African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients

Discrepancies in Race and Ethnicity in the Electronic Health Record Compared to Self-report

OBJECTIVE

Racial and ethnic disparities are commonplace in health care. Research often relies on sociodemographic information recorded in the electronic health record (EHR). Little evidence is available about the accuracy of EHR-recorded sociodemographic information, and none in pediatrics. Our objective was to determine the accuracy of EHR-recorded race and ethnicity compared to self-report.

METHODS

Patients/guardians enrolled in two prospective observational studies (10/2014-1/2019) provided self-reported sociodemographic information. Corresponding EHR information was abstracted. EHR information was compared to self-report, considered "gold standard." Agreement was evaluated with Cohen's kappa.

RESULTS

A total of 503 patients (42% female, median age 12.8 years) were identified. Self-reported race (N = 484) was 73% White, 16% Black or African American (AA), 4% Asian, 5% multiracial, and 2% other. Self-reported ethnicity (N = 410) was 9% Hispanic/Latino, and 88% non-Hispanic/Latino. Agreement between self-reported and EHR-recorded race was substantial (kappa = 0.77, 95% CI 0.72-0.83). Race was discordant among 10% (47/476). Hispanic/Latino ethnicity also had strong agreement (kappa = 0.77, 95% CI 0.65-0.89). Among those who self-reported Hispanic/Latino and reported race (N = 21), race was less accurately recorded in the EHR (kappa = 0.26, 95% CI 0-0.54). Race did not match among 43% with recorded race (9/21). Among self-reported racial and/or ethnic minorities, 13% (12/164) were misclassified in the EHR as non-Hispanic White.

CONCLUSIONS

We found race and ethnicity are often inaccurately recorded in the EHR for patients who self-identify as minorities, leading to under-representation of minorities in the EHR. Inaccurately recorded race and ethnicity has important implications for disparity research, and for informing health policy. Reliable processes are needed to incorporate self-reported race and ethnicity in the EHR at institutional and national levels.

Disparities in Emergency Department Waiting Times for Acute Gastrointestinal Bleeding: Results From the National Hospital Ambulatory Medical Care Survey, 2009-2018

OBJECTIVE

The primary aim of this study was to assess waiting time (WT) across different racial groups to determine whether racial disparities exist in patients presenting with gastrointestinal bleeding (GIB) to the United States emergency departments (EDs).

METHODS

Using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2009 to 2018, we compared WT of patients with GIB across different racial/ethnic groups, including nonhispanic white (NHW), African American (AA), Hispanic White (HW), and Nonhispanic other. Multinomial logistic regression was applied to adjust the outcomes for possible confounders. We also assessed the trend of the WT over the study interval and compared the WT between the first (2009) and last year (2018) of the study interval.

RESULTS

There were an estimated 7.8 million ED visits for GIB between 2009 and 2018. Mean WT ranged from 48 minutes in NHW to 68 minutes in AA. After adjusting for gender, age, geographic regions, payment type, type of GI bleeding, and triage status, multinomial logistic regression showed significantly higher waiting time for AA patients than NHW (OR 1.01, P =0.03). The overall trend showed a significant decrease in the mean WT ( P value<0.001). In 2009, AA waited 69 minutes longer than NHW ( P value<0.001), while in 2018, this gap was erased with no statistically significant difference ( P value=0.26).

CONCLUSION

Racial disparities among patients presenting with GIB are present in the United States EDs. African Americans waited longer for their first visits. Over time, ED wait time has decreased, leading to a decline in the observed racial disparity.

Racial and Ethnic Disparities Among Patients Hospitalized for Acute Cholangitis in the United States

GOALS

We sought to determine whether race/ethnicity is associated with hospitalization outcomes among patients admitted with acute cholangitis.

BACKGROUND

Few studies have evaluated the association between race and outcomes in patients with acute cholangitis.

STUDY

We analyzed United States hospitalizations from 2009 to 2018 using the Nationwide Inpatient Sample (NIS). We included patients 18 years old or above admitted with an ICD9/10 diagnosis of cholangitis. Race/ethnicity was categorized as White, Black, Hispanic, or Other. We used multivariable regression to determine the association between race/ethnicity and in-hospital outcomes of interest, including endoscopic retrograde cholangiopancreatography (ERCP), early ERCP (<48 h from admission), length of stay (LOS), and in-hospital mortality.

