No quality without access: ACS and NIH collaborate to ensure access to optimal care

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Participants in the NIH-ACS Symposium on Surgical Disparities Research gathered on the NIH campus in Bethesda. (Photo: Shoreline Productions)

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Symposium participants, from left: Drs. Hoyt, Haider, and Gawande; Patricia L. Turner, MD, FACS, Director, ACS Division of Member Services; Drs. Britt, Maddox, Pellegrini, and Dankwa-Mullan; and Edward E. Cornwell III, MD, FACS, ACS Secretary. (Photo: Shoreline Productions)

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Dr. Britt (left) and Dr. Haider (Photo: Shoreline Productions)

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Dr. Gawande (Photo: Shoreline Productions)

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Symposium attendees (Photo: Shoreline Productions)

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Panelists from stakeholder agencies (from left): Drs. Gracia, Uchendu, Bull, and Gray. (Photo: Shoreline Productions)

When L.D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), was President of the American College of Surgeons (ACS) from 2010 to 2011, he noted that the organization has historically devoted its resources to advancing quality and patient safety. However, he observed, “There is no quality without access.”

This bold statement led to the establishment of the ACS Committee on Optimal Access (recently renamed the ACS Committee on Health Care Disparities), which Dr. Britt chairs, and which developed an ACS Statement on Optimal Access.* The committee was charged with several tasks, including the development of specific strategies for addressing health care disparities and the production of resources that could be used as part of these strategic initiatives.

With the establishment of the committee and its charges, the stage was set for the College to develop a collaborative relationship with the National Institute on Minority Health and Health Disparities (NIMHD)—one of the National Institutes of Health (NIH). Given the College’s history with quality improvement programs and the NIMHD’s considerable research and scientific resources, the organizers of this effort saw the potential for a formidable partnership that could substantially expand access to surgical care.

To launch this collaborative effort, approximately 50 thought leaders from the ACS, NIH, other government agencies, and academic institutions gathered for what several participants described as a historic event—the NIH-ACS Symposium on Surgical Disparities Research, May 7–8, in Bethesda, MD. The purpose of this meeting was to create a national research agenda for use by scientists, funders, policymakers, and other stakeholders.

In preparation for the meeting, researchers and staff at the Center for Surgery and Public Health (CSPH) at Brigham and Women’s Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, MA, developed an extensive literature review on surgical disparities, now available through a searchable database at CSPH researchers then partnered with colleagues from the NIMHD to categorize this literature review into five themes:

  • Patient and host factors
  • Systemic factors and access issues
  • Clinical care and quality
  • Provider factors
  • Postoperative care and rehabilitation

These themes and the associated reviews were distributed as background information for the participants to consider before the meeting.

Dr. Britt co-chaired the symposium with Irene Dankwa-Mullan, MD, MPH, Acting Deputy Director, Extramural Scientific Programs, NIMHD. Adil Haider, MD, MPH, FACS, Vice-Chair of the ACS Committee on Health Care Disparities, served as the Symposium Organizing Secretary and moderated much of the program. Dr. Haider is the Kessler Director of the CSPH. At the outset, Dr. Haider stated that the goal of the meeting was to produce: (1) a national agenda for surgical disparities research to guide scientists as they pursue future investigative initiatives, and (2) a list of priorities to assist the NIMHD and other funding partners as they establish funding streams for this research.

A broken system

“The American health care system, by any metric, is broken,” Dr. Britt, Brickhouse Professor of Surgery, Eastern Virginia Medical School, Norfolk, said in his opening remarks. “For some, it is the best health care system in the world, but for many others, that is not the case.”

“The question is, how do we fix it?” asked Dr. Britt, noting that traditional approaches, such as increased entitlement spending and health care reform, have failed. “Albert Einstein said, ‘You should not use an old map to explore new territory,’ but that’s what we’ve been doing in health care,” he observed, adding that the symposium should be useful in generating a new charter for overcoming health care disparities. Given the College’s and the NIH’s records in health care research and innovation, Dr. Britt said, “If we can’t solve this, I don’t know who can.”

