few years become obvious and has been propagated by numerous population-based studies such as the one presented here: anesthetic and analgesic interventions do affect perioperative outcomes.

Multiple opportunities to influence quality along a patient’s perioperative journey within safety-net hospitals exist. First, one in five safety-net hospitals lack preoperative anesthesia clinics and may therefore have limited resources for identification and optimization of at-risk patient groups.5 Second, a diverse portfolio of anesthetic techniques, prominently featuring regional anesthesia, has been suggested to improve morbidity and mortality risk, both in individual patients and on a hospital level.6 To this extent, La and colleagues point out in their post hoc analysis that one of the interventions under the anesthesiologist’s control that has been associated with improvements in outcomes—that is, the provision of neuraxial anesthesia in hip arthroplasty patients—is utilized less frequently in high safety-net burden hospitals. This finding suggests that anesthesiologists and their practices might be part of the problem uncovered by the authors of the present study. Anesthesiology-led optimization of care—including preoperative assessment, adequate monitoring and, importantly, selection of an appropriate anesthetic modality—all hold significant potential to reduce complication and mortality risk. The study by La et al complements this notion by identifying a population that might benefit from—as well as a system that is in dire need of—such optimizations. Therefore, this study outlines an opportunity for our specialty to make an important contribution to public health as well as address the issue of outcome disparities. These contributions may come in the form of clinical initiatives leveraging knowledge gained from concepts developed within the Perioperative Surgical Home model as well as through research in the arena of Healthcare Delivery, as performed by La et al. Examples that may immediately be applied and could help minimize unwanted variations in care can be found in the form of screening programmes for sleep apnea to implementation of early-recovery-after-surgery care components such as the consistent deployment of multimodal analgesia as well as other protocols that have been shown to improve outcomes and reduce risk.

Although policy changes will undoubtedly take time, anesthesiologists need to recognize and take their role as stewards of the public health of our country seriously. While members of our specialty may not be able to influence the composition of patients seeking care in a particular hospital, we can and need to influence the quality of care provided anywhere where anesthesia is administered and perioperative care rendered.