Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors

Postoperative complications after gastrointestinal pediatric surgical procedures: outcomes and socio-demographic risk factors

BACKGROUND

Several socio-demographic characteristics are associated with complications following certain pediatric surgical procedures. In this comprehensive study, we sought to determine socio-demographic risk factors and resource utilization of children with complications after common pediatric surgical procedures.

METHODS

We performed a population-based cohort study utilizing the 2016 Healthcare Cost and Use Project Kids' Inpatient Database (KID) to identify and characterize pediatric patients (age 0-21 years) in the United States with common inpatient pediatric gastrointestinal surgical procedures: appendectomy, cholecystectomy, colonic resection, pyloromyotomy and small bowel resection. Multivariable logistic regression modeling was used to identify socio-demographic predictors of postoperative complications. Length of stay and hospitalization costs for patients with and without postoperative complications were compared.

RESULTS

A total of 66,157 pediatric surgical hospitalizations were identified. Of these patients, 2,009 had postoperative complications. Male sex, young age, African American and Native American race and treatment in a rural hospital were associated with significantly greater odds of postoperative complications. Mean length of stay was 4.58 days greater and mean total costs were $11,151 (US dollars) higher in the complication cohort compared with patients without complications.

CONCLUSIONS

Postoperative complications following inpatient pediatric gastrointestinal surgery were linked to elevated healthcare-related expenditure. The identified socio-demographic risk factors should be considered in the risk stratification before pediatric surgical procedures. Targeted interventions are required to reduce preventable complications and surgical disparities.

Patient characteristics associated with access to minimally invasive gynecologic surgery: Changes during the COVID-19 pandemic

Study Objective

To evaluate patient characteristics that affect access to minimally invasive gynecologic surgery (MIGS) subspecialty care and identify changes during the coronavirus disease 2019 pandemic.

Design

Retrospective cohort study of patients referred to MIGS from 2014 to 2016 (historic cohort) compared with those referred to MIGS in 2020 (pandemic cohort). Primary outcome was the interval between referral and first appointment.

Setting

Single-institution academic MIGS division.

Patients

Historic cohort (n = 1082) and pandemic cohort (n = 770).

Interventions

Not applicable.

Measurements and Main Results

Demographics and socioeconomic variables (race, ethnicity, language, insurance, employment, and socioeconomic factors by census tract) and distance from hospital were compared between historic and pandemic cohorts with respect to referral interval using the chi-square, Fisher exact tests, and logistic regression. After adjusting for referral indication, being unemployed and living in an area with less population density, less education, and higher percentage of poverty were associated with a referral interval >30 days in the historic cohort. In the pandemic cohort, only unemployment persisted as a covariate associated with prolonged referral interval and new associated variables were primary language other than English (odds ratio, 3.20; 95% confidence interval [CI], 1.60–6.40) and “other” race (odds ratio, 2.22; 95% CI, 1.34–3.68). The odds of waiting >30 days increased by 6% with the addition of 1 demographic risk factor (95% CI, 1.01–1.10) and by 17% for 3 risk factors (95% CI, 1.03–1.34) in the historic cohort whereas no significant intersectionality was identified in the pandemic cohort. Average referral intervals were significantly shorter during the pandemic (31 vs 50 days, p <.01). Telemedicine appointments had a significantly shorter referral interval than in-person appointments (27 vs 47 days, p <.01). Of patients using telemedicine, a greater proportion were non-Hispanic, English speaking, employed, privately insured, and lived further from the hospital (p <.05).

Conclusion

Time from referral to first appointment at a tertiary-care MIGS practice during the coronavirus disease 2019 pandemic was shorter than that before the pandemic, likely owing to the adoption of telemedicine. Differences in socioeconomic and demographic factors suggest that telemedicine improved access to care and decreased access disparities for many populations, but not for non–English-speaking patients.

The surgeon -rationalist- change agent: Stepping into our calling

As a profession Surgeons are the ultimate thinkers and rationalists. Historically, we have evolved our technique and the quality of the care we deliver through evaluation of our results and the challenge to effect change to improve our patient outcomes. This same discipline and rigor should be brought to the issue of disparities in surgical outcomes. We now understand that in addition to insurance, access and social determinants of health that implicit bias plays a significant role in disparate patient outcomes. Bias is human nature. We all have biases that can be managed and will lead us to provide better care. It is the responsibility of surgeons individually and collectively to be our best selves as persons and professionals. We should be at the cutting edge of the substantive change needed in medicine and our greater society.

A Rising Tide Lifts All Boats: Impact of Combined Volume of Complex Cancer Operations on Surgical Outcomes in a Low-Volume Setting

BACKGROUND

Centralization for complex cancer surgery may not always be feasible owing to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts postoperative outcomes at hospitals that are low-volume for a specific high-risk cancer operation.

STUDY DESIGN

Patients who underwent pneumonectomy, esophagectomy, gastrectomy, hepatectomy, pancreatectomy, or proctectomy were identified from the National Cancer Database (2004-2017). For every operation, 3 separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low volume for the individual cancer operation but high volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation.

RESULTS

LVH was significantly (all p ≤ 0.01) predictive for 30-day mortality compared with HVH across all operations: pneumonectomy (9.5% vs 7.9%), esophagectomy (5.6% vs 3.2%), gastrectomy (6.8% vs 3.6%), hepatectomy (5.9% vs 3.2%), pancreatectomy (4.7% vs 2.3%), and proctectomy (2.4% vs 1.3%). Patients who underwent surgery at MVH and HVH demonstrated similar 30-day mortality: esophagectomy (3.2 vs 3.2%; p = 0.993), gastrectomy (3.2% vs 3.6%; p = 0.637), hepatectomy (3.8% vs 3.2%; p = 0.233), pancreatectomy (2.8% vs 2.3%; p = 0.293), and proctectomy (1.2% vs 1.3%; p = 0.843). Patients who underwent pneumonectomy at MVH demonstrated lower 30-day mortality compared with HVH (5.4% vs 7.9%; p = 0.045).

CONCLUSION

Patients who underwent complex operations at MVH had similar postoperative outcomes to those at HVH. MVH provide a model for the centralization of complex cancer surgery for patients who do not receive their care at HVH.

Scar Perception: A Comparison of African American and White Self-identified Patients

Scars can have significant morbidity and negatively impact psychological, functional, and cosmetic outcomes as well as the overall quality-of-life, especially among ethnic minorities. The objective of this study was to evaluate African American and White patients' perception of their scars' impact on symptoms, appearance, psychosocial health, career, and sexual well-being, using validated assessment tools.

Method

A total of 675 abdominoplasty and breast surgery patients from four providers completed the SCAR-Q, and Career/Sexual Well-Being scales via phone or email. A higher score on both assessments indicates a more positive patient perception.

Results

Of the 675 respondents, 77.0% were White, and 23.0% were African American. White patients scored significantly higher on the SCAR-Q (232 ± 79 versus 203 ± 116), appearance (66 ± 26 versus 55 ± 29), and Career/Sexual Well-Being (16 ± 2 versus 15 ± 5) scales than African American patients (P < 0.001, P < 0.001, P < 0.001, respectively). There was no significant correlation between duration after surgery and symptoms or appearance scores for African American patients (P = 0.11, P = 0.37). There was no significant correlation between patient age and SCAR-Q score or time after surgery and psychosocial scores.

Conclusions

African American patients are more likely to have lower perceptions of their scarring appearance, symptoms, psychosocial impact, career impact, and sexual well-being impact than White patients. Scar appearance and symptoms are less likely to improve over time for African American patients. This study highlights the need to address patient ethnicity when considering further follow-up, counseling, or other measures to enhance scar perception.

Improving Post-Injury Care: Key Family Caregiver Perspectives of Critical Illness After Injury

There is little research about how caregiver experiences evolve from ICU admission to patient recovery, especially among caregivers for patients who have traumatic injuries. In this study, we characterize diverse caregiver experiences during and after ICU admission for injury.

Impact of ethnicity and race on outcomes after thoracic endovascular aortic repair

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) became the standard of care for treating Type B aortic dissections and descending thoracic aortic aneurysms. We aimed to describe the racial/ethnic differences in TEVAR utilization and outcomes.

METHODS

The National Inpatient Sample was reviewed for all TEVARs performed between 2010 and 2017 for Type B aortic dissection and descending thoracic aortic aneurysm (DTAA). We compared groups stratifying by their racial/ethnicity background in White, Black, Hispanic, and others. Mixed-effects logistic regression was performed to assess the relationship between race/ethnicity and the primary outcome, in-hospital mortality.

