The Integral Role of Anesthesia in Public Health: Ensuring Safe Surgical Care and Accessible Healthcare

2.1.1. Socioeconomic Status

Healthcare costs for the surgical and anesthesia care alone can be prohibitively high for some patients. This effect can further be compounded by the cost of time off from work for healthcare appointments, surgery, and recovery. For patients with limited socioeconomic resources or patients whose jobs may be at risk with extended time off, completing recommended perioperative care may be infeasible. Importantly, this can also affect the care of patients whose caregivers may be adversely affected by time off work (e.g., children of parents who may be unable to support the costs of living or may fear job loss when taking time off).

2.2.1. Health Literacy

Perioperative instructions can be complicated to understand for all individuals. However, these can become even more challenging with decreased health literacy or reading abilities. Inability to understand and follow these instructions may make surgery and anesthesia dangerous or can also lead to poor outcomes during the recovery period. In addition, a meta-analysis that assessed 66 articles found that decreased health literacy is associated with unhealthy behaviors, including smoking [7]. This is significant because smoking is well known to greatly increase the risk of perioperative and postoperative complications [8-10].

2.3.1. Access to Anesthesia Providers and Facilities

According to the World Federation of Societies of Anesthesiologists (WFSA), a global disparity exists in anesthesia providers [11]. After surveying 153 of 197 countries in 2016, the range was from 0 to 20 physician anesthesia providers (PAPs) per 100,000 population. Seventy-seven of the surveyed countries reported <5 PAP per 100,000 population, with the greatest disparities seen in Africa and Eastern Asia. The WFSA estimated that over 136,000 additional PAPs would be required to achieve a minimum density of 5 PAPs per 100,000 population in all countries worldwide. Additionally, there have been studies that assessed the access to proper anesthesia equipment and medications in certain developing countries and found compelling results about gaps in anesthesia care. In two separate studies conducted in Madagascar and Liberia, none of the 19 regional hospitals in Madagascar or the 27 hospitals in Liberia surveyed were able to meet the WFSA’s standards for patient monitoring [12, 13]. Even within regions or countries with a higher number of anesthesia providers, anesthesia care may still be concentrated in larger cities or academic settings, leaving gaps in anesthesia access in rural and medically underserved areas.

2.3.2. Insurance Barriers

Medical insurance in the United States ultimately determines where and when you can receive healthcare services. These disparities are most frequently observed in insurance programs for patients with low incomes (e.g., Medicaid), as fewer providers are accepting these forms of insurance over time [14]. The impact of insurance disparities on surgical outcomes is remarkable. After controlling for surgical complexity and patient comorbidity, the odds of post-operative death for patients undergoing noncardiac surgery were 29% higher for patients insured by Medicaid and 75% higher for patients with no insurance compared to patients with commercial insurance [15].

2.4.1. Transportation Barriers

For patients in rural and medically underserved areas, getting transportation to or from a surgical procedure may also prove to be extremely difficult or impossible. To compound this, rideshare and taxi services are not recommended after a patient receives anesthesia. Transportation barriers may affect patients’ ability to attend pre-operative appointments, arrive at planned surgical procedures, or participate in ambulatory surgical programs. Indeed, some insurers (such as Medicaid) recognize this barrier and reimburse for some transportation needs to healthcare appointments. However, access to these services may still be unreliable in areas where transportation infrastructure is limited (e.g., rural and medically underserved areas).

2.5.1. Language Barriers

Reports consistently show worse healthcare outcomes, decreased satisfaction, and lower adherence in U.S.-based patients with limited English proficiency [16], largely due to a lack of access to language-concordant health information and healthcare communication. Within anesthesia, the preoperative patient education and informed consent processes are vital for patient satisfaction, knowledge, and overall comfort [17]. However, these components heavily rely on communication and may be severely limited when there is a language discrepancy.

