Surgical Morbidity and Mortality among American Indian and Alaska Native Veterans: A Comparative Analysis

Native Americans have comparable transcatheter aortic valve replacement outcomes but higher stroke and venous thromboembolism after surgical aortic valve replacement

BACKGROUND

Racial disparities in aortic valve replacement outcomes have been established. However, the current literature lacks comprehensive studies that examine the outcomes for Native Americans, probably due to their limited population size. This study aimed to investigate whether disparities in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) also exist for outcomes among Native Americans.

METHODS

Patients who underwent SAVR and TAVR were identified in National Inpatient Sample from the last quarter of 2015 to 2020. A 1:5 propensity score matching was conducted between Native Americans and Caucasians. In-hospital perioperative outcomes, length of stay, wait from admission to operation, and total hospital charge, were compared.

RESULTS

In TAVR, 51,394 (84.41 %) were Caucasians and 171 (0.28 %) were Native Americans. In SAVR, there were 50,080 (78.52 %) Caucasians and 279 (0.44 %) Native Americans. After propensity matching, no significant difference was found in post-TAVR outcomes between Native Americans and Caucasians. However, Native Americans have a higher risk of neurological complications (2.88 % vs 0.79 %, p < 0.01) with stroke being the primary contributor (2.52 % vs 0.5 %, p < 0.01), as well as a higher incidence of venous thromboembolism (1.8 % vs 0.57 %, p < 0.05) after SAVR.

CONCLUSIONS

This study is the first to examine aortic valve replacement outcomes in Native Americans. Native Americans were found to be more likely to undergo SAVR than TAVR. Moreover, Native Americans were found to have five times higher stroke and three times higher VTE after SAVR. These disparities faced by Native Americans underscore the need for increased attention and targeted actions to guarantee health equity.

Outcome Disparities in Total Knee and Total Hip Arthroplasty among Native American Populations

BACKGROUND

No prior racial disparities studies in total knee arthroplasty (TKA) and total hip arthroplasty (THA) have specifically evaluated outcomes among American Indian or Alaska Native (AIAN) patients. We hypothesized that AIAN patients have worse outcomes than White patients after controlling for demographics and comorbidities.

METHODS

This was a retrospective cohort study comparing White and AIAN patients undergoing primary TKA/THA from 2012-2019 using the American College of Surgeons National Surgical Quality Improvement Program. Race, demographics, and comorbidities were analyzed for correlations with 30-day outcomes and complications using multivariable logistic and linear regression analyses.

RESULTS

Comparing 422,215 White and 2,676 AIAN patients, AIAN patients had higher American Society of Anesthesiologist (ASA) classifications, body mass index (BMI), and were younger at the time of surgery. AIAN patients more often stayed inpatient > 2 days (49.4% vs 36.2%, p < 0.001), underwent reoperation (2.1% vs 1.4%, p < 0.01), and were discharged home (91.4% vs 81.7%, p < 0.01). Regression analyses controlling for age, BMI, sex, ASA classification, and functional status found that AIAN race was significantly positively correlated with a length of stay > 2 days (OR 1.6), reoperation (OR 1.4), and discharging home (OR 2.0).

CONCLUSION

AIAN patients undergoing TKA/THA present with a greater comorbidity burden compared to White patients and experience multiple worse outcome metrics including increased hospital length of stay and reoperation rates. Interestingly, AIAN patients were more likely to discharge home, representing a unique racial disparity which warrants further study.

Disparities and Risk Factors for Surgical Complication in American Indians and Native Hawaiians

INTRODUCTION

American Indian and Alaskan Natives (AIAN) and Native Hawaiian and Pacific Islanders (NHPI) research is limited, particularly in postoperative surgical outcomes. This study analyzes disparities in AIAN and NHPI surgical complications across all surgical types and identifies factors that contribute to postoperative complications.

METHODS

This retrospective cohort study examined all surgeries from 2011 to 2020 in the National Surgical Quality Improvement Program, queried by race. Multivariable models analyzed the association of race and ethnicity and 30-day postoperative complication. Next, multivariable models were used to identify preoperative variables associated with postoperative complications, specifically in AIAN and NHPI patients. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

AIAN patients were associated with higher odds of postoperative complication (AOR: 1.008 [CI: 1.005-1.011], P < 0.001) compared to non-Hispanic white patients. The comorbidities that were of higher incidence in AIAN patients, which also adversely contributed to postoperative complication, included dependent functional status, diabetes, congestive heart failure (CHF), open wounds, preoperative weight loss, bleeding disorders, preoperative transfusion, sepsis, hypoalbuminemia, along with an active smoking status and ASA ≥3. In NHPI patients, dependent functional status, CHF, renal failure, preoperative transfusion, open wounds, and sepsis were of higher incidence and significantly contributed to postoperative complication.