RESULTS

A total of 25,260 admissions for TEVAR during 2010-2017 were identified. Of those, 52.74% (n = 13,322) were performed for aneurysm and 47.2% (n = 11,938) were performed for Type B dissection. 68.1% were White, 19.6% were Black, 5.7% Hispanic, and 6.5% were classified as others. White patients were the oldest (median age 71 years; p < .001), with TEVAR being performed electively more often for aortic aneurysm (58.8% vs. 34% vs. 48.3% vs. 48.2%; p < .001). In contrast, TEVAR was more likely urgent or emergent for Type B dissection in Black patients (65.6% vs. 41.1% vs. 51.6% vs. 51.7%; p < .001). Finally, the Black population showed a relative increase in the incidence rate of TEVAR over time. The adjusted multivariable model showed that race/ethnicity was not associated with in-hospital mortality.

CONCLUSION

Although there is a differential distribution of thoracic indication and comorbidities between race/ethnicity in TEVAR, racial disparities do not appear to be associated with in-hospital mortality after adjusting for covariates.

The Surgeon- Rationalist - Change Agent: Stepping into our calling

As a profession Surgeons are the ultimate thinkers and rationalists. Historically, we have evolved our technique and the quality of the care we deliver through evaluation of our results and the challenge to effect change to improve our patient outcomes. This same discipline and rigor should be brought to the issue of disparities in surgical outcomes. We now understand that in addition to insurance, access and social determinants of health that implicit bias plays a significant role in disparate patient outcomes. Bias is human nature. We all have biases that can be managed and will lead us to provide better care. It is the responsibility of surgeons individually and collectively to be our best selves as persons and professionals. We should be at the cutting edge of the substantive change needed in medicine and our greater society.

Race and insurance status outcome disparities following splenectomy in trauma patients are reduced in larger hospitals. A cross-sectional study

Background

Splenectomy, still a commonly performed treatment for splenic injury in trauma patients, has been shown to have a high rate of complications. The purpose of this study was to identify predictors, including race and insurance status, associated with adverse outcomes post-splenectomy in trauma patients. We discuss possible explanations and methods for reducing these disparities.

Methods

The American College of Surgeons – Trauma Quality Improvement Program (ACS-TQIP) participant user database was queried from 2010 to 2015 and patients who underwent total splenectomy were identified. All mechanisms of injury, including both blunt and penetrating trauma, were included. Patients with advance directives limiting care or aged under 18 were excluded. Propensity score matching was used to control for age, preexisting medical conditions, and the severity of the traumatic injury. A chi-squared test was used to find significant associations between available predictors and outcomes for this cross-sectional study.

Results

The post-splenectomy mortality rate was 9.2% (n = 1047), 8.0% (n = 918) of patients had three or more complications, and 20.3% (n = 2315) had major complications. A primary race of white (OR 0.7, 95% Confidence Interval (CI) 0.6–0.9, p < 0.01) and private insurance (OR 0.5, 95%CI 0.4–0.6, p < 0.01) were associated with lower risks of mortality A primary race of neither Black nor white (OR 1.3, 95%CI 1.03–1.7, p = 0.03) and a lack of health insurance (“self-pay”) (OR 1.6, 95%CI 1.3–1.9, p < 0.01) were both correlated with mortality. When limited to hospitals of 600+ beds, there were no associations between race and mortality.

Conclusion

The post-splenectomy mortality rate after trauma remains high. In U.S. trauma centers, a primary race of Black and payment status of “self-pay” are associated with adverse outcomes after splenectomy following a traumatic injury. These disparities are reduced when limiting analysis to larger hospitals. Efforts to reduce disparities in outcomes among trauma patients requiring a splenectomy should focus on improving resource availability and quality in smaller hospitals.

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The post-splenectomy mortality rate in trauma patients remains high.

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Mortality is less frequent in white patients, and more frequent in uninsured patients.

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Black patients were more likely to experience major complications following splenectomy.

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In hospitals with greater than 600 beds, there were no associations between race and mortality following splenectomy.

Evaluating the complex association between Social Vulnerability Index and trauma mortality

INTRODUCTION

Social determinants of health are known to impact patient-level outcomes, but they are often difficult to measure. The Social Vulnerability Index was created by the Centers for Disease Control to identify vulnerable communities using population-based measures. However, the relationship between SVI and trauma outcomes is poorly understood.

METHODS

In this retrospective study, we merged SVI data with a statewide trauma registry and used three analytic models to evaluate the association between SVI quartile and inpatient trauma mortality: (1) an unadjusted model, (2) a claims-based model using only covariates available to claims datasets, and (3) a registry-based model incorporating robust clinical variables collected in accordance with the National Trauma Data Standard.

RESULTS

We identified 83,607 adult trauma admissions from January 1, 2017, to September 30, 2020. Higher SVI was associated with worse mortality in the unadjusted model (odds ratio, 1.72 [95% confidence interval, 1.30-2.29] for highest vs. lowest SVI quintile). A weaker association between SVI and mortality was identified after adjusting for covariates common to claims data. Finally, there was no significant association between SVI and inpatient mortality after adjusting for covariates common to robust trauma registries (adjusted odds ratio, 1.10 [95% confidence interval, 0.80-1.53] for highest vs. lowest SVI quintile). Higher SVI was also associated with a higher likelihood of presenting with penetrating injuries, a shock index of >0.9, any Abbreviated Injury Scale score of >5, or in need of a blood transfusion (p < 0.05 for all).

CONCLUSION

Patients living in communities with greater social vulnerability are more likely to die after trauma admission. However, after risk adjustment with robust clinical covariates, this association was no longer significant. Our findings suggest that the inequitable burden of trauma mortality is not driven by variation in quality of treatment, but rather in the lethality of injuries. As such, improving trauma survival among high-risk communities will require interventions and policies that target social and structural inequities upstream of trauma center admission.

LEVEL OF EVIDENCE

Prognostic / Epidemiologic, Level IV.

Recognizing Racial Disparities in Postoperative Outcomes of Gender Affirming Surgery

Purpose: Given the increasing frequency with which gender affirming surgery (GAS) is performed, understanding risk factors for poor outcomes is imperative. Recent investigations highlight inferior health outcomes experienced by Black transgender and gender expansive (TGE) individuals. Herein, we evaluate the relationship between race and postoperative outcomes in TGE patients undergoing GAS, utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Methods: We conducted a retrospective review of ACS NSQIP from 2010 to 2018. Patients with a primary diagnosis of gender dysphoria undergoing GAS were identified and grouped by race. Patient characteristics and 30-day postoperative outcomes were recorded. Univariate analysis was used to compare patient characteristics and postoperative outcomes across groups. Multivariate logistic regression was used to determine independent predictors of complications. Results: We included 2308 patients (1780 White, 419 Black, 109 Asian). Gender, body mass index, smoking status, and type of surgery performed differed significantly between groups (p < 0.001). Univariate analysis revealed significant differences in 30-day readmission and organ space surgical site infection (SSI) across groups (p = 0.03). Multivariate logistic regression, adjusted for confounders, revealed that Black patients had higher odds of reoperation (odds ratio [OR] 1.82, p = 0.047), 30-day readmission (OR 2.46, p = 0.003), and organ space SSI (OR 4.65, p = 0.024) than White patients. Conclusion: We found that race was an independent predictor of important short-term postoperative outcomes in GAS. Inclusive clinical research, effective engagement with the TGE community, and surgery-specific enhanced recovery after surgery protocols may help address disparities, but we must acknowledge race as a social determinant of health.

Persistent Racial Disparities in Deep Brain Stimulation for Parkinson's Disease

We sought to determine whether racial and socioeconomic disparities in the utilization of deep brain stimulation (DBS) for Parkinson's disease (PD) have improved over time. We examined DBS utilization and analyzed factors associated with placement of DBS. The odds of DBS placement increased across the study period, whereas White patients with PD were 5 times more likely than Black patients to undergo DBS. Individuals, regardless of racial background, with 2 or more comorbidities were 14 times less likely to undergo DBS. Privately insured patients were 1.6 times more likely to undergo DBS. Despite increasing DBS utilization, significant disparities persist in access to DBS. ANN NEUROL 2022;92:246–254

Temporal trends in transcatheter aortic valve replacement use and outcomes by race, ethnicity, and sex

Objectives

To identify trends in transcatheter aortic valve replacement (TAVR) use and outcomes by race (non‐Hispanic White, Black), ethnicity (Hispanic), and sex over time.

Background

Despite rapid growth in TAVR use over time, our understanding of its use and outcomes among males and females of underrepresented racial/ethnic groups remains limited.

Methods

A retrospective analysis of hospitalizations from 2013 to 2017 from the Healthcare Cost and Utilization Project database was performed.