Dr. Dankwa-Mullan said the conference and collaboration with the ACS are “timely and encouraging for all of us at the NIH.” She noted leaders of both entities are deeply committed to ensuring that all patients receive quality care. She added that in her years of working in the health care sector, she has witnessed “the power of identity—the power of group identity—to really make an impact in our communities,” as well as the power of passion. “I’ve learned that if you are a teacher, your words can be meaningful, but if you are a passionate speaker, they can be especially meaningful. If you’re a nurse or clinician, you can do some good things, but if you’re a passionate clinician, physician, or caregiver, you can really make a difference for the patient and for the community.”

Where the College stands

ACS Executive Director David B. Hoyt, MD, FACS, gave a presentation on systems-based approaches to addressing health care issues, including the development of the U.S. trauma care system. Dr. Hoyt noted that the 1960s was a period of strife in the U.S., leading to an escalation in traumatic injury. In response, the government called for the development of a more systematic approach to resolving the nation’s “neglected epidemic.”

To develop a systems-based approach to trauma care, “we highlighted leadership and legislation,” Dr. Hoyt said. “We cannot do all of this just through goodwill. We’ve got to have leadership, we’ve got to have commitment, and we may need to have legislative oversight over some of the expectations that we hold.”

Dr. Hoyt outlined the four-step process that the ACS has used as the model for its trauma and other quality improvement programs. “You start by setting standards—what you expect to happen at a certain point. You then build out the infrastructure, you measure performance through the analysis of data, and, finally, you subject yourself to external verification,” he said.

In addition, Dr. Hoyt commented on the Affordable Care Act (ACA). “What [the legislators who crafted] the ACA hoped to do was improve access to care through insurance reform, control costs through payment reform, and create delivery system redesign through performance measurement and incentives,” he noted.

“So how have we done? The good news is that insurers can no longer deny patients coverage due to preexisting conditions, and patients have more coverage options,” Dr. Hoyt said. For instance, the ACA led to the expansion of Medicaid in most states. As a result, the percentage of uninsured Americans dropped from 18 percent in 2013 to 13 percent in 2014.

“Have we bent the cost curve? I would argue that we have,” Dr. Hoyt said. Although health care costs are still rising faster than inflation, the cost of care per worker in 2014 rose just 4.6 percent from 2013, he said. Previously, health care spending was increasing by more than 6 percent annually.

A transformation in how policymakers view health care reform has been a shift in focus “from volume to value,” Dr. Hoyt noted. This changing focus is central to H.R. 2, the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act and its Merit-based Incentive Payment System.

To truly eliminate disparities, however, the health care system must ensure that all patients have optimal access. “I would argue that verifying access has not been a priority in the United States. It has not been an adequate priority at the American College of Surgeons, and we can start today to change that,” Dr. Hoyt said.

NIH commitment

Providing an overview of the NIH’s efforts to address health care disparities were Lawrence Tabak, DDS, PhD, Principal Deputy Director, NIH, and Yvonne T. Maddox, PhD, Acting NIMHD Director.

Dr. Tabak noted that the NIMHD recently announced funding with intent for research that would focus on health care disparities with precision in medicine. He added that the NIH is excited to be partnering with the College on this initiative. “These types of collaborations assist in the development of the solutions needed to resolve these types of multidimensional problems,” he said.

Dr. Maddox described the NIMHD as “the entity within the NIH that is responsible for leading scientific research to improve minority health and eliminate health care disparities. Most importantly, we are responsible for translating and disseminating the research results that are created across the NIH,” Dr. Maddox said.

