Health disparities, defined as “differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific populations,” occur due to complex interactions of individual and environmental factors in the presence of structural inequities and social determinants of health (SDOH), and disproportionately impact disadvantaged and vulnerable patient populations [1]. These inequalities in health care delivery and outcomes are avoidable and unjust, but awareness of disparities is a first step in addressing them [2]. The specialty of vascular surgery uniquely cares for a broad spectrum of patients with variable resources and access to care. Understanding how to identify and elucidate barriers to care is important for our vascular surgery residents and fellows. Although health disparities curricula have been introduced in some general surgery residency programs, vascular surgery-specific health disparities curricula have not been formally described [[3], [4], [5], [6], [7], [8]]. The aim of this perspective article is to describe principles of health disparities curricula, identify barriers to implementation, and provide best practice recommendations for implementation of health disparities curricula in vascular surgery graduate medical education.

The Liaison Committee on Medical Education now requires health disparities curricula in undergraduate medical education. Similarly, the Accreditation Council on Graduate Medical Education requires exposure to training in, and experience with, addressing health care disparities. Surgical care requires unique considerations of health disparities and the impact of SDOH on surgical patients specifically. For example, postoperative wound care may pose challenges for some patients who do not have an adequate support system or live in rural areas with limited home health care options. In the most extreme of circumstances, patients living in regions like the Navajo Nation often do not even have clean running water in their hogans (homes), which severely limits their ability to adequately care for even clean, simple surgical incisions, and requires inpatient admission for what would otherwise be an outpatient procedure. Nuances of health inequities as they apply to surgical care, therefore, warrant consideration of formal education in the graduate medical education space. A recent systematic review identified 7 unique health disparities curricula described in general surgery residencies [3]. Delivery and design of these curricula varied, but the following 3 concepts were foundational to all: culture, structural racism, and allyship. All curricula used didactic sessions for delivery of educational material, and some included additional strategies, such as case-based discussions, objective structured clinical examinations, and flipped classroom models. Although most curricula were designed specifically for residents, some included faculty didactics as well. Curricular evaluation revealed significant improvement in resident knowledge and attitudes toward cultural competency in most programs.

Although general surgery health disparities curricula more broadly address cultural concepts related to health inequities, vascular surgery health disparities curricula could uniquely address specific presentation, management, and outcomes inequities in vascular surgical care. For example, race, ethnicity, gender, and SDOH are known to contribute to variability in outcomes across the spectrum of vascular pathology, including limb-salvage rates, rates of receiving functional permanent hemodialysis access, rates of receiving inappropriate procedures, screening and outcomes for those with abdominal aortic aneurysms (AAAs), and loss to follow-up [9]. Clinical trials, including medical and device trials, demonstrate a persistent lack of representation of vulnerable patient populations and, subsequently, outcomes for underrepresented patients are worse [10,11]. Vascular surgeon racial bias is also associated with non-guideline compliant care and worse outcomes for racially minoritized patients [12]. The reasons for disparities are multifactorial, and understanding the complex intersection of resource limitations, mistrust in the health care system, and inadequate representation of diverse patients in clinical trials are all potential areas of focus for vascular surgery–specific health disparities curricula. An ideal curriculum would address each of these disparities as they specifically apply to vascular surgery. We propose a general structure as follows:1.