Results

White patients comprised 65% (n = 2.16 × 10⁷) of all hospitalizations, yet they comprised 83% (n = 176,887) of the admissions for aortic stenosis (p < 0.0001). Among 91,693 hospitalizations for aortic valve replacement, 64,069 were surgical (34.0% female, 7.0% Hispanic, and 5.9% Black) and 27,624 were transcatheter (46.6% female, 4.5% Hispanic, and 4.4% Black). Growth in TAVR volumes was the slowest among minorities and females. Hispanic males, Hispanic females, and White females had the highest in‐hospital mortality (2.7%–3.3%; compared to White males, adjusted odds ratio: Hispanic males 1.9 [1.2–3.0], Hispanic females 1.9 [1.2–3.1], and White females 1.4 [1.2–1.7]). Despite less baseline vascular disease, females of all races/ethnicities had more vascular complications than men (female 5% vs. male 3.5%, p ≤ 0.001). Further adjustment for vascular complications only partially attenuated mortality differences. Black and Hispanic patients had a longer mean length of hospital stay than White patients, which was most pronounced among females. Pacemaker requirements were consistently low among all groups.

Conclusion

Differences in TAVR growth and outcomes by race, ethnicity, and sex over time highlight areas for focused efforts to close gaps in minimally invasive structural heart disease care.

Citizenship and Social Responsibility in Surgery: A Review

Importance

Social determinants of health have been shown to be key drivers of disparities in access to surgical care and surgical outcomes. Though the concept of social responsibility has received growing attention in the medical field, little has been published contextualizing social responsibility in surgery. In this narrative review, we define social responsibility as it relates to surgery, explore the duty of surgeons to society, and provide examples of social factors associated with adverse surgical outcomes and how they can be mitigated.

Observations

The concept of social responsibility in surgery has deep roots in medical codes of ethics and evolved alongside changing views on human rights and the role of social factors in disease. The ethical duty of surgeons to society is based on the ethical principles of benevolence and justice and is grounded within the framework of the social contract. Surgeons have a responsibility to understand how factors such as patient demographics, the social environment, clinician awareness, and the health care system are associated with inequitable patient outcomes. Through education, we can empower surgeons to advocate for their patients, address the causes and consequences of surgical disparities, and incorporate social responsibility into their daily practice.

Conclusions and Relevance

One of the greatest challenges in the field of surgery is ensuring that surgical care is provided in an equitable and sustainable way. Surgeons have a duty to understand the factors that lead to health care disparities and use their knowledge, skills, and privileged position to address these issues at the individual and societal level.

Association between implementation of a coordinated care pathway in idiopathic scoliosis patients and a reduction in perioperative outcome disparities

BACKGROUND

There are well-documented racial and ethnic disparities in treatment and perioperative outcomes for patients with adolescent idiopathic scoliosis.

AIMS

We hypothesize that the implementation of a coordinated care pathway for pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may be associated with a reduction in racial and ethnic disparities in perioperative outcomes.

METHODS

This is a retrospective pre- and post-test cohort study of patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution between July 1, 2013 and August 5, 2019. We implemented a coordinated care pathway in March 2015. Patient demographics included age, race, ethnicity, weight, gender, insurance status, ASA class, time between the date surgery was ordered and the date surgery occurred, degree of scoliosis, and the number of spinal levels fused. The primary outcome was length of stay. The secondary outcomes included transfusion rates, pain scores, and postoperative complications. Multivariable regression models compared outcome medians across race/ethnicity. Disparities were defined as the difference in adjusted outcomes by race/ethnicity.

RESULTS

Four hundred twenty-four patients underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution (116 prepathway and 308 postpathway). The median length of stay of Black patients was 1.0 day (95% CI: 0.4, 1.5; p = .006) longer than White patients prepathway. Prepathway patients who self-identified as Other had a 1.2 (95% CI: 0.5, 1.9; p = .004) higher median average pain score on postoperative day 1 compared with White patients. On postoperative day 2, patients who identified as Other had 2.0 (95% CI: 0.8, 3.2; p = .005) higher pain score compared with White patients prepathway. Postpathway, there were no significant differences in outcomes by race/ethnicity.

CONCLUSIONS

Our study supports the hypothesis that use of a coordinated care pathway is associated with a reduction in racial and ethnic disparities in length of stay and pain scores in pediatric patients undergoing posterior spinal fusion.

Surgical Outcomes Improvement and Health Inequity in a Regional Quality Collaborative

BACKGROUND

Surgical quality improvement initiatives may impact sociodemographic groups differentially. The objective of this analysis was to assess the trajectory of surgical morbidity by race and age over time within a Regional Collaborative Quality Initiative.

STUDY DESIGN

Adults undergoing eligible general surgery procedures in South Carolina Surgical Quality Collaborative hospitals were analyzed for the presence of at least 1 of 22 morbidities between August 2015 and February 2020. Surgery-level multivariable logistic regression assessed the racial differences in morbidity over time, stratified by age group (18 to 64 years, 65 years and older), and adjusting for potential patient- and surgical-level confounders.

RESULTS

A total of 30,761 general surgery cases were analyzed, of which 28.4% were performed in Black patients. Mean morbidity rates were higher for Black patients than non-Black patients (8.5% vs 6.0%, p < 0.0001). After controlling for race and other confounders, a significant decrease in monthly mean morbidity through time was observed in each age group (odds ratio [95% CI]: age 18 to 64 years, 0.986 [0.981 to 0.990]; age 65 years and older, 0.991 [0.986 to 0.995]). Comparing morbidity rates from the first 4 months of the collaborative to the last 4 months reveals older Black patients had an absolute decrease in morbidity of 6.2% compared with 3.6% for older non-Black patients. Younger Black patients had an absolute decrease in morbidity of 4.7% compared with a 3.0% decrease for younger non-Black patients.

CONCLUSIONS

Black patients had higher morbidity rates than non-Black patients even when controlling for confounders. The reasons for these disparities are not apparent. Morbidity improved over time in all patients with older Black patients seeing a larger absolute decrease in morbidity.

Risk Factors for Surgical Site Infection in the Undeserved Population After Ventral Hernia Repair: A 3936 Patient Single-Center Study Using National Surgical Quality Improvement Project

Background: Ventral hernia repair (VHR) is one of the most common surgical procedures performed in the United States. Surgical site infections (SSI) carry significant morbidity for the patient and pose a very challenging problem for the surgeon, associated with up to 6.6% of cases. Thus, surgeons should be well versed in the risk factors implicated in SSI after VHR. Given the high burden of diabetes, obesity, and smoking in our patient population, we sought to study the rate of SSI and the risk factors that led to SSI in our population. Study Design: This is a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for the years 2014-2019. We identified patients who underwent VHR at a single institution in the Bronx, New York. The rate of SSI was calculated, and then, risk factors for SSI were identified using logistic regression analysis. Results: A total of 3936 patients underwent VHR. Incisional hernias made up 41% of the cohort, and there were 37.4% laparoscopic repairs. During the 30-day follow-up, SSI was identified in 101 patients (2.6%). Factors associated with SSI include emergent surgery (adjusted odds ratio [aOR] = 2.57), body mass index >35 kg/m² (aOR = 2.38), insulin-dependent diabetes mellitus (aOR = 2.36), and incisional hernia (aOR = 1.81). In addition, a laparoscopic approach was found to be a protective factor (aOR = 0.43, 95% confidence interval 0.25-0.75). Surprisingly, different from other studies, smoking cigarettes was not associated with SSI in our cohort. Conclusions: The rate of SSI after VHR in our institution is 2.6%, which is within that reported in the literature. Most of the variables associated with SSI are modifiable and are similar to those previously reported. Laparoscopic repairs appear to be protective for its occurrence.

Community Based Participatory Research (CBPR): An Underutilized Approach to Address Surgical Disparities

Disparities are well-documented across the continuum of surgical care. Counteracting such disparities requires new multidisciplinary approaches that utilize the expertise of affected individuals, such as community-based participatory research (CBPR). CBPR is an approach to research that is anchored in equitable, sustainable community-academic partnerships, and has been shown to improve intervention implementation and outcomes. In this article, community stakeholders and researchers outline the principles and benefits of CBPR, examples of CBPR in trauma and transplant, and future directions for CBPR within surgery.

Racial Disparities in Mitral Valve Surgery: A Statewide Analysis

OBJECTIVE

Racial disparities in health care have come to the forefront. We hypothesized that Black race was associated with worse preoperative risk, lower repair rates, and worse outcomes among patients who underwent mitral valve surgery.

METHODS

All patients who underwent mitral valve repair or replacement with or without coronary artery bypass grafting from 2011 to 2020 in a statewide collaborative database were stratified into 3 racial groups, White, Black, and other. Preoperative characteristics, procedure type, and outcomes were evaluated.

