Strategies to Address Worsening HNC Care Disparities During the COVID-19 Pandemic
While the COVID-19 crisis has shone a light on already-marked disparities, it has also provided an impetus for structural changes that can mitigate inequities in access and outcomes both in times of pandemic and beyond. We offer the following suggestions:
Collect detailed data on access to care by race/ethnicity, income, education, and community.
It is imperative that we collect data about HNC care delivery and access to care in a manner that allows us to more comprehensively examine racial and ethnic disparities as well as the underlying social determinants of health. Otolaryngology-head and neck surgery groups analyzing the impact of COVID-19 on access to care did not report or analyze data by race/ethnicity, income, education, or community.20 A similar problem with data collection in part delayed the recognition that COVID-19 was disproportionately harming African-Americans and Hispanic/Latinos.5In-depth exploration of the social determinants of health that are the underlying drivers of disparate outcomes are needed6, and such data need to be publicly available to allow clinicians, policy makers, public health professionals, and policy makers to make informed decisions to better care for these marginalized groups within the broader HNC population. These steps will indeed require investment of time and resources; but the absence of data does not imply the absence of a problem.
Raise awareness that racial and ethnic disparities exist.
We should be proactive in recognizing the potential for exacerbating disparities in access and outcomes during this massive upheaval of clinical care. Raising awareness at individual, team, and hospital administrative levels will be key to ensuring that a broad range of stakeholders can be brought together and can combine their collective areas of expertise to proactively seek out, identify, and address areas of concern. As clinicians and team leaders, we share responsibility for drawing attention to this problem and addressing it.
Engage communities and stakeholders to understand their challenges and develop culturally-appropriate solutions.
We also need to reach out to the African American, Hispanic/Latino, and other at-risk communities to better understand the specific challenges they are facing during this crisis. Although publications from reputable institutions describing their experiences altering HNC care delivery during times of crisis may also inform current solutions,33 it would be presumptuous and ineffective for clinicians or administrators to pre-suppose that they already know how to address the problem. Building a strong coalition of involved stakeholders will help ensure that whatever healthcare delivery interventions arise will be delivered in a manner that is culturally appropriate, community competent, and relevant to the needs of the more vulnerable populations. Furthermore, such a coalition will enable us to also look beyond health care services into improving community support systems and policy-level solutions, which can have significant influences on individual health outcomes.34,35
Ensure that surgical care prioritization protocols proactively address the potential for racial/ethnic bias.
We should develop and utilize measures that acknowledge the role that racial/ethnic implicit or explicit bias can play in prioritizing surgical cases. While the content and underlying ethical principles of these prioritization decision-aids could vary, the role of race and ethnicity will have to be carefully considered. While omitting race/ethnicity data in prioritization may give the sense of a “color-blind” approach, clinical stage and severity of comorbidity would likely be part of a prioritization scheme,28particularly if one of the guiding ethical principles is maximizing benefit (e.g. life-years).36 However, African American and Hispanic patients are significantly more likely to present with advanced-stage disease and have more severe comorbidities. Therefore, a “color-blind” prioritization system based on maximizing benefit that includes comorbidity and stage may systematically de-prioritize care for African American and Hispanic/Latino HNC patients. While it might be inappropriate to eliminate use of stage or comorbidity, one could consider incorporating race/ethnicity into prioritization schemes with an evidence-based, data-driven weight, determined by relative patient populations and local or regional prevalence of HNC so as to avoid building implicit racial bias into prioritization schemes.27 Alternatively, developing a prioritization framework based on different ethical principles (e.g. giving priority to the worst off)36 might actually prioritize racial/ethnic minorities. Although the details of the optimal solution are not known, there is a critical need to establish objective measures and metric-based interventions to diminish current disparities in the receipt of HNC care. Such a solution would likely be consistent with the recommendation from the World Health Organization that the process of surgical prioritization adhere to principles of inclusiveness, transparency, accountability, and consistency.37