Comparison of Enhanced Recovery After Surgery (ERAS) metrics by race among gynecologic oncology patients: Ensuring equitable outcomes

Racial Disparities in the Adherence to an Enhanced Recovery After Cesarean Protocol (ERAC): A Retrospective Observational Study at Two NYC Hospitals, 2016-2020

Enhanced recovery after surgery programs for cesarean deliveries (ERAC) aim to optimize the quality of care for all patients. Race is not routinely monitored in ERAC programs. Given the extensive reports of racial disparities in obstetrical care, the goal of this study was to investigate racial differences in adherence rates to individual ERAC protocol elements.A cohort study was performed among cesarean delivery patients enrolled in an ERAC program at two hospitals from October 2016 to September 2020. Compliance with anesthesia-specific ERAC metrics, including ketorolac, ondansetron, and active warming methods, were compared by race. Race was self-reported by all patients. Logistic regression models stratified by pre- and post-ERAC status were used to assess relationships.The sample consisted of 7,812 cesarean delivery patients, of which 4,640 were pre-ERAC (59.4%) and 3,172 were post-ERAC (40.6%). There were no racial differences found in overall ERAC protocol adherence, active warming methods, or ondansetron administration in the pre- and post-ERAC groups. The odds of ketorolac administration in Black patients (adjusted odds ratio [aOR]: 0.72; 95% confidence interval [CI]: 0.55-0.95; p = 0.020) and Asian patients (aOR: 0.81; 95% CI: 0.68-0.98; p = 0.027) pre-ERAC were significantly lower compared with white patients. In the post-ERAC group, this disparity persisted in Black (aOR: 0.80; 95% CI: 0.65-0.99; p = 0.042) and Asian patients (aOR: 0.85; 95% CI: 0.73-0.98; p = 0.023).Appropriate implementation and adherence to all elements of the ERAC program may provide a practical approach to reducing disparities in outcomes and ensuring equitable treatment for all patients. · No racial differences were found in ondansetron administration pre- and post-ERAC.. · No racial differences were found in active warming methods pre- and post-ERAC.. · Black patients had significantly lower odds of ketorolac administration pre- and post-ERAC.. · Asian patients had significantly lower odds of ketorolac administration pre- and post-ERAC.. · ERAC metrics must be routinely monitored by race to resolve any observed inequities..

Racial health disparities in severe maternal morbidity before and after implementation of an enhanced recovery after cesarean delivery protocol: a retrospective observational study at two NYC hospitals (2016-2020)

BACKGROUND

Enhanced recovery after cesarean delivery (ERAC) is an evidence-based pathway that aims to improve the quality of care for all patients. Standardization of care has been seen as a tool to promote equality and equity. Our goal was to evaluate racial differences in severe maternal morbidity (SMM) among patients before and after implementation of an ERAC program.

METHODS

A retrospective study was performed among cesarean delivery patients pre- and post-ERAC implementation at two large academic hospitals in New York City from October 2016 to September 2020. Logistic regression models were created to compare peripartum SMM complications pre-ERAC, post-ERAC, and overall, by race.

RESULTS

The sample consisted of 7,812 cesarean delivery patients, of which 4,640 were pre-ERAC (59.4%) and 3172 were post-ERAC (40.6%). Within the overall population, Black (aOR 1.57, 95% CI 1.07 to 2.28; P=0.018) and Asian (aOR 1.61, 95% CI 1.20 to 2.14; P=0.001) patients had higher odds of SMM compared to white patients. Pre-ERAC, Black (aOR 1.92, 95% CI 1.16 to 3.14; P=0.010) and Asian patients (aOR 1.86, 95% CI 1.26 to 2.74; P=0.002) had higher odds of SMM relative to white patients. Post-ERAC, this relationship was no longer statistically significant [Black (aOR 1.13, 95% CI 0.61 to 2.01; P=0.69) and Asian (aOR 1.39, 95% CI 0.88 to 2.17; P=0.15)].