RESULTS

A total of 9074 mitral valve operations were performed at 33 centers (Black 1009 [11.1%], White 7862 [86.6%]). Preoperative combined Society of Thoracic Surgeons morbidity and mortality was higher for Black patients (Black 32%, White 22%, other 23%, [P < .001]) because of a greater proportion of diabetes, hypertension, and chronic lung disease. White patients were more likely to undergo mitral repair (White 66%, Black 53.3%, other 57%; P < .001). Operative mortality was similar across racial groups (White 3.7%, Black 4.6%, other 4.5%; P = .36). After adjusting for preoperative factors, mitral etiology, and hospitals, race was not associated with mitral valve repair, complications, or mortality, but Black patients had higher odds of extended care facility utilization and readmission.

CONCLUSIONS

Contrary to our hypothesis, there was no difference in the odds of repair or operative mortality across races after accounting for risk and etiology. However, Black patients were more likely to be readmitted after discharge. These findings support a greater focus on reducing disparities in mitral valve surgery.

Contemporary Outcomes of Limb-Salvage Procedures Using Vascular Quality Initiative-Medicare Linked Data: Racial and Ethnic Disparities Persist

INTRODUCTION

Several reports have shown that ethnic and racial minorities with chronic limb-threatening ischemia (CLTI) are more likely to undergo major amputation. Whether this disparity is driven by limited access to care, statistical discrimination or biological factors remains a matter of debate. We sought to study the effect of race/ethnicity on short and long-term outcomes of limb-salvage procedures among patients with new onset CLTI.

METHODS

We identified all patients who underwent first time (open or endovascular) revascularization for CLTI between January 2010 and December 2016 in the Vascular Quality Initiative-Medicare linked database. These patients were divided into non-Hispanic whites (NHW) and racial/ethnic minority (REM) groups. Early end points included length of stay and operative mortality, while 2-year outcomes included major amputation, freedom from subsequent revascularization, number of limb salvage reinterventions and all-cause mortality. A sub-analysis comparing NHWs to Hispanics and NHWs to blacks was also performed.

RESULTS

Of 16,249 presenting with CLTI, 73.9% were non-Hispanic whites. Racial/ethnic minority patients were younger (mean age, 69.9 ± 11.3 years vs 74.2 ± 10.5 years; P < .001) and more likely to be female (45.9% vs 37.7%; P < .001). Other baseline differences included a higher rate of smoking history, coronary artery disease, chronic obstructive pulmonary disease and chronic kidney disease among non-Hispanic whites, whereas racial/ethnic minority patients were more likely to have diabetes and hypertension and more likely to present with tissue loss (78% vs 76.6%; P =.04). Preoperative ankle-brachial index and procedure type (endovascular vs open) were similar between the groups. On multivariable analysis, NHW's had a 13% increase in length of stay and a 25% decrease in operative mortality. In regard to 2-year outcomes, limb salvage estimates were 86% for the NHW group versus 77.1% for the REM group; P < .001. Comparison between the two groups showed similar rates of freedom from subsequent revascularization (67.9% vs 67.1%; P =.2). REM patients achieved higher rates of overall survival (70.3% vs 68.4%; P =.01) when compared to their white counterparts. Patients in the REM group were more likely to undergo more than two limb salvage reinterventions during follow-up (14.2% vs 8.6%; P < .001). After adjusting for potential confounders, REM patients had significantly higher odds of major amputation at 2 years (adjusted hazard ratio, 1.49; 95% confidence interval, 1.36-1.63; P < .001) CONCLUSIONS: In this Vascular Quality Initiative-Medicare matched study, racial and ethnic minority patients continue to face a higher major amputation risk despite having equivalent attempts at limb salvage. Further studies identifying risk factors and evaluating intervention strategies that may be more effective in preventing amputation in this particular population are warranted.

Understanding the surgical experience for Black and White patients with inflammatory bowel disease (IBD): The importance of health literacy

BACKGROUND

Racial/ethnic disparities in outcomes exist for patients with inflammatory bowel disease (IBD) undergoing surgery. The underlying mechanism(s) remain unclear and patient perspectives are needed. We therefore aimed to characterize the surgical experience for Black and White IBD patients using qualitative methods.

METHODS

Patients with IBD who had undergone surgery were recruited to same-race qualitative interviews. Semi-structured interviews explored barriers and facilitators to a positive or negative surgical experience. Transcripts were analyzed with NVivo 12 software.

RESULTS

Six focus groups were conducted that included 10 Black and 17 White IBD participants. The mean age was 44.8 years (SD 13.2), 52% were male and 65% had Crohn's disease. Four themes emerged that most defined the surgical experience: the impact of the IBD diagnosis, the quality of provided information, disease management and the surgery itself. Within these themes, barriers to a positive surgical experience included inadequate personal knowledge of IBD, ineffective written and verbal communication, lack of a support system and complications after surgery. Both groups reported that information was provided inconsistently which led to unclear expectations of surgical outcomes.

CONCLUSIONS

Black and White patients with IBD have varied surgical experiences but all stressed the importance of accurate, trustworthy and understandable health information. These findings highlight the value of providing health literacy-sensitive care in surgery.

Disparities in ACL Reconstruction: the Influence of Gender and Race on Incidence, Treatment, and Outcomes

PURPOSE OF REVIEW

Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury.

RECENT FINDINGS

Females are at increased risk for ACL injury compared to males. Intrinsic differences such as increased quadriceps angle and increased posterior tibial slope may be contributing factors. Despite lower rates of injury, males undergo ACL reconstruction (ACLR) more frequently. There is conflicting evidence regarding gender differences in graft failure and ACL revision rates, but males demonstrate higher return to sport (RTS) rates. Females report worse functional outcome scores and have worse biomechanical metrics following ACLR. Direct evidence of racial and ethnic disparities is limited, but present. White athletes have greater risk of ACL injury compared to Black athletes. Non-White and Spanish-speaking patients are less likely to undergo ACLR after ACL tear. Black and Hispanic youth have greater surgical delay to ACLR, increased risk for loss to clinical follow-up, and less physical therapy sessions, thereby leading to greater deficits in knee extensor strength during rehabilitation. Hispanic and Black patients also have greater risk for hospital admission after ACLR, though this disparity is improving. Females have higher rates of ACL injury with inconclusive evidence on anatomic predisposition and ACL failure rate differences between genders. Recent literature has suggested inferior RTS and functional outcomes following ACLR in females. Though there is limited and mixed data on incidence and outcome differences between races and ethnic groups, recent studies suggest there may be disparities in those who undergo ACLR and time to treatment.

Racial Disparities in Surgery for Malignant Bowel Obstruction

BACKGROUND

Operative management of patients with malignant bowel obstruction (MBO) may provide effective palliation, but is associated with substantial risks. This study aimed to analyze racial and ethnic differences in surgical outcomes for patients with MBO.

METHODS

This retrospective study, using National Surgical Quality Improvement Program (NSQIP) registry data from 2010 to 2019, compared differences in outcomes by race and ethnicity for 2762 patients undergoing surgery for MBO. Multivariable logistic regression controlled for relevant covariates.

RESULTS

Black patients (n = 407) had higher rates of preoperative comorbidity and were more likely than White patients (n = 2081) to have major complications (28.5% vs 21.8%; p = 0.0031), overall complications (47.4% vs 40.4%; p = 0.0087), a longer median hospital stay (12 days; interquartile range [IQR, 8-19 days] vs 10 days [IQR, 7-17 days]; p = 0.0007), and unplanned readmission (17.1% vs 12.9%; p = 0.0266). Black patients had a similar mortality rate to that of White patients and were less frequently discharged to home (67.6% vs 73.0%; p = 0.0315). Differences in morbidity between Black patients and White patients persisted after controlling for potentially confounding variables. Hispanic patients had lower mortality than White patients (6.3% vs 13.1%; p = 0.0130) and a longer hospital stay (12 days [IQR, 8-18 days] vs 10 days [IQR, 7-17 days]; p = 0.0313). Outcomes did not differ between Asian patients and White patients.

CONCLUSIONS

This study demonstrated significant disparities for Black patients undergoing surgery for MBO. Understanding and addressing what drives these differences, including systemic inequalities such as access to care and racial biases, is essential to the achievement of more equitable, higher-quality patient care.

Disparities in Utilization and Outcomes of Minimally Invasive Techniques for Gastric Cancer Surgery in the United States

Background

This study investigated national implementation patterns and perioperative outcomes of minimally invasive gastrectomy (MIG) in gastric cancer surgery in the United States.

Methods

The National Inpatient Sample (NIS) was queried for patients who underwent elective gastrectomy for gastric cancer from 2008-2018. The MIG versus open gastrectomy approach was correlated with hospital factors, patient characteristics, and complications.

