Disparities in Health Care: Social Injustice and AMI

Beauchamp and Childress defined the major principles of bioethics: beneficence, maleficence, autonomy, and justice (Beauchamp and Childress. Principles of Biomedical Ethics, 5th ed. Oxford, UK: Oxford University Press; 2001). The principle of justice is cited least often. The counterpart of justice, social injustice, is relevant to disparities occurring in the United States, forming the basis for this discussion of health-care disparities observed in patients with acute myocardial infarction (AMI).

Two Institute of Medicine reports stated that health-care quality in the United States is below expectations (To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000; Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001). The IOM drew attention to health care disparities experienced by rural US residents. Rural residents represent one in five citizens, are distributed throughout 87% of the US, are older, are more likely to have chronic illness, and generally exhibit poor health behaviors, including a reduced commitment to regular exercise (Crossing the Quality Chasm).

Many areas of the United States are not served by a hospital or are serviced by a regional critical access hospital. Critical access hospitals deliver fewer resources than urban facilities, receive less funding, lack staffing by emergency medicine physicians, and offer reduced, if any, access to cardiologists. In particular, disparities in treatment and mortality related to AMI have been documented, demonstrating that patients receiving care in urban areas have reduced mortality compared with those receiving care in rural communities.

The scope of social injustice related to rural health care negatively impacts mortality in AMI due to lack of adequately trained primary care physicians, reduced access to subspecialists, paucity of evidence-based medical guideline implementation, and distant locations of hospitals without trained EM specialists. This form of social injustice requires proactive and aggressive attention.

Representative Cases
At 4:00 am, three patients awaken with “pressure-like” chest pain. Each has previously experienced chest discomfort and believed it to be heartburn, as prior episodes responded to antacid therapy. Each takes an antacid, repeats the dose 10 min later, and fails to obtain relief for progressively worsening chest pain. Each summons help. In the interim, each individual develops diaphoresis and is unable to sit or stand due to dizziness.

Patient A is a stockbroker in Kansas City, MO. Paramedics arrive within 7 min; the patient’s blood pressure is 80 systolic; an ECG is performed and interpreted by an EM physician. Within 3 min, oxygen, aspirin, and a beta-blocker are administered. The patient is taken to the closest hospital where an invasive cardiologist awaits. En route, he develops asystole, CPR is initiated, and he is emergently taken to the cardiac catheterization laboratory, where a temporary pacemaker is placed. He undergoes emergent angioplasty, thrombolytics are administered, and coronary artery stents are placed within 3 h of developing symptoms. He recovers overnight in the ICU and is released 5 days later with preserved cardiac function. During the hospitalization, he receives counseling about exercise and dietary modification, enrolls in a smoking cessation program, and is started on a regimen of a cholesterol-lowering medication, an angiotensinconverting enzyme (ACE) inhibitor, long-term beta-blocker therapy, and aspirin. He enters cardiac rehabilitation and is given an appointment to followup with a cardiologist in 1 week. He returns to work 4 weeks later.

Patient B is an unemployed construction worker living in a small Missouri town. An ambulance is called, arriving 30 min later. Paramedics place an IV, administer oxygen, record an ECG, administer a chewable aspirin, and transport him to the nearest hospital (50 beds, 20 miles away). The on-call primary care physician assesses the patient. Following blood tests and an ECG (60 min), Patient B is diagnosed with an AMI. A referral hospital is contacted, and the ECG and lab tests are faxed to the “on-call” cardiologist. Patient B has no health insurance, and two hospital administrators are contacted to accept the patient. Thrombolytic therapy is given after a pharmacist is paged from home to come to the hospital to prepare the medication.

After the thrombolytic therapy is administered, an ambulance transports the patient to a small landing strip outside of town, where a life-flight helicopter arrives soon afterwards.

En route to the referral hospital, Patient B develops an irregular heart rhythm, loses consciousness, and develops ventricular fibrillation. CPR is initiated, and defibrillation is performed until a cardiologist unsuccessfully attempts placement of a temporary pacemaker. The patient dies in the ED. An autopsy demonstrates evidence of an AMI.

