Surgical Quality and Equity

Field: Health Professions (Health Sciences)

Decades of medical and public health advancements have led to individuals living longer, more productive lives than at the turn of the 20th century. However, disparities in health and health care continue in strikingly similar ways. From cancer to cardiovascular disease, non-white patients continue to present with more advanced pathology, are less likely to receive optimal treatment, and have worse outcomes relative to white patients. While many look for innovative models to enhance the quality of care, key insights into improving equity may lie in the work of two men—EA Codman and WEB Du Bois—who started their professional careers on the same overcast Massachusetts day, May 26, 1895. Codman would establish the framework for surgical outcomes assessment with a window toward the social determinants of health. Concurrently, Du Bois put a microscope to these social factors and their role in postreconstruction health and healthcare disparities. Over the ensuing century, work to improve outcomes and reduce disparities progressed in parallel. Yet, we are now seeing the convergence of these two legacies, and with it, powerful opportunities to improve both the quality and equity of surgical care. The healthcare quality movement can in many ways be traced back to Dr Ernest Amory Codman, a surgeon and pioneer of outcomes measurement, with the introduction of his End Results Idea.1 Less than a decade after graduating from Harvard Medical School in 1895, Dr Codman began formulating his vision for a new system of care delivery. Codman spent his entire adult life advocating that hospitals be accountable for the outcomes of their patients. His fight was a very personal endeavor that ultimately cost him his job, financial well being, and professional reputation. Codman's mission can be summarized with two equal but importantly unique tenets. First, hospitals should determine and follow outcomes for all patients. Second, hospitals should address the underlying reason for adverse outcomes to help minimize that they do not happen in the future. He further clarified the latter tenet in stating that hospitals: ...should see that all cases in which the treatment is found to have been unsuccessful or unsatisfactory are carefully analyzed, to fix the responsibility for failure on the following: The physician or surgeons responsible for the treatment. The organization carrying out the detail of the treatment. The disease or condition of the patient. The personal or social conditions preventing the cooperation of the patient. This will give a definite basis on which to make effort at improvement.1 The inclusion of patient "cooperation" as a driver of complications may seem callous on first reading, especially in the present era of patient-centered medicine. Yet, looking closer, we see that Codman fixes responsibility not on patients or their cooperation, but rather the personal and social factors that influence health and healthcare behaviors. For Codman, addressing these personal and social conditions was as important for surgical optimization as the preceding, more explicit medical factors. Today, surgeons widely track outcomes and dissect sources of adverse events. Although errors in technique or judgment, system breakdowns, or progression of disease are frequently referenced as the underlying cause of complications, attention has only recently begun to be placed on the personal, interpersonal, or social conditions that often drive patient outcomes. However, the recognition of such social determinants of health disparities is as old as Codman himself. While Codman was constructing his End Results Idea, WEB Du Bois had initiated sociological study of Black America, including evaluations of health and health care. In 1895, at the same ceremony as Codman, Du Bois became the first African American to receive a graduate degree from Harvard University. In response to the then common thought of physical and physiologic inferiority of African Americans, Professor Du Bois quickly applied robust sociologic methodologies to identify the broader social determinants of health that were driving the poor health of African American populations in the United States. With his 1899 publication of The Philadelphia Negro and the 1906 release of The Health and Physique of the Negro American, Du Bois had documented widespread inequity in health and health care across the country.2,3 He linked these disparities in health to broader social drivers that included poverty, education, employment, environmental exposures, lack of access to health care, and limited diversity in the healthcare workforce. As with Codman, Du Bois' effort to address health inequity was deeply personal, having lost his first born son, Burghardt, to diphtheria. He would later blame Burghardt's death on a paucity of black physicians in the area and the refusal of white physicians to treat a black child. In the decades after Codman's introduction of the End Results Idea and Du Bois dissection of racial disparities in health care, the broad efforts to incorporate these legacies took similar though divergent paths. From a medical standpoint, healthcare systems increasingly valued outcomes assessment while simultaneously limiting the realm of medical influence to within the walls of hospitals. The shadows of this perception can be seen with the incorporation of socioeconomic factors, including patient race, in risk-adjustment models that compare hospital outcomes. Social and personal drivers of health outcomes are often perceived by health systems as being beyond their immediate responsibility. On the civil front, early postreconstruction efforts to address disparate health outcomes initially focused attention specifically within minority communities, in part due to racial accommodation strategies championed by Du Bois contemporary Booker T. Washington. Here too, the individuals and communities of color were deemed responsible for adverse outcomes rather than fragmented health systems providing care. The creation of Black medical schools and hospitals, and also public health initiatives like the National Negro Health Week movement concentrated efforts within African American communities, making significant strides for the health of populations, but not addressing broader structural inequities that drive disparities. Although desegregation of hospitals, civil rights legislation, and expansion of health insurance were expected to reduce disparities, multiple national reports over the century, including the 2002 Institute of Medicine's Unequal Treatment, have shown stubbornly persistent inequity in health and health care across the decades.4 These lessons collectively inform us that outcomes measurement, elimination of de jure discrimination, and increased access to care are necessary, but not alone sufficient, to bring about healthcare equity. In the introduction to his 1903 seminal work—The Souls of Black Folk—WEB Du Bois declared, "the problem of the Twentieth Century is the problem of the color-line."5 More than 100 years later, well into the 21st century, this "problem of the color-line" has clearly yet to be resolved. However, we are also at a unique point in history where we might be able to fully integrate the legacies of both Codman and Du Bois to improve both the quality and equity of health care. The prevalence and utilization of outcomes data are at the highest point ever. Health services researchers are now bridging these clinical data with population health and social sciences to capture a more comprehensive assessment of inter-related systems at work. As hospitals evolve to include newer models of care delivery including Accountable Care Organizations, a shift towards managing populations affords the unique opportunity to address social determinants of health for the betterment of individual patients and the well being of communities that the systems serve. Measurement of disparities at the hospital level has begun to provide another promising approach. Equity metrics have been shown to help systems identify gaps in care and target population-specific quality improvement to reduce disparities.6 The University Health System Consortium (UHC) is now including measures of equity in annual hospital quality report and using equity as a component of overall rankings of academic medical centers. Additionally, the Affordable Care Act now requires the majority of US hospitals to perform regular community health needs assessments and construct action plans that prioritize not only "barriers to care but also the need to … address social, behavioral, and environmental factors that influence health in the community."7 The implementation of equity as a quality indicator and requirement of community needs assessments provide important tools for systems to reduce disparities in health and health care. Health care disparities have become widely accepted as a persistent problem across the country, beginning with Du Bois and continuing with countless modern studies. As Codman suggested, we need to not only track adverse outcomes but also intervene on their underlying drivers, including personal and social factors. Equity in care delivery should thus become a priority at the hospital level that is treated with the same level of methodological rigor and institutional commitment as readmission rates or preventable infections. Without such acknowledgment of the personal, social, and institutional conditions that drive adverse outcomes coupled with appropriately targetted quality improvement, little should be expected to change when we convene our next national assessment of healthcare disparities. Yet, with concerted, coordinated collaboration between hospitals and communities, patients and providers, we are also presented with the great opportunity to realize the highest degree of healthcare quality and equity that was but a dream a century ago.