Results

There was more than a fivefold increase in MIG from 5.8% in 2008 to 32.9% in 2018 (nptrend < 0.001). Patients undergoing MIG had a lower Elixhauser Comorbidity Index (p = 0.001). On risk adjusted analysis, black patients (AOR = 0.77, p = 0.024) and patients with income below 25th percentile (AOR = 0.80, p = 0.018) were less likely to undergo MIG. When these analyses were limited to minimally invasive capable centers only, these differences were not observed. Hospitals in the upper tertile of gastrectomy case volume, Northeast, and urban teaching centers were more likely to perform MIG. Overall, MIG was associated with a 0.7-day decrease in length of stay, reduced risk adjusted mortality rates (AOR = 0.58, p = 0.05), and a $4,700 increase in total cost.

Conclusions

In this national retrospective study, we observe socioeconomic differences in patients undergoing MIG, which is explained by hospital level factors in MIG utilization. We demonstrate that MIG is associated with a lower mortality compared with open gastrectomy. Establishing MIG as a safe approach to gastric cancers and understanding regional differences in implementation patterns can inform delivery of equitable high-quality health care.

Language Proficiency and Survival in Pancreatic Cancer: a Propensity Score-Matched Analysis

BACKGROUND

Limited English proficiency has been shown to negatively affect health outcomes. However, as of now, little is known about survival rates of patients with limited English proficiency (LEP) and pancreatic ductal adenocarcinoma (PDAC) when compared to patients with English proficiency (EP) in an urban, non-safety net setting. We aimed to compare survival rates between patients with LEP and those with EP who had a diagnosis of PDAC.

METHODS

A single-institution retrospective propensity-matched cohort study of patients with biopsy-proven PDAC was undertaken. Demographics, clinical characteristics, and language information were collected for all participants. Patients were classified as having LEP or EP based on their preferred speaking language at the time of admission and matched on baseline characteristics using propensity scores. Survival analysis methods were used to study survival rates in patients with PDAC based on their EP status.

RESULTS

Of 739 included patients, 71 (9.48%) had LEP, mean age was 68.4 ± 10.9, and 51.8% were female. Both groups of patients were comparable for age, gender, marital status, and time to treatment. LEP status was associated with higher odds of death in both unmatched (HR 1.65, 95% CI 1.22-2.22) and matched (HR 1.60, 95% CI 1.03-2.47) analyses. Additionally, patients with LEP had significantly decreased odds of receiving cancer-directed treatment and increased odds of advanced stage cancer at presentation.

CONCLUSIONS

In this cohort of patients with PDAC, LEP predicted worse survival. The results of this study suggest that, after accounting for interpreter use, other factors contribute to this disparity. Such factors, as yet unmeasured, may include health literacy and cultural expectations, for which further investigation is warranted to better understand and limit this survival disparity.

Association of Race With Postoperative Mortality Following Major Abdominopelvic Trauma in Children

BACKGROUND

The leading cause of mortality among children is trauma. Race and ethnicity are critical determinants of pediatric postsurgical outcomes, with minority children generally experiencing higher rates of postoperative morbidity and mortality than White children. This pattern of poorer outcomes for racial and/or ethnic minority children has also been demonstrated in children with head and limb traumas. While injuries to the abdomen and pelvis are not as common, they can be life-threatening. Racial and/or ethnic differences in outcomes of pediatric abdominopelvic operative traumas have not been examined. Our objective was to determine whether disparities exist in postoperative mortality among children with major abdominopelvic trauma.

MATERIALS AND METHODS

We performed a retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Patients were included if they were < 18 years, sustained a major abdominopelvic injury, and underwent subsequent surgical intervention. Our primary outcome was inpatient mortality, comparing children of different race and/or ethnicity.

RESULTS

We identified a weighted cohort of 13,955 children, of whom 6765 (48.5%) were White, 3614 (25.9%) Black, and 2647 (19.0%) Hispanic. After adjusting for covariates, Black children were 94% more likely to die than their White peers (3.3% versus 1.6%, adjusted-RR:1.94, 95%CI: 1.33-2.82, P = 0.001). Hispanic children (adjusted-RR:1.99, 95%CI: 1.36-2.91, P < 0.001) and those of other race and/or ethnicity (adjusted-RR: 2.02, 95%CI:1.20-3.40, P = 0.008) were also more likely to die compared to their White peers.

CONCLUSIONS

Black and Hispanic children who require operative intervention following major abdominopelvic trauma have a higher risk of postoperative mortality compared with White children.

Exploring the Challenges for International Medical Graduates Pursuing Minimally Invasive Surgery Training in the United States and Canada: A Cross-Sectional Analysis

Background:

International Medical Graduates (IMGs) are an important component of the US healthcare workforce. Prior studies have investigated bias against IMGs during the general surgery residency application in the United States. Minimally invasive surgery (MIS) is a growing field; The MIS fellowship match was established in 2004 and is a competitive process with a match rate of 47%. Opportunities for applicants who are non-US citizens are limited by a series of factors that are not related to their professional qualifications.

Objectives:

The aim of the study was to explore the challenges faced by IMG in the MIS fellowship match.

Methods:

This is a cross-sectional study analyzing the minimally invasive surgery application requirements of all the programs listed in the Fellowship Council. Individual program requirements were collected into a database and a descriptive analysis was performed comparing programs who accept IMGs versus those that do not. Further statistical analysis was performed to explore those differences and associated factors.

Results:

There were 148 MIS fellowship programs and 187 positions offered during the 2021 match year in the US. Ninety-seven programs (65.5%) were found to accept graduates of foreign medical schools if they were US-citizens, whereas only 49 programs (33.1%) were found to accept IMG and sponsor a visa for their training. University affiliated programs (88.9% vs 75.0%, p = 0.04), programs with a general surgery residency (94.4% vs 75.0%, p = 0.003), and older programs (63.0% vs 45.5%, p = 0.04) were more likely to accept IMGs requiring visa sponsorship.

Conclusions:

There is a significant bias against IMGs in the MIS fellowship match, with a reduced number of positions available based on factors not related to their professional performance or qualifications. Well established programs, university, and residency affiliated programs are more likely to consider these physicians for training.

Social Vulnerability Subtheme Analysis Improves Perioperative Risk Stratification in Hepatopancreatic Surgery

BACKGROUND

There has been increased interest in understanding how social determinants of health (SDH) may affect care both in the medical and surgical setting. We sought to define the impact of various aspects of social vulnerability on the ability of patients to achieve a "textbook outcome" (TO) following hepatopancreatic surgery.

METHODS

Medicare beneficiaries who underwent hepatopancreatic resection between 2013 and 2017 were identified using the Medicare database. Social vulnerability was defined using the Centers for Disease Control Social Vulnerability Index (SVI), which is comprised of four subthemes: socioeconomic (SE), household composition and disability (HCD), minority status and language (MSL), and housing type and transportation (HTT). TO was defined as the composite endpoint: absence of 90-day mortality or readmission, absence of an extended length of stay (LOS), and no complications during the index admission. Cluster analysis was used to identify vulnerability cohorts, and multivariable logistic regression was utilized to assess the impact of these SVI subthemes on the likelihood to achieve a textbook outcome.

RESULTS

Among 37,707 Medicare beneficiaries, 64.9% (n = 24,462) of patients underwent pancreatic resection while 35.1% (n = 13,245) underwent hepatic resection. Median patient age was 72 years (IQR: 68-77), just over one-half were male (51.9%; n = 19,558), and the median CCI was 3 (IQR: 2-8). Cluster analysis revealed five distinct SVI profiles with wide variability in the distribution of SVI subthemes, ranging from 15 (profile 1 IQR: 7-26) to 83 (profile 5 IQR: 66-93). The five profiles were grouped into 3 categories based on median composite SVI: "low vulnerability" (profile 1), "average vulnerability" (profiles 2 and 3), or "high vulnerability" (profiles 4 and 5). The rate of TO ranged from 44.6% in profile 5 (n = 4022) to 49.2% in profile 1 (n = 4836). Multivariable analyses comparing patients categorized into the two average SVI profiles revealed that despite having similar composite SVI scores, the risk of adverse postoperative outcomes was not similar. Specifically, patients from profile 5 had lower odds of achieving a TO (OR 0.89, 95%CI: 0.83-0.95) and higher odds of 90-day mortality (OR 1.29, 95%CI: 1.15-1.44) versus patients in profile 4.

CONCLUSION

Distinct profiles of SVI subtheme characteristics were independently associated with postoperative outcomes among Medicare beneficiaries undergoing HP surgery, even among patients with similar overall composite SVI scores.