CONCLUSIONS

Surgical outcome disparities exist particularly in AIAN patients. Identification of modifiable patient risk factors may benefit perioperative care for AIAN and NHPI patients, which are historically understudied racial groups.

Racial Disparities in General Surgery Outcomes

INTRODUCTION

While disparities in Black and Hispanic and Latino patients undergoing general surgeries are well described, most analyses leave out Asian, American Indian or Alaskan Native (AIAN), and native Hawaiian or Pacific Islander patients. This study identified general surgery outcomes for each racial group in the National Surgical Quality Improvement Program.

METHODS

National Surgical Quality Improvement Program was queried to identify all procedures conducted by a general surgeon from 2017 to 2020 (n = 2,664,197). Multivariable regression models were used to investigate the impact of race and ethnicity on 30-day mortality, readmission, reoperation, major and minor medical complications, and non-home discharge destinations. Adjusted odds ratios (AOR) and 95% confidence intervals were calculated.

RESULTS

Compared to non-Hispanic White patients, Black patients had higher odds of readmission and reoperation, and Hispanic and Latino patients had higher odds of major and minor complications. AIAN patients had higher odds of mortality (AOR: 1.003 (1.002-1.005), P < 0.001), major complication (AOR: 1.013 (1.006-1.020), P < 0.001), reoperation (AOR: 1.009, (1.005-1.013), P < 0.001), and non-home discharge destination (AOR: 1.006 (1.001-1.012), P = 0.025), while native Hawaiian or Pacific Islander patients had lower odds of readmission (AOR: 0.991 (0.983-0.999), P = 0.035) and non-home discharge destination (AOR: 0.983 (0.975-0.990), P < 0.001) compared to non-Hispanic White patients. Asian patients had lower odds of each adverse outcome.

CONCLUSIONS

Black, Hispanic and Latino, and AIAN patients are at higher odds for poor postoperative results than non-Hispanic White patients. AIANs had some of the highest odds of mortality, major complications, reoperation, and non-home discharge. Social health determinants and policy adjustments must be targeted to ensure optimal operative results for all patients.

Racial Disparities in Tympanoplasty Surgery: A 30-Day Morbidity and Mortality National Cohort Study

OBJECTIVES

To assess the impact of race and ethnicity on 30-day complications after tympanoplasty surgery.

METHODS

The National Surgical Quality Improvement Program database was queried for tympanoplasty procedures from 2005 to 2019. Demographic, comorbidity, and postoperative complication data were compared according to race using univariate and binary logistic regression analyses.

RESULTS

A total of 11,701 patients were included, consisting of 80.3% White, 3.0% Black, 7.7% Asian, 5.7% Hispanic, 2.5% American Indian/Alaska Native, and 0.8% other. Binary logistic regression model indicated that Black patients had increased odds of unplanned readmittance (p = 0.033; odds ratio [OR], 3.110) and deep surgical site infections (p = 0.008; OR, 6.292). American Indian/Alaska Native patients had increased odds of reoperation (p = 0.022; OR, 6.343), superficial surgical site infections (p < 0.001; OR, 5.503), urinary tract infections (p < 0.001; OR, 18.559), surgical complications (p < 0.001; OR, 3.820), medical complications (p = 0.001; OR, 10.126), and overall complications (p < 0.001; OR, 4.545).

CONCLUSION

Although Black and American Indian/Alaskan Native patients were more likely to have complications after tympanoplasty surgery after adjusting for comorbidities, age, and sex, these results are tempered by an overall low rate of complications. Future studies should be devoted to understanding the drivers of these health inequities in access to otologic care and surgical treatment to improve outcomes and achieve equitable care.

Social determinants of health and the prediction of 90-day mortality among brain tumor patients

OBJECTIVE

Within the neurosurgical oncology literature, the effect of structural and socioeconomic factors on postoperative outcomes remains unclear. In this study, the authors quantified the effects of social determinant of health (SDOH) disparities on hospital complications, length of stay (LOS), nonroutine discharge, 90-day readmission, and 90-day mortality following brain tumor surgery.