Dr. Maddox provided background information on the NIMHD and other federal efforts to address health care disparities, including the 1985 release of the U.S. Department of Health and Human Services (HHS) Report of the Task Force on Black and Minority Health. Several years later, during the Clinton Administration, HHS launched an initiative to address health disparities with a focus on the following:

  • Cancer
  • Diabetes
  • Human immunodeficiency virus (HIV)
  • Cardiovascular health
  • Immunization
  • Infant mortality

“Have we had success in these six areas? With respect to cancer, we see about a 1 percent reduction in cancer deaths each year. When it comes to cardiovascular disease, we’ve seen about a 60 percent reduction overall and about a 70 percent reduction in stroke,” Dr. Maddox said. Across all populations, infant mortality also has declined, but when the rates in the African-American population and various subpopulations of the Hispanic community are compared with the Caucasian population, the gap remains. “Over the last 30 years, infant mortality has dropped significantly in all populations, but it will take another 39 years for infant mortality in the African-American population to get to where it was 39 years ago for the Caucasian population, if we continue to track the way we’re tracking today,” she said.

Dr. Maddox emphasized the importance of examining health care disparities not only among racial and ethnic minority populations, but among other subpopulations as well. Examples include the lesbian, gay, bisexual, transgender, queer (LGBTQ) community; rural Americans; people who live in low-income, inner-city neighborhoods; and people with disabilities or special needs.

“We need to be mindful that when you’re going to do health care disparities research, you need to look at it from various domains. It’s at the individual domain, it’s at the community domain, it’s at the provider domain, and it’s at the health care systems domain,” Dr. Maddox said.

The science of systems

Atul Gawande, MD, MPH, FACS, professor of surgery, Harvard Medical School; professor, Harvard School of Public Health; general surgeon, Brigham and Women’s Hospital; and executive director, Ariadne Labs, Boston, reinforced some of the concepts that Dr. Hoyt and Dr. Maddox brought forth, adding his own insights on global health care disparities in a keynote address on “the science of systems.”

Dr. Gawande spoke about the increasing interest in addressing global disparities in surgical care as evidenced by the formation of The Lancet Commission on Global Surgery (LCoGS), on which he serves. He noted that “surgery was not on the map” in the global health care community until the World Health Organization (WHO) released a report containing a chapter by Haile T. Debas, MD, FACS, professor emeritus, University of California-San Francisco, on surgery’s effect on lifespan. Dr. Debas offered evidence that surgery contributed as significantly to lifespan as many public health activities, such as vaccinations. “That gave us an opportunity to approach the World Bank and tell them [surgical disease] needs to be on the [research] map along with HIV, along with tuberculosis,” and other health care issues.

“Now the reality is that there are enormous disparities in access to care and in the quality of that care,” he added. The LCoGS found that approximately 5 billion of the more than 7 billion people in the world today lack access to safe, affordable surgical care when they need it. The LCoGS defines “affordable” as less than 40 percent of a patient’s annual disposable income.

Just as there are global disparities, “within every country there are disparities, the U.S. clearly very much included,” Dr. Gawande said. He suggested that a scientific approach was used to promote public health improvements in the U.S. and would be useful in expanding access to surgical care as well. “The only way I see to change that is through scientific discovery—scientific discovery of how you drive systems to produce these kinds of changes,” he said.

More specifically, Dr. Gawande noted that many scientific discoveries and innovations that occurred in the 19th century began to bear fruit in the 20th century with the advent of penicillin, insulin, new surgical procedures, and so on. As a result, “we started the 20th century with an average life expectancy of 47 years and ended it at 79 years,” Dr. Gawande said.

While life expectancy has increased and mortality has remained relatively flat since 2000, health care costs have continued to rise, leading the public to question the value of the care they receive. Value is determined on the basis of outcome in relation to cost. “There is a huge difference in quality of care depending on where you go and your community, and there are huge differences in the costs of care depending on where you go,” Dr. Gawande said.