Association between Race and Perioperative Outcomes after Carotid Endarterectomy for Asymptomatic Carotid Artery Stenosis in NSQIP

BACKGROUND

Previous studies have documented that Black patients have worse outcomes after lower extremity revascularization procedures compared with White patients. However, the association of race on carotid endarterectomy (CEA) outcomes is not well described. The aim of this study was to compare perioperative outcomes of CEA for Black vs White patients with asymptomatic carotid artery stenosis.

STUDY DESIGN

All patients who underwent CEA for asymptomatic carotid stenosis in the ACS-NSQIP targeted vascular database (2011-2019) were included. Perioperative (30-day) outcomes were compared for Black vs White patients using multivariable logistic regression adjusting for age/sex, comorbidities, and disease characteristics.

RESULTS

Of 16,764 asymptomatic CEA patients, 95.2% (N = 15,960) were White and 4.8% (N = 804) were Black. Black patients were slightly younger (mean age 71.4 ± 0.1 vs 69.9 ± 0.3 years, P < 0.001) and more frequently had high-grade carotid artery stenosis compared to White patients (79.5% vs 74.0%, p = 0.001). Comorbidities including hypertension, diabetes, kidney disease, congestive heart failure, and coronary artery disease were all more prevalent among Black patients (p ≤ 0.01). Crude perioperative stroke (2.4% vs 1.3%, p = 0.007) and stroke/death (2.6% vs 1.4%, p = 0.003) were higher for Black patients, but myocardial infarction (1.7% vs 1.5%, p = 0.67) and death (0.4% vs 0.2%, p = 0.12) were similar. After adjusting for baseline differences between groups, the risk of perioperative stroke (odds ratio 1.66, 95% CI 1.01 to 2.73) and stroke/death (odds ratio 1.75, 95% CI 1.10 to 2.81) remained significantly higher for Black patients compared with White patients.

CONCLUSIONS

Black patients undergoing CEA for asymptomatic carotid artery stenosis had more severe stenosis, more comorbidities, and worse perioperative outcomes compared to White patients. Overall, our data suggest substantial differences in the treatment and outcomes of asymptomatic carotid artery stenosis based on race.

Exploring Access to Surgical Interventions for Hidradenitis Suppurativa: Retrospective Population-Based Analysis

BACKGROUND

Hidradenitis suppurativa (HS) is a painful inflammatory disorder that confers significant distress to patients, with surgery as an integral treatment modality.

OBJECTIVE

To inform improvements in care, patterns in HS surgery were assessed.

METHODS

A retrospective population-based analysis was performed on Ontario billing claims for HS surgery across a period of 10 years from January 1, 2008 to December 31, 2017. HS surgery was defined as the excision of inguinal, perineal, or axillary skin and sweat glands for hidradenitis. The top 5 billing specialties, including general and plastic surgery, were analyzed. The total number of procedures performed as well as the number performed per physician were investigated. Patient and physician locations were compared.

RESULTS

A total of 7195 claims for the excision of inguinal, perineal, or axillary skin and sweat glands for HS were submitted across the study period. Annual HS surgery claims showed an increasing trend across 10 years, ranging between 4.9 and 5.8 per 100,000 population. However, overall, for every additional year, the number of claims per 100,000 population only increased slightly, by 0.03 claims. The number of providers steadily decreased, ranging between 1.7 and 1.9 per 100,000, with approximately twice as many general than plastic surgeons. However, again overall, for every additional year, the number of providers per 100,000 population decreased slightly, by 0.002 physicians. The mean annual number of procedures per physician rose from 2.8 to 3.1. In rural areas, analyzed per claim, general surgeons performed the majority of surgeries (1318/2003, 65.8%), while in urban areas, surgeries were more equally performed by general (2616/5192, 50.4%) and plastic (2495/5192, 48.1%) surgeons. Of HS surgery claims, 25.7%-35.9% were provided by a physician residing in a different area than the patient receiving care.

CONCLUSIONS

No significant improvements in access to HS surgery were seen across the study period, with access potentially worsening with annual HS claims rising overall and number of providers decreasing, with patients travelling further to access surgery. System barriers across the continuum of HS diagnosis and management must be evaluated to improve access to surgical care.

Racial disparity in recommendation for surgical resection of skull base chondrosarcomas: A Surveillance, Epidemiology, and End Results (SEER) analysis

INTRODUCTION

There is increased appreciation of racial disparities in the delivery of neurosurgical care. Here, we explore whether race influences surgical recommendations in the management of skull base chondrosarcomas.

METHODS

We identified 493 patients with skull base chondrosarcoma using the Surveillance, Epidemiology, and End Results (SEER) registry (November 2017 submission). Regression analyses were performed to identify demographic variables associated with recommendation against surgery. Univariate and multivariate cox proportional hazards models were used for survival analysis.

RESULTS

In a univariate analysis, we found that the African-American race was associated with an increased likelihood of surgeon recommendation against surgery (OR = 4.416, 95% CI = 1.893-10.302, p = 0.001). This association remained robust in the multivariate model that controlled for other covariates, including age of diagnosis (OR = 5.091, 95% CI = 2.127-12.187, p < 0.001). For patients who received a recommendation against surgery, the likelihood of dying from non-chondrosarcoma causes was comparable between Caucasian and African-American patients, suggesting that the prevalence and severity of medical conditions that increase the risk of death were comparable between these cohorts (HR = 0.466, 95% CI = 0.057-3.802, p = 0.475). The likelihood of dying from chondrosarcoma was comparable between Caucasian and African-American patients who underwent surgery (HR = 0.982, 95% CI = 0.353-2.732, p = 0.973), suggesting absence of race-specific surgical benefits.

CONCLUSION

We identified a racial disparity against African-Americans in recommendations for surgical resection of skull base chondrosarcomas.

Ethnic Disparities and Incidence of Postoperative Complications in Obese Patients Undergoing Total Knee Arthroplasty: Analysis of the American College of Surgeons National Surgical Quality Improvement Program Data Set

INTRODUCTION

Total knee arthroplasty (TKA) is common but complex operation. A paucity of literature exists on differences between Hispanics and non-Hispanics with TKA. Our study aims to investigate the association between Hispanic ethnicity and complications in obese patients undergoing TKA.

METHODS

This is a retrospective cohort study using the National Surgical Quality Improvement Program database for patients with body mass index ≥30 kg/m2 who underwent TKA. Exposure in this study was ethnicity (Hispanic versus non-Hispanic), and the primary outcome was postoperative complications. Associations between ethnicity and baseline characteristics and between covariates and the outcome were assessed via bivariate analysis. Multiple logistic regression was done to determine associations between Hispanic ethnicity and complications while controlling for confounders.

RESULTS

Thirty five thousand twenty-seven patients were included in our study, of which 6.3% were Hispanic. Among obese adults, Hispanics had a 1.24 (95% CI 1.11 to 1.39) times greater odds of having a postoperative complication after TKA than non-Hispanics. This increased to 1.36 (95% CI 1.20 to 1.54) after adjusting for confounders. Hispanics were notably more likely to receive transfusion (2.62% vs. 1.59%, P < 0.001) and have prolonged length of stay (13.29% vs. 11.12%, P = 0.002) but were less likely to have wound disruption (0.05% vs. 0.27%, P = 0.042).

CONCLUSION

In a national database, Hispanic ethnicity was associated with greater odds of postoperative complication in obese patients undergoing TKA compared with non-Hispanics. Future studies focusing on a wide range metrics of social determinants of health are needed to further investigate barriers and intervention to eliminate racial/ethnic disparities in surgical patients.

Variation in Use of Surgical Care During the COVID-19 Pandemic by Surgical Urgency and Race and Ethnicity

Question

To what extent did the COVID-19 pandemic reduce access to surgical care, and were racial and ethnic minority groups more likely to have reduced access to surgical care?

Findings

In this cohort study of more than 13 million inpatient and outpatient surgical encounters in 767 US hospitals in a hospital administrative database, surgical use was 13% lower in 2020 compared with 2019, with the greatest decrease concentrated in elective surgical procedures. While Black and Hispanic patients experienced a reduction in surgical encounters, White patients experienced the greatest reduction in surgical encounters.

Meaning

Despite severe and persistent disruptions to health systems during the COVID-19 pandemic, racial and ethnic minority groups did not experience a disproportionate decrease in access to surgical care.

Importance

The extent of the disruption to surgical care during the COVID-19 pandemic has not been empirically characterized on a national level.

Objective

To characterize the use of surgical care across cohorts of surgical urgency during the COVID-19 pandemic, and to assess for racial and ethnic disparities.