RESULTS

Of 116,889 hospitalizations for acute cholangitis, 70% identified as White, 10% identified as Black, 11% identified as Hispanic, and 9% identified as Other. The proportion of non-White patients increased over time. On multivariate analysis controlling for clinical and sociodemographic variables, compared with White patients, Black patients had higher in-hospital mortality (adjusted odds ratio: 1.4, 95% confidence interval: 1.2-1.6, P <0.001). Black patients were also less likely to undergo ERCP, more likely to undergo delayed ERCP, and had longer LOS ( P <0.001 for all).

CONCLUSIONS

In this contemporary cohort of hospitalized patients with cholangitis, Black race was independently associated with fewer and delayed ERCP procedures, longer LOS, and higher mortality rates. Future studies with more granular social determinants of health data should further explore the underlying reasons for these disparities to develop interventions aimed at reducing racial disparities in outcomes among patients with acute cholangitis.

Understanding the Role of Urology Practice Organization and Racial Composition in Prostate Cancer Treatment Disparities

PURPOSE

Black men have a higher risk of prostate cancer diagnosis and mortality but are less likely to receive definitive treatment. The impact of structural aspects on treatment is unknown but may lead to actionable insights to mitigate disparities. We sought to examine the associations between urology practice organization and racial composition and treatment patterns for Medicare beneficiaries with incident prostate cancer.

METHODS

Using a 20% sample of national Medicare data, we identified beneficiaries diagnosed with prostate cancer between January 2010 and December 2015 and followed them through 2016. We linked urologists to their practices with tax identification numbers. We then linked patients to practices on the basis of their primary urologist. We grouped practices into quartiles on the basis of their proportion of Black patients. We used multilevel mixed-effects models to identify treatment associations.

RESULTS

We identified 54,443 patients with incident prostate cancer associated with 4,194 practices. Most patients were White (87%), and 9% were Black. We found wide variation in racial practice composition and practice segregation. Patients in practices with the highest proportion of Black patients had the lowest socioeconomic status (43.1%), highest comorbidity (9.9% with comorbidity score ≥ 3), and earlier age at prostate cancer diagnosis (33.5% age 66-69 years; P < .01). Black patients had lower odds of definitive therapy (adjusted odds ratio, 0.87; 95% CI, 0.81 to 0.93) and underwent less treatment than White patients in every practice context. Black patients in practices with higher proportions of Black patients had higher treatment rates than Black patients in practices with lower proportions. Black patients had lower predicted probability of treatment (66%) than White patients (69%; P < .05).

CONCLUSION

Despite Medicare coverage, we found less definitive treatment among Black beneficiaries consistent with ongoing prostate cancer treatment disparities. Our findings are reflective of the adverse effects of practice segregation and structural racism, highlighting the need for multilevel interventions.

Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013–2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88–6.69) (OR: 11.24; 95% CI: 8.53–13.95), more time spent in ICU (2.73; 1.70–3.76) (7.98; 6.10–9.87), and increased risk for surgical site infection (1.32; 1.03–1.68) (2.54; 1.71–3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.

Racial Disparities After Stoma Construction Exist in Time to Closure After 1 Year but Not in Overall Stoma Reversal Rates

INTRODUCTION

Conflicting data exist on racial disparities in stoma reversal (SR) rates. Our aim was to investigate the role of race in SR rates, and time to closure, in a longitudinal, racially diverse database.

METHODS

All adult patients (>18 years) who received an ileostomy or colostomy from 1999 to 2016 at a single institution were identified. Primary outcomes were SR rates and time to closure. Failure to reverse and time to closure was modeled using Cox regression. Kaplan-Meier survival curves, stratified by race, were generated for time to closure and hazard ratios (HRs) calculated.

RESULTS

Of 770 patients with stomas, 65.6% of patients underwent SR; 76.6% were white and 23.4% were black. On adjusted analysis, race did not predict overall SR rates or time to closure if performed less than 1 year. Instead, significant predictors for failure in SR included age, insurance status, end colostomy/ileostomy, and loop colostomy (p < 0.05). Predictors of delay in time to closure included insurance, end colostomy/ileostomy, and loop colostomy (p < 0.05). In patients who underwent reversal after 1 year, black race was an independent predictor of time to closure (HR 0.21, 95% CI 0.07-0.63, p < 0.05).

CONCLUSION

SR rates were equal between black and white patients. Disparities in time to closure existed only for black patients if reversed more than 1 year after index stoma construction. While equitable outcomes were achieved for most patients, further investigation is necessary to understand stoma disparities after 1 year.

Diversity and Inclusion in Plastic Surgery Education

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