“The best places behave most like a system. A system has diverse components that are able to work together to achieve a successful outcome. It’s like a car in that way,” he said. “We, in medicine, have been obsessed with having the best components—with having the best drugs, the best devices, the best specialists—but the real question is how they fit together.”

Dr. Gawande added that unlike most research conducted at the NIH, investigations into health care disparities and the development of systems-based approaches “is not a cure for pneumonia. It’s a cure for failure.”

Comparative effectiveness research

According to Romana Hasnain-Wynia, MS, PhD, disparities program director, Patient-Centered Outcomes Research Institute (PCORI), Washington, DC, the 2003 release of the Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, “was kind of the pivotal point for stakeholders to recognize that disparities are real—that they exist.” More specifically, the report, which is based on more than 600 studies, demonstrates that racial and ethnic minorities consistently receive poorer-quality health care for a range of conditions, even after accounting for socioeconomic status (SES) and access-related factors, such as insurance coverage.

Like Dr. Gawande, Dr. Hasnain-Wynia said where patients receive care affects quality of care. “Are disparities driven by who you are or where you go? We discovered that who you are matters, but where you go really matters—I mean really matters. Disparities are driven by minority patients receiving care from different hospitals, clinics, and physicians than their white counterparts.”

Dr. Hasnain-Wynia’s agency, PCORI, is an independent research institute authorized by Congress in 2010, which funds comparative effective research (CER) aimed at discovering which health care options work for which patients under which circumstances. “We have about $1.3 billion to disperse to conduct clinical research through 2019,” she said. PCORI’s disparities program does “not fund studies that describe disparities or even studies of what drives disparities,” Dr. Hasnain-Wynia said. “We are very focused on observational studies that can really help us get to the solutions,” particularly research that would assist in addressing notable gaps in clinical therapeutic evidence.

“Disparities are caused by multiple factors at multiple levels,” she added. “So there is no quick fix. If there were, I think we would have made it long ago.”

Plotting the agenda

A central purpose of the symposium was to develop a research agenda for the five cross-cutting themes mentioned earlier: patient factors, systemic factors and access, clinical care and quality, provider factors, and postoperative care and rehabilitation. Dr. Dankwa-Mullan set the tone for the thematic presentations, noting, “In the health care setting, disparities often present as a difference in the quality or quantity of care, but there are really several other dimensions that may influence disparities.” Health care disparities exist across many clinical conditions and many health care settings, she said. “Across the NIH, we are really interested in measures. What will actually reduce disparities?”

To help answer this question, Dr. Haider explained that surgical residents were invited to present summaries of existing literature relating to each theme, followed by commentary from experts as to what should be studied.

Provider factors

Navin R. Changoor, MD, a general surgery resident at Howard University Hospital, Washington, DC, said provider level factors refer to variations in practice patterns, such as provider bias, competencies, and awareness, which may influence quality of care and outcomes. Dr. Changoor also spoke about the lack of diversity in the surgical workforce.

Olivia D. Carter-Pokras, PhD, associate professor in epidemiology, University of Maryland School of Public Health, Baltimore, said that little research has been conducted on the impact of cultural competency education. Current efforts to teach cultural competence to physicians often reinforce stereotypes, she added

According to Dr. Carter-Pokras, some of the existing literature on provider factors indicates that it is possible for people to unlearn implicit biases.

“What we really need cultural competency education to evolve into is teaching skills that actually can be applied to improve care, such as learning to work with translators effectively,” she said.

Patient factors

Lisa Kodadeck, MD, a surgery resident at Johns Hopkins Hospital, said patient factors that affect surgical disparities include demographics, physiology, SES, and culture. According to Dr. Kodadeck, blacks are less likely than whites to receive appropriate surgical services and have higher operative mortality rates and morbidity. Hispanic patients, on the other hand, experience similar or better operative mortality in comparison with white counterparts. In addition, patients of lower SES are less likely to receive surgical services and more likely to experience operative mortality.