CONCLUSION

Implementation of the ERAC protocol improved SMM outcomes by race. Standardization of practices in ERAC protocols can help address disparities by reducing variations in obstetrical care.

Racial and ethnic disparities in reproductive medicine in the United States: a narrative review of contemporary high-quality evidence

There has been increasing debate around how or if race and ethnicity should be used in medical research-including the conceptualization of race as a biological entity, a social construct, or a proxy for racism. The objectives of this narrative review are to identify and synthesize reported racial and ethnic inequalities in obstetrics and gynecology (ob/gyn) and develop informed recommendations for racial and ethnic inequity research in ob/gyn. A reproducible search of the 8 highest impact ob/gyn journals was conducted. Articles published between January 1, 2010 and June 30, 2023 containing keywords related to racial and ethnic disparities, bias, prejudice, inequalities, and inequities were included (n=318). Data were abstracted and summarized into 4 themes: 1) access to care, 2) adherence to national guidelines, 3) clinical outcomes, and 4) clinical trial diversity. Research related to each theme was organized topically under the headings i) obstetrics, ii) reproductive medicine, iii) gynecologic cancer, and iv) other. Additionally, interactive tables were developed. These include data on study timeline, population, location, and results for every article. The tables enable readers to filter by journal, publication year, race and ethnicity, and topic. Numerous studies identified adverse reproductive outcomes among racial and ethnic minorities as compared to white patients, which persist despite adjusting for differential access to care, socioeconomic or lifestyle factors, and clinical characteristics. These include higher maternal morbidity and mortality among Black and Hispanic/Latinx patients; reduced success during fertility treatments for Black, Hispanic/Latinx, and Asian patients; and lower survival rates and lower likelihood of receiving guideline concordant care for gynecological cancers for non-White patients. We conclude that many racial and ethnic inequities in ob/gyn cannot be fully attributed to patient characteristics or access to care. Research focused on explaining these disparities based on biological differences incorrectly reinforces the notion of race as a biological trait. More research that deconstructs race and assesses efficacy of interventions to reduce these disparities is needed.

Adapting Enhanced Recovery After Surgery (ERAS) Protocols to Promote Equity in Cancer Care and Outcomes

MINI ABSTRACT

Equity-focused evaluations of existing healthcare system-level policies, clinical practices, and interventions are needed to identify factors that may narrow, or unintentionally widen, the racial disparity in cancer outcomes. We focus here on the evaluation of enhanced recovery after surgery (ERAS) protocols and their potential to promote equity in cancer care and outcomes.

Racial and ethnic disparities in regional anesthesia in the United States: A narrative review

BACKGROUND

Racial and ethnic disparities exist in the delivery of regional anesthesia in the United States. Anesthesiologists have ethical and economic obligations to address existing disparities in regional anesthesia care.

OBJECTIVES

Current evidence of racial and ethnic disparities in regional anesthesia utilization in adult patients in the United States is presented. Potential contributors and solutions to racial disparities are also discussed.

EVIDENCE REVIEW

Literature search was performed for studies examining racial and ethnic disparities in utilization of regional anesthesia, including neuraxial anesthesia and/or peripheral nerve blocks.

FINDINGS

While minoritized patients are generally less likely to receive regional anesthesia than white patients, the pattern of disparities for different racial/ethnic groups and for types of regional anesthetics can be complex and varied. Contributors to racial/ethnic disparities in regional anesthesia span hospital, provider, and patient-level factors. Potential solutions include standardization of regional anesthetic practices via Enhanced Recovery After Surgery (ERAS) pathways, increasing patient education, health literacy, language translation services, and improving diversity and cultural competency in the anesthesiology workforce.

CONCLUSION

Racial and ethnic disparities in regional anesthesia exist. Contributors and solutions to these disparities are multifaceted. Much work remains within the subspecialty of regional anesthesia to identify and address such disparities.