METHODS

The authors retrospectively reviewed the records of brain tumor patients who had undergone resection at a single institution in 2017-2019. The prevalence of SDOH disparities among patients was tracked using International Classification of Diseases Ninth and Tenth Revisions (ICD-9 and ICD-10) codes. Bivariate (Mann-Whitney U-test and Fisher's exact test) and multivariate (logistic and linear) regressions revealed whether there was an independent relationship between SDOH status and postoperative outcomes.

RESULTS

The patient cohort included 2519 patients (mean age 55.27 ± 15.14 years), 187 (7.4%) of whom experienced at least one SDOH disparity. Patients who experienced an SDOH disparity were significantly more likely to be female (OR 1.36, p = 0.048), Black (OR 1.91, p < 0.001), and unmarried (OR 1.55, p = 0.0049). Patients who experienced SDOH disparities also had significantly higher 5-item modified frailty index (mFI-5) scores (p < 0.001) and American Society of Anesthesiologists (ASA) classes (p = 0.0012). Experiencing an SDOH disparity was associated with a significantly longer hospital LOS (p = 0.0036), greater odds of a nonroutine discharge (OR 1.64, p = 0.0092), and greater odds of 90-day mortality (OR 2.82, p = 0.0016) in the bivariate analysis. When controlling for patient demographics, tumor diagnosis, mFI-5 score, ASA class, surgery number, and SDOH status, SDOHs independently predicted hospital LOS (coefficient = 1.22, p = 0.016) and increased odds of 90-day mortality (OR 2.12, p = 0.028).

CONCLUSIONS

SDOH disparities independently predicted a prolonged hospital LOS and 90-day mortality in brain tumor patients. Working to address these disparities offers a new avenue through which to reduce patient morbidity and mortality following brain tumor surgery.

Racial Disparities in 30-Day Outcomes After Colorectal Surgery in an Integrated Healthcare System

BACKGROUND

Racial disparities in colorectal surgery outcomes have been studied extensively in the USA, and access to healthcare resources may contribute to these differences. The Veterans Health Administration (VHA) is the largest integrated healthcare network in the USA with the potential for equal access care to veterans. The objective of this study is to evaluate the VHA for the presence of racial disparities in 30-day outcomes of patients that underwent colorectal resection.

METHODS

Colon and rectal resections from 2008 to 2019 were reviewed retrospectively using the Veterans Affairs Surgical Quality Improvement Program database. Patients were categorized by race and ethnicity. Multivariable analysis was used to compare 30-day outcomes. Cases with "unknown/other/declined to answer" race/ethnicity were excluded.

RESULTS

Thirty-six-thousand-nine-hundred-sixty-nine cases met inclusion criteria: 27,907 (75.5%) Caucasian, 6718 (18.2%) African American, 2047 (5.5%) Hispanic, and 290 (0.8%) Native American patients. There were no statistically significant differences in overall complication incidence or mortality between all cohorts. Compared to Caucasian race, African American patients had longer mean length of stay (10.7 days vs. 9.7 days; p < 0.001). Compared to Caucasian race, Hispanic patients had higher odds of pulmonary-specific complications (adjusted odds ratio with 95% confidence interval = 1.39 [1.17-1.64]; p < 0.001).

CONCLUSIONS

The VHA provides the benefits of integrated healthcare and access, which may explain the improvements in racial disparities compared to existing literature. However, some racial disparities in clinical outcomes still persisted in this analysis. Further efforts beyond healthcare access are needed to mitigate disparities in colorectal surgery. CLASSIFICATIONS: [Outcomes]; [Database]; [Veterans]; [Colorectal Surgery]; [Morbidity]; [Mortality].

Postoperative Mortality of Indigenous Populations Compared With Nonindigenous Populations: A Systematic Review

Importance

A range of factors have been identified as possible contributors to racial/ethnic differences in postoperative mortality that are also likely to hold true for indigenous populations. Yet despite its severity as an outcome, death in the period following a surgical procedure is underresearched for indigenous populations.

Objective

To describe postoperative mortality experiences for minority indigenous populations compared with numerically dominant nonindigenous populations and examine the factors that drive any differences observed.