Presentation and diagnosis: Several studies have reported that vascular surgery patients present at different disease severities based on barriers to access to care, such as insurance, rurality, area deprivation index, and other SDOH. These barriers may limit what management strategies are likely to benefit patients and ultimately impact their downstream outcomes. For example, patients with chronic limb-threatening ischemia or diabetic foot ulcers who present with higher Wound, Ischemia, and Foot Infection classification system grades are less likely to experience successful limb salvage with revascularization. Socioeconomic distress and rurality have also been associated with higher rates of presentation with ruptured, as opposed to intact, AAAs [13,14]. Delays in the initial diagnosis of patients with vascular disease are associated with geographic rurality, socioeconomic distress, and residence in a “vascular desert” (ie, area lacking cardiovascular providers), with a known shortage of vascular surgeons practicing in underserved regions [[15], [16], [17]]. Black, Hispanic, and Native American physicians, groups persistently underrepresented in the vascular surgery workforce, are more likely than White or Asian physicians to work in rural settings [[18], [19], [20]]. Connecting workforce diversity and overall workforce shortages to geographic distribution of care, and demonstrating how these challenges are further compounded by patient resource limitations related to SDOH, is one way vascular surgery health disparities curricula can uniquely connect multiple systemic barriers that result in delays in care. Other delays may be related to implicit biases. For example, women experience delays in diagnosis when presenting with acute aortic dissection [21]. Specific didactics focusing on these objective differences in how patients present and are diagnosed, with exploration into the multifaceted nature by which these delays occur, will help to improve the quality of direct patient care, as well as bring awareness to presentation disparities that will allow for development of innovative solutions to mitigate these disparities.

2.

Management: Variability in management of disease processes across different patient groups occurs across the spectrum of vascular diseases. This occurs for several reasons. First, recognition that some patients may not have consistent follow-up due to transportation or other resource issues may impact a surgeon’s decision making. In some cases, 2 plans of care may be equivalent and considering resource limitations may improve a patient’s outcomes. In other cases, assumptions about ability or willingness to follow-up may lead a surgeon to offer suboptimal care. Patients with higher socioeconomic disadvantage are less likely to undergo repair of both ruptured and intact AAAs with endovascular repair compared with open repair [22]. Patients with end-stage renal disease with socioeconomic disadvantage are less likely to undergo autogenous hemodialysis access placement [23]. Black patients and patients with low socioeconomic status are less likely to receive advanced therapeutic interventions for pulmonary embolism [24,25]. Finally, implicit bias is directly associated with differences in management of patients with intermittent claudication, whereby Black patients treated by a physician with pro-White bias on the race implicit association test were more frequently treated with non–guideline compliant care in the form of treatment of infrapopliteal revascularization procedures [12]. In each of these cases, outcomes for vulnerable patient populations are worse. How management choice and outcomes are directly related is unknown. However, considering these differences in practice patterns and how they may ultimately contribute to worse downstream outcomes is important in addressing health disparities.

3.

Outcomes: Outcomes differences in disadvantaged vascular patient populations have been described at length. Female patients experience decreased survival and higher rates of reintervention when undergoing endovascular repair for AAAs. It is hypothesized that this is due to differences in anatomy, specifically artery diameter in women, which is not appreciated during device design and trials due to underrepresentation of women in device trials [26]. Black, Hispanic, and socioeconomically deprived patients with peripheral artery disease and diabetic foot ulcers experience lower rates of limb salvage [27,28]. Female patients experience higher rates of perioperative stroke after carotid endarterectomy for both symptomatic and asymptomatic cerebrovascular disease [29]. Permanent autogenous hemodialysis access in patients experiencing socioeconomic disadvantage are less likely to mature and more likely to require multiple reinterventions for access maintenance [23]. Black patients require more procedures for optimal results in the treatment of superficial venous reflux [30]. Self-pay insurance status is associated with failure of medical treatment for patients presenting with acute uncomplicated type B aortic dissection [31]. Understanding outcomes differences is critical to counseling patients appropriately for successful shared decision making between surgeons and patients.

4.

Research and clinical trials: Women and racially and ethnically marginalized patients are persistently underrepresented in research and clinical trials in vascular surgery [11,26]. Thus, many relevant trials may not be generalizable to disadvantaged patient populations. Historically, device trials in vascular surgery have limited representation of women and racially and ethnically marginalized principal investigators [10]. Clinical trial publications with women as first and senior authors are associated with higher representation of women enrolled in these trials [11]. How race and ethnicity of investigators might also influence trial enrollment is unknown. However, diversification of race, ethnicity, and gender in leaders of research and device trials may diversify patient inclusion and lead to results that are more generalizable to all vascular surgery patients.