Design, Setting, and Participants

This was a retrospective observational study using the geographically diverse, all payer data from 767 hospitals in the Premier Healthcare Database. Procedures were categorized into 4 cohorts of surgical urgency (elective, nonelective, emergency, and trauma). A generalized linear regression model with hospital-fixed effects assessed the relative monthly within-hospital reduction in surgical encounters in 2020 compared with 2019.

Main Outcomes and Measures

Outcomes were the monthly relative reduction in overall surgical encounters and across surgical urgency cohorts and race and ethnicity.

Results

The sample included 13 175 087 inpatient and outpatient surgical encounters. There was a 12.6% relative reduction in surgical use in 2020 compared to 2019. Across all surgical cohorts, the most prominent decreases in encounters occurred during Spring 2020 . For example, elective encounters began falling in March, reached a trough in April, and subsequently recovered but never to prepandemic levels (March: −26.8%; 95% CI, −29.6% to −23.9%; April: −74.6%; 95% CI, −75.5% to −73.5%; December: −13.3%; 95% CI, −16.6%, −9.8%). Across all operative surgical urgency cohorts, White patients had the largest relative reduction in encounters.

Conclusions and Relevance

As shown by this cohort study, the COVID-19 pandemic resulted in large disruptions to surgical care across all categories of operative urgency, especially elective procedures. Racial and ethnic minority groups experienced less of a disruption to surgical care than White patients. Further research is needed to explore whether the decreased surgical use among White patients was owing to patient discretion and to document whether demand for surgical care will rebound to baseline levels.

Diversity Matters: A 21-Year Review of Trends in Resident Recruitment into Surgical Specialties

Background

Diversity within the healthcare workforce is essential to improve quality of care, although evaluation of diversity within surgical training remains limited. This study analyzed diversity in recruitment of residents into surgical subspecialties at a large academic medical institution and national trends.

Methods

A 21-year cross-sectional study of medical school graduates accepted into all surgical subspecialty training programs was performed. The institutional cohort was divided into two groups (1997-2006, 2007-2017). Subspecialty acceptance rates were determined between 2011 and 2018. Data on candidate demographics including gender, race, ethnicity, citizenship, and origin of medical education at a single institution and nationally were extracted.

Results

Two thousand found hundred seventy-two residents were included in this study. From 1997 to 2018, female acceptances increased from 21.1% to 29.7% (p < 0.01), non-White increased from 27.9% to 31.8% (p = 0.01), and international medical graduates decreased from 28.8% to 25.5% (p = 0.02). There was no significant change in accepted Hispanic and Non-US candidates. Female subspecialty rates for subspecialties increased nationally and was comparable to our cohort, except in general surgery. Hispanic subspecialty acceptance rates were less than 10% and Black/African American acceptance rates remained less than 5% across subspecialties nationally and at our institution.

Conclusion

Diversity in surgical training has modestly progressed over the last two decades, but the degree of positive change has not been universal and highlights the critical need for improvement and action. Continued institution driven and collaborative strategies are essential to promote diversity in recruitment across all surgical specialties that has implications on our future workforce and surgical leadership.

Teaching what matters: Integrating health equity education into the core surgery clerkship

BACKGROUND

Significant disparities in surgical outcomes exist. It is imperative to prepare future doctors to eliminate disparities. Our team of senior medical students developed a surgical clerkship module examining equity in prostate cancer. Student attitudes before and after a facilitated teaching session were assessed.

METHODS

A surgical equity pilot module was integrated into the core surgical clerkship starting in July 2020. This module was composed of (1) asynchronous preparatory material and (2) a synchronous interactive case discussion regarding disparities in prostate cancer. Discussion sessions were facilitated by upper-level medical students. Participants answered optional anonymous Likert-style and open-ended survey questions before and after the session. Pre- and post-responses were compared.

RESULTS

One hundred and sixteen students completed the module between July 2020 and January 2021. Pre- and post-survey response rates were 66% and 29%, respectively. At baseline, almost all students (95%) agreed knowledge of disparities would make them a better physician. However, the majority (95%) described their general knowledge of surgical disparities as "nonexistent," "poor," or "average." Most students did not have a framework for assessing causes of surgical disparities (86%) and were not aware of interventions for reducing disparities (90%). After intervention, the majority rated their knowledge of surgical disparities as "good" or "excellent" (71%; P < .001). Most students indicated they had a framework 79%; P < .001) and were aware of effective interventions (62%; P < .001).

CONCLUSION

We demonstrated a successful pilot of an equity-focused clerkship module. Student attitudes after a single session reflected significant improvement in knowledge of causes and interventions related to surgical disparities. Equity-focused teaching can be incorporated into the surgical clerkship.

Disparities in the Surgical Treatment of Cerebrovascular Pathologies: A Contemporary Systematic Review

INTRODUCTION

This systematic review analyzes contemporary literature on racial/ethnic, insurance, and socioeconomic disparities within cerebrovascular surgery in the United States to determine areas for improvement.

METHODS

We conducted an electronic database search of literature published between January 1990 and July 2020 using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies analyzing a racial/ethnic, insurance, or socioeconomic disparity within adult cerebrovascular surgery.

RESULTS

Of 2873 articles screened for eligibility by title and abstract, 970 underwent full-text independent review by 3 authors. Twenty-seven additional articles were identified through references to generate a final list of 47 included studies for analysis. Forty-six were retrospective reviews and 1 was a prospective observational cohort study, thereby comprising Levels III and IV of evidence. Studies investigated carotid artery stenting (11/47, 23%), carotid endarterectomy (22/47, 46.8%), mechanical thrombectomy (8/47, 17%), and endovascular aneurysm coiling or surgical aneurysm clipping (20/47, 42.6%). Minority and underinsured patients were less likely to receive surgical treatment. Non-White patients were more likely to experience a postoperative complication, although this significance was lost in some studies using multivariate analyses to account for complication risk factors. White and privately insured patients generally experienced shorter length of hospital stay, had lower rates of in-hospital mortality, and underwent routine discharge. Twenty-five papers (53%) reported no disparities within at least one examined metric.

CONCLUSIONS

This comprehensive contemporary systematic review demonstrates the existence of disparity gaps within the field of adult cerebrovascular surgery. It highlights the importance of continued investigation into sources of disparity and efforts to promote equity within the field.

Failure to Rescue After Cardiac Surgery at Minority-Serving Hospitals: Room for Improvement

BACKGROUND

Despite living closer to high-performing centers, minority patients reportedly receive care at lower-quality hospitals. Investigating opportunities for improvement at minority-serving hospitals may help attenuate disparities in care among cardiothoracic surgery patients. We sought to investigate the relationship between hospital quality and failure-to-rescue (FTR).

METHODS

Over 451,000 cardiac surgery patients from 2000-2011 at minority-serving hospitals (MSH) were identified from the Nationwide Inpatient Sample. After stratifying patients by hospital mortality quartile, outcomes at poorly performing MSH were compared to those at high-performing MSH. Propensity-score matching was used for comparisons.

RESULTS

Though patients at poorly performing centers were more likely black, there were no significant differences in admission status (urgent vs elective), income, insurance, or risk before matching. There were no differences in comorbidities between low- and high-performing MSH including chronic lung disease, coagulopathy, hypertension, and renal failure. While complications remained similar across mortality quartiles (29%, 32%, 31%, 36% respectively; p<0.0001), FTR increased in a stepwise manner (5.4%, 8.7%, 11.2%, 15.5%; p<0.0001). The same was true after propensity-score matching - FTR nearly tripled in the highest-mortality centers (14.4% vs 5.3%; p<0.0001) while complications only increased 1.2-fold from 31.1% to 36.7% (p=0.0058). This finding persisted even when stratified by procedure type and by complication.

CONCLUSIONS

Improving timely management of complications after cardiac surgery may serve as a promising opportunity for increasing quality of care at MSH. When considering centralization of care in cardiac surgery, equal emphasis should be placed on collaboration between tertiary care centers and low-quality MSH to mitigate disparities in care.

Association of socioeconomic status with 30- and 90-day readmission following open and laparoscopic hernia repair: a nationwide readmissions database analysis

BACKGROUND

Socioeconomic disparities have been associated with outcomes in many medical conditions. The association of socioeconomic status (SES) with readmissions after ventral and inguinal hernia repair has not been well studied on a national level. This study aims to evaluate the association of SES with readmission as a significant outcome in patients undergoing ventral and inguinal hernia repair.

METHODS

A retrospective cohort study was performed evaluating patients undergoing ventral hernia and inguinal hernia repair with 1:1 propensity score matching using the Nationwide Readmissions Database (2016-2017). Both 30- and 90-day readmissions were examined. After matching, a multivariate logistic regression analysis was performed using confounding variables including hospital setting, comorbidities, urgency of repair, sociodemographic status, and payer. Likelihood of readmission was reported in odds ratio form.