Evidence Review

This review was conducted according to PRIMSA guidelines and registered on PROSPERO. Articles were identified through searches of the Embase, Ovid MEDLINE, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases, with manual review of references and gray literature searches conducted. Eligible articles included those that reported associations between ethnicity/indigeneity and mortality up to 90 days following surgery and published in English between January 1, 1990, and March 26, 2019. Data on the study design, setting, participants (including indigeneity), and results were extracted. A modified Newcastle-Ottawa Quality Assessment Scale was used to determine study quality.

Findings

A total of 442 abstracts were screened, 92 articles were reviewed in full text, and 21 articles (from 20 studies) and 7 reports underwent data extraction. All included studies were cohort studies (3 prospective and the remainder retrospective) investigating a wide range of surgical procedures in the US, Australia, or New Zealand. Seven studies were from single facilities, while the remainder used data from national databases. Sample sizes ranged, with indigenous sample sizes ranging from 20 to 3052 patients and a number of studies reporting less than 10 indigenous deaths. The postoperative mortality experience for minority indigenous populations compared with the nonindigenous populations was mixed. There was evidence from several studies that indigenous populations may be more likely to die following cardiac procedures. However, the available evidence has overall poor study quality, with methods to identify the indigenous populations being a major limitation of most of the studies.

Conclusions and Relevance

Postoperative mortality experiences for indigenous populations should not be interpreted in isolation from the broader context of inequities across the health care pathway and must take into account the quality of data used for indigenous identification.

Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map

BACKGROUND

Continued racial/ethnic health disparities were recently described as "the most serious and shameful health care issue of our time." Although the 2014 US Affordable Care Act-mandated national insurance coverage expansion has led to significant improvements in health care coverage and access, its effects on life expectancy are not yet known. The Veterans Health Administration (VHA), the largest US integrated health care system, has a sustained commitment to health equity that addresses all 3 stages of health disparities research: detection, understanding determinants, and reduction or elimination. Despite this, racial disparities still exist in the VHA across a wide range of clinical areas and service types.

OBJECTIVES

To inform the health equity research agenda, we synthesized evidence on racial/ethnic mortality disparities in the VHA.

SEARCH METHODS

Our research librarian searched MEDLINE and Cochrane Central Registry of Controlled Trials from October 2006 through February 2017 using terms for racial groups and disparities.

SELECTION CRITERIA

We included studies if they compared mortality between any racial/ethnic minority and nonminority veteran groups or between different minority groups in the VHA (PROSPERO# CRD42015015974). We made study selection decisions on the basis of prespecified eligibility criteria. They were first made by 1 reviewer and checked by a second and disagreements were resolved by consensus (sequential review).

DATA COLLECTION AND ANALYSIS

Two reviewers sequentially abstracted data on prespecified population, outcome, setting, and study design characteristics. Two reviewers sequentially graded the strength of evidence using prespecified criteria on the basis of 5 key domains: study limitations (study design and internal validity), consistency, directness, precision of the evidence, and reporting biases. We synthesized the evidence qualitatively by grouping studies first by racial/ethnic minority group and then by clinical area. For areas with multiple studies in the same population and outcome, we pooled their reported hazard ratios (HRs) using random effects models (StatsDirect version 2.8.0; StatsDirect Ltd., Altrincham, England). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: odds ratio or HR of mortality for racial/ethnic minority group versus Whites, clinical area, strength of evidence, statistical significance, and racial group.

MAIN RESULTS

From 2840 citations, we included 25 studies. Studies were large (n ≥ 10 000) and involved nationally representative cohorts, and the majority were of fair quality. Most studies compared mortality between Black and White veterans and found similar or lower mortality for Black veterans. However, we found modest mortality disparities (HR or OR = 1.07, 1.52) for Black veterans with stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, or stroke; for American Indian and Alaska Native veterans undergoing noncardiac major surgery; and for Hispanic veterans with HIV or traumatic brain injury (most low strength).

AUTHOR'S CONCLUSIONS

Although the VHA's equal access health care system has reduced many racial/ethnic mortality disparities present in the private sector, our review identified mortality disparities that have persisted mainly for Black veterans in several clinical areas. However, because most mortality disparities were supported by single studies with imprecise findings, we could not draw strong conclusions about this evidence. More disparities research is needed for American Indian and Alaska Native, Asian, and Hispanic veterans overall and for more of the largest life expectancy gaps. Public Health Implications. Because of the relatively high prevalence of diabetes in Black veterans, further research to better understand and reduce this mortality disparity may be prioritized as having the greatest potential impact. However, other mortality disparities affect thousands of veterans and cannot be ignored.