Dr. Kodadek said patient education and systematic changes may help to mitigate health care disparities and suggested that future disparities research efforts address outcome variations among racial and ethnic subgroups and look more closely at SES data.

James Rodrigue, PhD, professor of psychology and surgery, Harvard Medical School, said two patient factors that significantly affect access to surgical services are net economic resources and geographic/social isolation. He suggested that studies on patient factors are needed to better understand and then eradicate disparities.

Systems factors and access

John Rose, Jr., MD, a surgery resident at University of California, San Diego, spoke about systemic factors and access issues. Systemic factors that affect disparities include public policies, insurance status, management protocols, data systems and electronic health records, triage, and referrals. Access issues influence the likelihood of operation versus no operation, cancer resection, delays in presentation, diagnosis to treatment time, and receipt of care from high-volume providers, Dr. Rose said.

Joel Weissman, PhD, deputy director, chief scientific officer, CSPH, explained how insurance and payment affect access to care, noting that in states where surgeons receive lower Medicaid reimbursement patients have longer wait times for breast-conserving operations. He suggested that researchers study how payment affects referrals and outcomes and whether enrollment in accountable care organizations affects disparities.

Clinical care and quality

Peter A. Najjar, MD, a Harvard Medical School fellow in patient safety and quality and Arthur Tracy Cabot Fellow in Health Services Research, CSPH, presented on the topic of disparities in clinical care and quality. He offered a health care quality framework based on the Donabedian model centered on the interconnectedness of structure, process, and outcomes. Dr. Najjar suggested that future research focus on the causes and impact of structural differences associated with race.

Otis Webb Brawley, MD, chief medical and scientific officer and executive vice-president, research, American Cancer Society, spoke about disparities in cancer care. He noted, “We spend a lot of money on health care, and costs are still going up,” adding that “part of the problem is that some people get too much care,” while others receive too little care or receive definitive care after their condition is too advanced.

Postoperative care and rehabilitation

Elizabeth Lilley, MD, MPH, a general surgery resident at Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, and postdoctoral fellow, CSPH, spoke on postoperative care and rehabilitation. She described racial/ethnic disparities in timing and follow-up care for cancer patients, in long-term functional outcomes for patients with traumatic brain injury, and in palliative/end-of-life care.

David C. Chang, PhD, MPH, MBA, director of health care research and policy development, Codman Center for Clinical Effectiveness Research in Surgery, department of surgery, Massachusetts General Hospital, Harvard Medical School, said postoperative care and rehabilitation “is really about quality of life.” Dr. Chang added that “culturally competent care begins with culturally competent science. To truly address disparity problems, not only do we need to continue our efforts and recruitment of minorities in the making of science, but also promote participation of minorities in the setting of agendas to help break the glass ceilings.”

Creating a national research agenda

To generate a research agenda, symposium attendees participated in a thematic ranking exercise. Following each of these thematic presentations on the first day of the conference, attendees were asked to submit three to five free-response research questions or recommendations of interest for each theme. These recommendations were then collected, sorted by theme, and collated by a group led by Allysha Robinson, PhD; Maya Torain; and Cheryl Zogg, MS, qualitative researchers at the CSPH. More than 400 research questions and ideas were generated through this exercise. The collated and thematically sorted materials were then used by breakout groups on day two of the conference to determine the most important research questions for each theme. (Details are provided later in this article under the subhead “Moving forward.”)

From disparities to parity

ACS Immediate Past-President Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), The Henry Harkins Professor and Chair, department of surgery, University of Washington, Seattle, kicked off the second day of the symposium with a keynote address, From Success to Significance: A Call for Leadership. “Eliminating health care disparities requires acknowledging and recognizing all people equally and recognizing social injustices, many of which are still present today,” he said.

Using treatment for end-stage renal disease as an example of unequal care, Dr. Pellegrini noted that this condition disproportionately affects blacks and Latinos, yet these patients are generally underrepresented on wait lists for kidney transplants.