Although health disparities curricula have the potential to positively impact patient care and mitigate inequities in health care, significant challenges to implementation of curricula exist. In general surgery, lack of faculty qualified to deliver education on health disparities was the most commonly cited barrier to health disparities curricula implementation [3]. Furthermore, department-wide buy-in supporting such curricula is critical. Allowing for protected learning time for this additional educational material and ensuring a positive attitude toward the material among faculty members are key elements to success. For example, one general surgery program experienced worsening attitudes toward cultural competency as a result of implementation of a new health disparities–related curriculum. Furthermore, current surgical health disparities curricula, including the Provider Awareness and Cultural Dexterity Toolkit for Surgeons, focus primarily on “culture.” As detailed by Carter et al [3], a focus on culture is problematic in that:1.

Culture is a widely variable social construct with complexities of intersectionality that “inhibit the ability to fully understand any one person through the lens of culture.”

2.

Culture as a focus of curricula risks perpetuating biases and a sense of “otherness.” Such frameworks may unintentionally “paint majority culture as the reference, or standard group.”

3.

Extensive literature “maintains that culture, or the practice, preferences, and beliefs of one group of people, has little, if anything to do with health disparities” [3].

Thus, most existing curricula for surgical health disparities education may not provide an effective framework for truly understanding and addressing health disparities in a meaningful way. Finally, recent legislative changes pose additional barriers to health disparities curricula implementation. For example, state-level legislation impacting institutions of higher education, including medical schools, now exist in 14 states. These bills, termed “anti-DEI [diversity, equity, and inclusion] legislation” vary from state to state, with some explicitly prohibiting teaching of “differences between groups" and others exempting teaching and research from anti-DEI restrictions. More recently, federal mandates in the form of executive orders have been issued requiring removal of all DEI-relatd material from kindergarten through grade 20 (graduate) insittutions, including a threat to cut federal funding to any noncompliant institution [32]. Such mandates explicitly prohibit the practice of “renaming” DEI initiatives to keep them in place under alternate guises. These political strategies induce fear in medical schools and other institutions and lead to resistance to pursue any educational efforts that may imply support of concepts of DEI. How federal policy will ultimately impact our ability to continue teaching and researching health disparities remains unknown.

Given these barriers, how might a vascular surgery training program successfully develop and implement health disparities curricula in an effective and engaging manner? First, shifting the foundational framework from concepts of cultural competency to concepts of structural competency will more directly address health disparities. Structural competency acknowledges the impact of SDOH on health disparities. Specific to vascular surgery, structural competency would address the intersection of factors related to patient presentation, diagnosis, management, outcomes, and workforce diversity. For example, the historical lack of diversity in clinical device trial leadership is associated with lack of diversity in patients participating in device trials, and ultimately associated with differences in practice patterns in the treatment of underrepresented patients, and subsequently worse outcomes in real-world use of these devices. Second, providing resources for faculty development to gain the necessary fund of knowledge to develop and deliver health disparities curricula would address the primary barrier to successful implementation identified in general surgery programs. Third, faculty engagement is necessary for success. A survey of general surgery faculty revealed only 37% of respondents believed racial and ethnic disparities in health care even exist, and of those, 90% believed the disparities were due to patient factors, such as attitude toward health care and mistrust in providers [3]. This highlights the critical need for health disparities curricula in order to objectively deliver education surrounding the numerous inequities identified in vascular surgery patient populations that are systemic, or structural, in nature.

Health disparities curricula have the potential to improve overall quality of care delivered to vascular surgery patients, and mitigate current inequities in care delivery, management, and outcomes that exist in the majority of pathologies treated by vascular surgery specialists. Although implementation barriers exist, formal inclusion of such curricula in vascular residency and fellowship training programs has the potential to standardize vascular specialist knowledge of health disparities, thereby closing gaps in the care of disadvantaged patient populations.