Prevalence and predictors of complications following facial reconstruction procedures

Facial reconstruction procedures are immensely challenging and are done for a multitude of reasons. The purpose of this report is to provide nationally representative estimates of different types of facial reconstructive procedures and to examine prevalence and predictors of a wide range of complications associated with these procedures in the USA. The Nationwide Inpatient Sample, the largest inpatient dataset for the USA, was used. Data for the years 2004-2010 related to facial reconstruction procedures were identified through ICD-9-CM procedure codes. Associated complications were identified using secondary diagnosis field codes. Multivariable logistic regression models were used to examine the association between patient/hospital-level factors and the occurrence of complications. A total 26,374 facial reconstruction procedures were performed. About 20% of all patients who had facial reconstruction procedures developed a complication. Frequently occurring complications included postoperative pneumonia (4.9% of hospitalizations), hemorrhage (3.9%), other infections (3.6%), non-healing wounds (3.5%), and iatrogenically induced complications (3.2%). Significant factors found to be consistently associated with different types of complications included age, co-morbid burden, sex, and type of admission. The reported results are generalizable within limitations and can be used by health care providers to tailor quality improvement initiatives to minimize or better treat complications in the high-risk cohorts.

Meta-analysis of operative mortality and complications in patients from minority ethnic groups

BACKGROUND

Insight into the effects of ethnic disparities on patients' perioperative safety is necessary for the development of tailored improvement strategies. The aim of this study was to review the literature on safety differences between patients from minority ethnic groups and those from the ethnic majority undergoing surgery.

METHODS

PubMed, CINAHL, the Cochrane Library and Embase were searched using predefined inclusion criteria for available studies from January 1990 to January 2013. After quality assessment, the study data were organized on the basis of outcome, statistical significance and the direction of the observed effects. Relative risks for mortality were calculated.

RESULTS

After screening 3105 studies, 26 studies were identified. Nine of these 26 studies showed statistically significant higher mortality rates for patients from minority ethnic groups. Meta-analysis demonstrated a greater risk of mortality for these patients compared with patients from the Caucasian majority in studies performed both in North America (risk ratio 1·22, 95 per cent confidence interval 1·05 to 1·42) and outside (risk ratio 2·25, 1·40 to 3·62). For patients from minority groups, the length of hospital or intensive care unit stay was significantly longer in five studies, and complication rates were significantly higher in ten. Methods used to identify patient ethnicity were not described in 14 studies.

CONCLUSION

Patients from minority ethnic groups, in North America and elsewhere, have an increased risk of perioperative death and complications. More insight is needed into the causes of ethnic disparities to pursue safer perioperative care for patients of minority ethnicity.

Surgical outcomes in American Indian veterans: a closer look

BACKGROUND

American Indian/Alaska Native (AI/ANs) male veterans have considerably higher postoperative mortality rates than their Caucasian counterparts, but similar postoperative morbidity rates even after adjusting for major preoperative risk factors. This study seeks to explain the discrepancy in morbidity and mortality.

STUDY DESIGN

We obtained data from the Veterans Affairs National Surgical Quality Improvement Program on major, noncardiac, surgical procedures performed from 1991 to 2002 for all AI/AN men (n = 2,155), and a random sample of Caucasian men (n = 2,264), matched by site. We compared the number and types of postoperative complications and mortality rates for those patients in whom complications developed. We also examined complication and mortality rates by whether they occurred after hospital discharge, or by specific type of surgical procedure. Preoperative risk factors were assessed in patients who died. Chi-square or Fisher's exact tests were used for all comparisons.

RESULTS

AI/ANs and Caucasians did not differ by number of complications but Caucasian patients had considerably higher rates for three specific complications. There was no difference in deaths after discharge or in mortality rates after specific surgical procedures. The groups differed considerably in the types of procedures performed. Among patients who died, three preoperative risk factors, ie, hemiplegia, diabetes, and wound infection, occurred more frequently among AI/AN than Caucasian veterans.

CONCLUSIONS

We cannot fully explain higher postoperative mortality rates experienced by AI/AN relative to Caucasian veterans after examining complications, types of procedures, and other relevant factors. AI/ANs with certain preoperative risk factors can be vulnerable to 30-day postoperative mortality and benefit from closer postoperative surveillance.