Patient C lives in very rural Missouri area without EMS coverage. His son, who works 30 miles from home, is contacted and arrives 40 min later; he loads the patient into the back of a flatbed pickup truck and drives him to the closest facility, a 20-bed clinic/hospital located 1 h away. During transport, the patient loses consciousness, and upon arrival is pulseless. A family physician and a nursing assistant perform unsuccessful CPR. The patient dies 4 h after he developed symptoms. An autopsy demonstrates an AMI.

Each of these patients experienced a massive AMI. Patient A lived in a large metropolitan area and recovered without sequelae. Patient B lived in a small town and was first transported to a rural health facility and, subsequently, by helicopter, to a referral center. He died despite receiving thrombolytic therapy and transfer to a referral center as quickly as possible. Patient C lived in a very remote rural area and received no intervention from the time of awakening with chest pain until arriving at the closest hospital.

Same diagnosis, three different outcomes, with only one of three patients with preserved life. These cases are evidence of an all too common but somewhat well-kept secret in the United States: a critical lack of access to state-of-the-art medical care in rural America. This represents social injustice.

“Justice,” said Aristotle, “involves treating like cases alike and different cases differently” (Medicine and Social Justice. Oxford, UK: Oxford University Press, 2002). Patients A, B, and C did not receive equitable treatment. In the late 1990s, there were 134.1 specialists per 100,000 residents in urban counties in the United States, compared with 40.1 per 100,000 in rural counties (Rosenblatt RA and Hart LG. “Physicians and rural America.” In: Ricketts TC, ed. Rural Health in the United States. Oxford, UK: Oxford University Press, 1999; 38-51). Despite the presence of evidence-based medicine protocols for treatment of AMI, rural centers are generally less efficient in making a prompt diagnosis and less likely overall to implement evidence-based guideline therapy.

A study published in 2002 evaluating care for AMI among Medicare patients found that these patients treated in rural hospitals were less likely than urban patients to receive aspirin during hospitalization or at discharge, IV nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty (Baldwin et al. Quality of Care for Acute Myocardial Infarction in Rural and Urban US Hospitals. Working Paper #72. Seattle, WA: WWAMI Rural Health Research Center, University of Washington; June 2002).

Though the existence of health-care disparities related to access has been acknowledged, effective and meaningful long-term action plans have not yet been instituted. Some suggest that changes are required, beginning with undergraduate medical education (Rabinowitz et al. Acad Medicine. 2008;83[3]:235; Glass et al. Acad Medicine. 2008;83[10]:952).

Procuring the right mix of specialty and primary care providers for rural areas will be critically important in addressing rural health-care disparities. Linking rural hospitals and health clinics with tertiary care hospitals via distance technology/telemedicine systems offers promise. One mechanism that has shown some success is the concept of an e-ICU, which has been shown in preliminary studies to reduce mortality in small rural centers. Widespread implementation of e-ICU services in rural centers has the potential to positively impact diagnostic capabilities and implementation of evidence-based protocols, as well as appropriately timed, scoop-and-run transfers to referral centers.

Conclusion
In order to achieve social justice in rural health care, increased access to quality health care by rural residents must be provided. This represents a challenge, particularly in today’s economic and political climate.

Only with increased numbers of appropriately trained primary care providers practicing evidencebased medicine, linked with a network of subspecialist providers, will substantive changes in outcomes begin to occur in rural America.

Rural residents, who account for more than one in five of all US citizens, deserve social justice and access to state-of-the-art health care. Anything less represents social injustice.

Critical care physicians must join together to highlight the injustices experienced by many of the rural residents of our country. Absent such efforts, the health-care community is passively allowing social injustice to continue.

Dr Sandra K. Willsie, MA, FCCP
PRA International
Lenexa, KS

Editor’s Insights
Chest physicians have many roles: medical education of patients and/or trainees; clinical practice; novel research and development of innovative therapies; and medical policy, planning, and medical specialty projections for the evolving needs of our constituents. All of these roles involve patient advocacy. Our ethical responsibilities to our patients are far more complex than those which we commonly recognize, such as decisions during end-of-life care. Though her illustrations are hypothetical, the problem described is very real. Dr Willsie has not only provided us with a discussion of a common and significant health-care disparity involving access to care and distribution of medical resources; she has also provided several potential remedies. Our concern in such matters is consistent with the long tradition of moral and humanitarian initiatives from the American College of Chest Physicians.

Dr Marilyn G. Foreman, FCCP