According to Dr. Pellegrini, racism is at the core of health care disparities. “I say racism plays a major role. I believe it is alive and well, and unless we understand it, and we change it, we cannot eliminate disparities,” he said.

Dr. Pellegrini defined racism as a system of structuring and assigning value based on the social interpretation of appearances. “I think of racism as including all forms of human differences,” he said, because all of these differences—race, religion, ethnicity, and so on—are used to place some people at a disadvantage, while placing others at an unfair advantage.

Multiple forms of bias affect health care disparities, Dr. Pellegrini said. Institutional racism results in patients having less access to health care facilities and other resources. Personally mediated biases include consciously held beliefs about a group based on gender, race, or other characteristics. Internalized bias occurs when people accept the negative perceptions about their own abilities and intrinsic worth, which results in self-devaluation. “You see it when, for example, a Hispanic patient asks to be treated by a white physician,” Dr. Pellegrini said.

“We are all biased,” Dr. Pellegrini said. “We bring our prejudices every single time into every single interaction, and if you’re conscious of that, and you accept the fact that you are imperfect, then you can try and correct your actions and mitigate [them].”

For a capitalistic society to truly embrace diversity, it is time to stop emphasizing equality as a moral imperative—“something we do because we’re good people”—and start to sell it as marketable product—“as part of the value-driven proposition,” he said. The new strategy focuses on inclusion—the act of recognizing, embracing, and maximizing diversity. “Without diversity, we can’t have excellence. Diversity brings new ways of thinking, different ways of thinking, and diversity brings innovation.”

Dr. Pellegrini concluded that cultural change is needed to move from disparities to parity. “Going from to success to significance will require moving from knowing to doing.”

Military health system

Jonathan Woodson, MD, FACS, Assistant Secretary of Defense for Health Affairs, gave a special keynote address on the military health system (MHS), describing the resources and experience that the MHS brings to efforts to improve diversity in health care.

“I believe the military health system is in a particularly good position to be a collaborator because of whom we take care of and what we have at our disposal,” Dr. Woodson said. “We can help to define and answer some of the questions because we level the playing field on a number of issues.”

The MHS comprises 54 hospitals and more than 600 medical and dental clinics. The MHS educates health care professionals at approximately 217 graduate medical education programs and runs a robust research and development program, Dr. Woodson noted. The system provides health insurance to approximately 9.5 million Americans.

The military’s demographics reflect a microcosm of America and has largely succeeded in ensuring equal access for all patients. “In the military, it doesn’t matter if you’re black, white, or Hispanic, you are going to get the same health care as everyone else,” he noted.

“We consider ourselves an undiscovered laboratory for health services research,” Dr. Woodson added. “We’ve got amazing repositories of data and are working with the Brigham and Women’s Hospital to refine those databases so we can ask difficult questions and find solutions and answers.”

In addition, the MHS has a memorandum of understanding with the NIH across a number of programs. Furthermore, the MHS has been strengthening its ties with the ACS. MHS hospitals participate in the ACS National Surgical Quality Improvement Program, and last October, the MHS signed a collaborative agreement with the ACS that will benefit both parties in the areas of education, systems-based practices, and research.

Other stakeholders and potential partners

Representatives from other federal agencies described the role these entities play in addressing health care disparities.

J. Nadine Gracia, MD, Deputy Assistant Secretary for Minority Health and Director, Office of Minority Health, HHS, said her team is charged with raising awareness about minority health and is forming partnerships and networks with community-based organizations, faith-based organizations, and other groups to address health care disparities. The agency also funds research into factors that contribute to health care disparities and is “interested in promoting cultural competence, including the development and promotion of national standards,” she said.

