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