2.5.2. Social Support

In the perioperative period, patients’ safety, well-being, and recovery rely heavily on the ability to adhere to anesthesia recommendations (e.g., pre-operative food and medication intake and post-operative monitoring). For many patients, this process involves the support of friends, family members, and other caregivers who can assist patients with completing the recommendations, including those post-operative recommendations that patients may be less able to achieve independently. Patients who have limited social support resources or whose loved ones are unable to provide immediate social support due to other obligations (e.g., work, childcare, illness) may face barriers to achieving these recommendations. Similarly, for ambulatory procedures, poor social support may intersect with transportation barriers (as mentioned above), making it difficult or impossible to arrange for safe transportation and post-operative monitoring.

2.5.3. Racial or Ethnic Inequalities

Prior research has demonstrated that patients from minoritized racial or ethnic groups have higher rates of anesthetic and surgical morbidity compared to white patients across surgical specialties and environments [18]. Such disparities may represent a combination of underlying inequities in other social determinants of health, as well as practice inequalities that have been documented. For instance, disparities have been reported in the preoperative setting with discrepancies in preoperative anxiolytic administration and postoperatively with pain management [18].

2.5.4. Unhealthy Behaviors

Various unhealthy behaviors, such as smoking and poor eating habits, can be transferred between generations. For example, a meta-analysis found that the odds of smoking uptake by children and young adults were significantly higher if a parent or sibling was a smoker [19]. Another study found that parental obesity more than doubles the risk of adult obesity among children less than 10 years old [20]. As such, the exposure to unhealthy behaviors in a child’s social context can result in similar behaviors as an adult. This is significant because these transferred behaviors are associated with increased complications and mortality if anesthesia is required.

2.6.1. Addressing Social and Structural Support Needs During the Perioperative Period

Pre-operative evaluations related to the social determinants of anesthesia care may help to reduce delays in care (e.g., avoidable postponements of procedures), improve patient outcomes, and enhance both patients’ and providers’ interactions with the healthcare process. Such evaluations might emphasize common barriers to care related to insurance, transportation, post-operative assistance, and other essential social support. These evaluations could be undertaken by trained social workers, care coordinators, or patient navigators whose primary role is to build rapport, trust, and communication with patients and caregivers. Through the established relationship, they can then assist patients with navigating social and structural needs throughout the care process. Healthcare institutions might also consider engaging or employing trained community health workers to facilitate this process.

2.6.2. Engaging or Employing Community Health Workers

According to the American Public Health Association, a community health worker (CHW) is “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery [21].” This definition outlines a very broad role, which has increasingly been applied within healthcare settings. For example, CHWs can “offer interpretation and translation services, provide culturally appropriate health education and information, help people get the care they need, give informal counseling and guidance on health behaviors, advocate for individual and community health needs, and provide some direct services such as first aid and blood pressure screening [22].” In other words, CHWs engaged or employed by healthcare systems can help to navigate most or all of the social determinants of anesthesia care in collaboration with healthcare teams and may serve a crucial, practical role in addressing the public health gaps affecting anesthesia care.

CHW-based programs have been shown to improve health outcomes. For example, one study found that using CHWs as patient navigators resulted in greater timely cancer care among low-income and minority populations [23]. In another study, Hispanic patients at urban clinics were randomly assigned to receive CHW assistance versus no CHW assistance; those offered CHW assistance had improved health status and lower emergency department use [24]. As of January 2024, at least 24 U.S. states offer Medicaid funding for CHW services [25], nearly doubling from 13 states in 2023 [26]. This number is expected to increase in response to growing needs in both the public health and healthcare workforces.

2.6.3. Ensuring Language Inclusion Throughout the Anesthesia Care Process

Language inclusion is essential to ensuring safe and effective anesthesia care. This includes full communication of pre-operative and post-operative recommendations to both patients receiving anesthesia care and any caregivers who may be responsible for carrying out such recommendations after patients have received anesthesia. Healthcare centers and anesthesia care programs should work closely with qualified language interpretation and translation services to ensure that language-concordant patient/caregiver counseling and education are provided, that information is effectively communicated, and that patients’ and caregivers’ questions or concerns are fully addressed. Although patients may choose to have bilingual or multilingual family members or friends present during healthcare encounters or after surgery, anesthesia providers should not rely upon or expect family or friends to provide interpretation/translation services themselves. Patients and their caregivers may also wish to receive written and/or audio-video resources in their primary spoken language to review during or after a healthcare encounter or before or after surgery [27].