Uchenna S. Uchendu, MD, Executive Director, Veterans Health Administration (VHA), Office of Health Equity, said that approximately 22 million veterans live in the U.S., and that number is expected to grow as troops continue to return home from the wars in the Middle East. Many of these individuals will transition back into the civilian workforce and, consequently, may receive health care coverage through the private sector. Hence, the VHA is interested in partnerships that will ensure that community-based providers understand veterans’ unique needs and challenges.

Darryl Gray, MD, Medical Officer, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality (AHRQ), said the agency has a considerable grant portfolio that may be expanded to support partnerships in this area. AHRQ has published reports on health care disparities and inequities and has developed a disparities analytic file.

Jonca Bull, MD, an ophthalmologist and Director of the Office of Minority Health, Food and Drug Administration (FDA), highlighted a recent congressional mandate that the agency examine demographic subgroups and develop an action plan to ensure all populations have better access to medication and technologically advanced procedures. In August 2014, the FDA issued an action plan that has three priority areas: (1) improve data collection and coding of data, (2) advance clinical trials, and (3) improve transparency.

Moving forward

Rounding out the program, the participants broke into small groups to discuss areas for future research and collaboration based on the questions and comments raised in the previous day’s overview of the meeting’s five core themes.

Ali Salim, MD, FACS, chief, division of trauma, burns, and surgical critical care, Brigham and Women’s Hospital, and professor of surgery, Harvard Medical School, stated that improving health literacy was the major concern of the group that discussed patient factors. The group called for better engagement with primary care professionals and improved patient education.

ACS Regent Henri Ford, MD, MHA, FACS, vice-president and chief of surgery, Children’s Hospital Los Angeles; and professor and vice-chair for clinical affairs, department of surgery, Keck School of Medicine, University of Southern California, said the group that looked at provider factors called for improving cultural dexterity, improving patient-provider communication, and addressing implicit biases through mindfulness and empathy.

Steven Stain, MD, FACS, a member of the ACS Board of Governors Executive Committee, and the Henry and Sally Schaffer Chair, department of surgery, Albany Medical Center, NY, said the group focused on systemic factors identified the following areas for research: (1) the effect of payment strategies in the context of policy reform; (2) care coordination, integration, and tailored guidelines; and (3) regionalization of care.

Shadid Shafi, MD, MPH, FACS, clinical scholar, Baylor Scott & White Health System, and director, Research Institute at John Peter Smith Hospital and Health System, Baylor University, Houston, TX, led the panel on clinical care and quality, which emphasized leveraging the electronic health record to improve adoption of evidence-based care.

ACS Regent Beth H. Sutton, MD, FACS, a general surgeon in private practice, Wichita Falls, TX, and clinical professor of surgery, University of Texas Southwestern Medical School, Dallas, led the postoperative care and rehabilitation group, which identified the need to leverage existing databases, long-term strategies for communication with patients, and how postoperative care affects patient perceptions of satisfaction and quality of life.

Each of the five group leaders also presented the top research questions and topics for their theme. These are now being written up for peer-reviewed publication and approval by the various federal and institutional participants.

Overall, the symposium set the stage for the ACS, NIH, and other partners to work together to ensure that surgical patients have better access to care, regardless of race, gender, ethnicity, geographic location, and other characteristics.

“I’ve heard nothing but positive feedback from the speakers, attendees, and colleagues at the ACS and the NIH,” Dr. Haider said at the conclusion of the symposium. “We have accomplished our goal of creating a national research agenda, and I anticipate that it will be widely adopted by researchers and funders alike as we continue to produce research that moves us closer to eliminating disparities.”

Dr. Britt added, “I can’t say it enough—I think this is historic. I think we can advance the science and move the needle a little bit more.” Dr. Dankwa-Mullan agreed, noting, “There is enormous, tremendous work to be done. We look forward to working together and collaborating on this effort.”


To view a video featuring key participants at the symposium, go to the ACS website.


American College of Surgeons. Statement on optimal access. Bull Am Coll Surg. 2013;98(4):47. Available at: Accessed July 8, 2015.


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