RESULTS

Readmission rates were 11.56% (24,323 out of 210,381) and 17.94% (30,893 out of 172,210) for 30- and 90-day readmissions, respectively. Patients with Medicaid and in the lower income quartile were more likely to present in an emergent fashion for hernia repair. After matching, a multivariate logistic regression analysis showed socioeconomic status (OR 1.250 and 1.229) was a statistically significant independent predictor of readmission at 30 and 90 days, respectively. Inversely, factors associated with the least likely chance of readmission were a laparoscopic approach (OR 0.646 and 0.641), elective admission (OR 0.824 and 0.779), and care in a teaching hospital (OR 0.784 and 0.798).

CONCLUSION

SES is an independent predictor of readmission at 30 and 90 days following open and laparoscopic ventral and inguinal hernia repair. Patients with a lower socioeconomic status were more likely to undergo hernia repair in the emergent setting. Efforts toward mitigating SES disparities by potentially promoting MIS techniques, enhancing access to elective cases, and systematic approaches to perioperative care for this disadvantaged population can potentially enhance overall hernia outcomes.

Challenges in the Methodology for Health Disparities Research in Thoracic Surgery

Research on health disparities in thoracic surgery is based on large population-based studies, which is associated with certain biases. Several methodological challenges are associated with these biases and warrant review and attention. The lack of standardized definitions in health disparities research requires clarification for study design strategy. Further inconsistencies remain when considering data sources and collection methods. These inconsistencies pose challenges for accurate and standardized downstream data analysis and interpretation. These sources of bias should be considered when establishing the infrastructure of health disparities research in thoracic surgery, which is in its infancy and requires further development.

Associations of gender, race, and ethnicity with disparities in short-term adverse outcomes after pancreatic resection for cancer

BACKGROUND

Several studies have identified disparities in pancreatic cancer treatment associated with gender, race, and ethnicity. There are limited data examining disparities in short-term adverse outcomes after pancreatic resection for cancer. The aim of this study is to evaluate associations of gender, race, and ethnicity with morbidity and mortality after pancreatic resection for malignancy.

METHODS

The American College of Surgeons National Surgical Quality Improvement database was retrospectively reviewed. The χ² test and Student's t-test were used for univariable analysis and hierarchical logistic regression for multivariable analysis.

RESULTS

Morbidity and major morbidity after pancreaticoduodenectomy are associated with male gender, Asian race, and Hispanic ethnicity, whereas 30-day mortality is associated with the male gender. Morbidity and major morbidity after distal pancreatectomy are associated with the male gender. Morbidity after pancreaticoduodenectomy is independently associated with male gender, Asian race, and Hispanic ethnicity; major morbidity is independently associated with male gender and Asian race, and mortality is independently associated with Hispanic ethnicity.

CONCLUSIONS

Gender, race, and ethnicity are independently associated with morbidity after pancreaticoduodenectomy for cancer; gender and race are independently associated with major morbidity; and ethnicity is independently associated with mortality. Further studies are warranted to determine the basis of these associations.

Symptom Status of Patients Undergoing Carotid Endarterectomy in Canada and United States

BACKGROUND

Previous studies have demonstrated significant geographic variations in the management of carotid artery stenosis despite standard guidelines. To further characterize these practice variations, we assessed differences in patient selection, operative technique, and outcomes for carotid endarterectomy (CEA) in Canada vs. United States.

METHODS

The Vascular Quality Initiative (VQI) was used to identify all patients who underwent CEA between 2010 and 2019 in Canada and United States. Demographic, clinical, and procedural characteristics were recorded and differences between countries were assessed using independent t-test and chi-square test. The primary outcome was the percentage of CEA performed for asymptomatic versus symptomatic disease. The secondary outcomes were 30-day and long-term stroke or death. Associations between country and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis.

RESULTS

During the study period, 131,411 US patients and 701 Canadian patients underwent CEA in VQI sites. Patients from the US were older with more comorbidities including hypertension, diabetes, congestive heart failure, and chronic kidney disease. The use of a shunt, patch, drain, or protamine was less common in the US. Most patients had 70 - 99% stenosis, with no difference between regions. The percentage of CEA performed for asymptomatic disease was significantly higher in the US even after adjusting for demographic, clinical, and procedural characteristics (72.4% vs. 30.7%, adjusted OR 3.91 [95% CI 3.21 - 4.78], p < 0.001). Thirty-day stroke/death was low (1.8% vs. 1.9%) and 1-year stroke/death was similar between groups (HR 0.98 [95% CI 0.69 - 1.39], P = 0.89). The similarities in 1-year stroke/death persisted in asymptomatic patients (HR 0.70 [95% CI 0.37 - 1.30], P = 0.26) and symptomatic patients (HR 1.14 [95% CI 0.74 - 1.73], P = 0.56).

CONCLUSIONS

There are significant variations in CEA practice between Canada and US. In particular, most US patients are treated for asymptomatic disease, whereas most Canadian patients are treated for symptomatic disease. Furthermore, adjunctive procedures including shunting, patch use, and protamine administration are performed less commonly in the US. Despite these differences, perioperative and 1-year stroke/death rates are similar between countries. Future studies should investigate reasons for these variations and quality improvement projects are needed to standardize care.

The Influence of Household Income on Survival following Posterior Fossa Tumor Resection at a Large Academic Medical Center

Objectives  The present study examines the effect of median household income on mid- and long-term outcomes in a posterior fossa brain tumor resection population. Design  This is a retrospective regression analysis. Setting  The study conducted at a single, multihospital, urban academic medical center. Participants  A total of 283 consecutive posterior fossa brain tumor cases, excluding cerebellar pontine angle tumors, over a 6-year period (June 09, 2013-April 26, 2019) was included in this analysis. Main Outcome Measures  Outcomes studied included 90-day readmission, 90-day emergency department evaluation, 90-day return to surgery, reoperation within 90 days after index admission, reoperation throughout the entire follow-up period, mortality within 90 days, and mortality throughout the entire follow-up period. Univariate analysis was conducted for the whole population and between the lowest (Q1) and highest (Q4) socioeconomic quartiles. Stepwise regression was conducted to identify confounding variables. Results  Lower socioeconomic status was found to be correlated with increased mortality within 90 postoperative days and throughout the entire follow-up period. Similarly, analysis between the lowest and highest household income quartiles (Q1 vs. Q4) demonstrated Q4 to have significantly decreased mortality during total follow-up and a decreasing but not significant difference in 90-day mortality. No significant difference in morbidity was observed. Conclusion  This study suggests that lower household income is associated with increased mortality in both the 90-day window and total follow-up period. It is possible that there is an opportunity for health care providers to use socioeconomic status to proactively identify high-risk patients and provide additional resources in the postoperative setting.

Influence of psychosocial and sociodemographic factors in the surgical management of traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

Background

Socioeconomic factors can bias clinician decision-making in many areas of medicine. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, and major psychiatric disorder are emerging as potential sources of conscious and unconscious bias. We hypothesized that these psychosocial factors, in addition to socioeconomic factors, may impact the decision to operate on patients with a traumatic cervicothoracic fracture and associated spinal cord injury (SCI).

Methods

We performed a cohort analysis using clinical data from 2012-2016 in the American College of Surgeons (ACS) National Trauma Data Bank at academic level I and II trauma centers. Patients were eligible if they had a diagnosis of cervicothoracic fracture with SCI. Using ICD codes, we evaluated baseline characteristics including race; insurance status; diagnosis of alcoholism, substance abuse, or major psychiatric disorder; admission drug screen and blood alcohol level; injury characteristics and severity; and hospital characteristics including geographic region, non-profit status, university affiliation, and trauma level. Factors significantly associated with surgical intervention in univariate analysis were eligible for inclusion in multivariate logistic regression.

Results

We identified 6,655 eligible patients, of whom 62% underwent surgical treatment (n=4,137). Patients treated non-operatively were more likely to be older; be female; be Black or Hispanic; have Medicare, Medicaid, or no insurance; have been assaulted; have been injured by a firearm; have thoracic fracture; have less severe injuries; have severe TBI; be treated at non-profit hospitals; and be in the Northeast or Western U.S. (all P<0.01). After adjusting for confounders in multivariate analysis, only insurance status remained associated with operative treatment. Medicaid patients (OR=0.81; P=0.021) and uninsured patients (OR=0.63; P<0.001) had lower odds of surgery relative to patients with private insurance. Injury severity and facility characteristics also remained significantly associated with surgical management following multivariate regression.

Conclusions

Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, or psychiatric illness do not appear to bias the decision to operate after traumatic cervicothoracic fracture with SCI. Baseline sociodemographic imbalances were explained largely by insurance status, injury, and facility characteristics in multivariate analysis.