Impact of Race on the Surgical Management of Adhesive Small Bowel Obstruction

The impact of rurality on racial disparities in costs of bowel obstruction treatment

Background

Black race has been associated with increased resource utilization after operation for small bowel obstruction (SBO). While prior literature has similarly demonstrated differences between urban and rural institutions, limited work has defined the impact of rurality on resource utilization by race.

Methods

The 2016-2020 National Inpatient Sample was used to identify adults undergoing adhesiolysis after non-elective admission for SBO. The primary endpoint was hospitalization costs. Additional outcomes included surgical delay (≥ hospital day 3), length of stay (LOS), and nonhome discharge. Regression models were developed to identify the impact of Black race and rurality on the outcomes of interest with an interaction term to examine the incremental association of Black race on rurality.

Results

Of an estimated 132,390 patients, 11.4 % were treated at an annual average of 377 rural hospitals (18.5 % of institutions). After adjustment, rural hospitals had higher costs (β + $4900, 95 % Confidence Interval [CI] [4200, 5700]), compared to others. However, rurality was associated with reduced odds of surgical delay (Adjusted Odds Ratio [AOR] 0. 76, CI[0.69, 0.85]), decreased LOS (β -1.66 days, CI[-1.99, -1.36]), and nonhome discharge (AOR 0.78, CI[0.70, 0.87]). While White patients experienced significant cost reductions at urban centers ($26,100 [25,800-26,300] vs $31,000 [30,300-31,700]), this was not noted for Black patients ($30,100 [29,400-30,700] vs $30,800 [29,300-32,400]).

Conclusions

We found that Black patients do not benefit from the same cost protection afforded by urban settings as White patients after operative SBO admission. Future work should focus on setting-specific interventions to address drivers of disparities within each community.

Impact of delayed intervention following admission for small bowel obstruction: A contemporary analysis

Background

The optimal timing of surgical intervention for small bowel obstruction (SBO) remains debated.

Methods

All adults admitted for SBO were identified in the 2018-2019 National Inpatient Sample. Patients undergoing small bowel resection or lysis of adhesion after three days were considered part of the Delayed cohort. All others were classified as Early. Multivariable regressions were used to assess independent predictors of delayed surgical intervention as well as associations between delayed management and in-hospital mortality, major adverse events (MAE), perioperative complications, postoperative length of stay (LOS), hospitalization costs and non-home discharge.

Results

Among 28,440 patients who met study criteria, 52.0 % underwent delayed intervention. Black race (AOR 1.19, 95 % CI 1.03-1.36, ref.: White) and Medicare coverage (AOR 1.16, 95 % CI 1.01-1.33, ref.: private payer) were associated with increased odds of delayed surgical management. While delayed intervention was not significantly associated with death (AOR 1.27, 95 % CI 0.97-1.68), it was linked to greater odds of MAE (AOR 1.30, 95 % CI 1.16-1.45) and several perioperative complications. The Delayed cohort also faced an incremental increase in postoperative LOS (+1.29 days, 95 % CI 0.89-1.70) and hospitalization costs (+$11,000, 95 % CI 10,000-12,000). Moreover, delayed intervention was linked to increased odds of non-home discharge (AOR 1.64, 95 % CI 1.47-1.84).

Conclusions

Delay in surgical management following SBO is linked to inferior clinical outcomes and increased resource use. Our findings highlight the need to ensure proper timing of surgery for SBO as well as efforts to standardize these practices across all demographics of patients.

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.

Review article: Implicit bias towards Aboriginal and Torres Strait Islander patients within Australian emergency departments

Aboriginal and Torres Strait Islander peoples continue to suffer adverse experiences in healthcare, with inequitable care prevalent in emergency settings. Individual, institutional and systemic factors play a significant part in these persisting healthcare disparities, with biases remaining entrenched in healthcare institutions. This includes implicit racial bias which can result in stereotyping of racial minorities and premature diagnostic closure. Furthermore, it may contribute to distrust of medical professionals resulting in higher rates of leave events and hinder racial minorities from seeking care or following treatment recommendations. The aim of this review is to analyse the effect of implicit bias on patient outcomes in the ED in international literature and explore how these studies correlate to an Australian context.