Intersectionality and the Surgical Patient: Expanding the Surgical Disparities Framework

The modern-day "Rest Cure": "The yellow Wallpaper" and underrepresentation in clinical research

Gothic literature-a genre brimming with madness, supernaturalism, and psychological terror-offers innumerable case studies potentially representing how psychiatric patients perceive their treatment from healthcare professionals. Charlotte Perkins Gilman's famous 1892 short story "The Yellow Wallpaper" offers a poignant example of this through its fictional narrator, a diarist many interpret to be suffering from postpartum depression. The fiction here does not stray far from reality: Gilman orchestrated her diarist's experience to mirror her own, as both real author and fictional character suffocated from a melancholy only made worse by their physicians' insistence on following the "Rest Cure." While this instruction to cease all work and activity was a prevalent depression treatment at the time, Gilman, through "The Yellow Wallpaper," reveals how the intervention ultimately harmed more than helped because it overlooked her-and, by extension, her fictional diarist's- unique needs and identities. Today, while the ineffective Rest Cure no longer exists, applying observations from "The Yellow Wallpaper" to clinical research calls attention to underrepresentation in treatment development, a costly problem that could be mitigated by mindful incorporation of intersectionality theory into study designs.

Low adoption of mobility device in later life: Insights from the lens of intersectionality

OBJECTIVES

To investigate the utilization of mobility device, whether age and gender-related use disparities exist, and whether falls can further explain use disparities over time among Chinese older adults in need of devices.

METHODS

Community-dwelling older adults who needed mobility devices and completed four waves of the China Health and Retirement Survey 2011-2018 were included (N = 1,302). A categorical variable was created to represent respondents' intersectionality of age (50-64, 65-74, and ≥75 years) and gender (men vs. women).

RESULTS

The baseline prevalence of device use was 18.2 % (n = 237). Overall, the device use increased over time. Intersectionality-wise, oldest-old women were 1.53 times more likely than youngest-old men to use devices over time. Respondents with falls were more likely to use devices over time.

CONCLUSIONS

Older adults with mobility impairment, especially the oldest-old women and those with falls, lag in mobility devices utilization, suggesting future tailored interventions to support these populations.

Race and Socioeconomic Disparities in Proximal Aortic Surgery

BACKGROUND

Substantial socioeconomics-based disparities exist in cardiac surgery. Although there are robust data for revascularization and valve procedures, the effect of race and socioeconomic status on proximal aortic surgery is not well studied. This study analyzed the impact of race and socioeconomic status on in-hospital outcomes after proximal aortic surgery.

METHODS

All adult patients who underwent proximal aortic surgery for aortic dissection or thoracic aneurysm from the 2016 to 2018 National Inpatient Sample were included. Primary outcomes included in-hospital mortality and in-hospital composite morbidity (stroke, pulmonary embolus, major bleeding, acute kidney injury, or permanent pacemaker insertion). Adjusted outcomes were assessed with multivariable analysis.

RESULTS

A weighted total of 32,895 patients were included; 25,461 (77.4%) classified as White, 3224 (9.8%) Black, 2039 (6.2%) Hispanic, and 2171 (6.6%) other. Black and Hispanic patients had significantly lower median household income, higher proportion of self-pay insurance status, younger age, higher comorbidity burden, and a higher proportion of urgent or emergency procedures compared with White patients. There was no significant difference in observed in-hospital mortality by patient race, but non-White patients had significantly higher composite morbidity. On adjusted analysis, there was no difference in in-hospital mortality, but non-White race was an independent predictor of in-hospital morbidity (adjusted odds ratio, 1.6; 95% CI, 1.4-1.8; P < .001).

CONCLUSIONS

Patients of non-White race who undergo proximal aortic surgery have less insurance coverage, more urgent procedures, and a higher comorbidity burden than White patients, disparities that translate to significantly higher morbidity in non-White. A greater focus on nonfatal outcome differentials and improving access to care likely will improve aortic surgery disparities.

Redefining global cardiac surgery through an intersectionality lens

Although cardiovascular diseases are the leading cause of morbidity and mortality worldwide, six billion people lack access to safe, timely and affordable cardiac surgical care when needed. The burden of cardiovascular disease and disparities in access to care vary widely based on sociodemographic characteristics, including but not limited to geography, sex, gender, race, ethnicity, indigeneity, socioeconomic status and age. To date, the majority of cardiovascular, global health and global surgical research has lacked intersectionality lenses and methodologies to better understand access to care at the intersection of multiple identities and traditions. As such, global (cardiac) surgical definitions and health system interventions have been rooted in reductionism, focusing, at most, on singular sociodemographic characteristics. In this article, we evaluate barriers in global access to cardiac surgery based on existing intersectionality themes and literature. We further examine intersectionality methodologies to study access to cardiovascular care and cardiac surgery and seek to redefine the definition of 'global cardiac surgery' through an intersectionality lens.

Real-time monitoring and feedback to improve shared decision-making for surgery (the ALPACA Study): protocol for a mixed-methods study to inform co-development of an inclusive intervention

INTRODUCTION

High-quality shared decision-making (SDM) is a priority of health services, but only achieved in a minority of surgical consultations. Improving SDM for surgical patients may lead to more effective care and moderate the impact of treatment consequences. There is a need to establish effective ways to achieve sustained and large-scale improvements in SDM for all patients whatever their background. The ALPACA Study aims to develop, pilot and evaluate a decision support intervention that uses real-time feedback of patients' experience of SDM to change patients' and healthcare professionals' decision-making processes before adult elective surgery and to improve patient and health service outcomes.

METHODS AND ANALYSIS

This protocol outlines a mixed-methods study, involving diverse stakeholders (adult patients, healthcare professionals, members of the community) and three National Health Service (NHS) trusts in England. Detailed methods for the assessment of the feasibility, usability and stakeholder views of implementing a novel system to monitor the SDM process for surgery automatically and in real time are described. The study will measure the SDM process using validated instruments (CollaboRATE, SDM-Q-9, SHARED-Q10) and will conduct semi-structured interviews and focus groups to examine (1) the feasibility of automated data collection, (2) the usability of the novel system and (3) the views of diverse stakeholders to inform the use of the system to improve SDM. Future phases of this work will complete the development and evaluation of the intervention.

ETHICS AND DISSEMINATION

Ethical approval was granted by the NHS Health Research Authority North West-Liverpool Central Research Ethics Committee (reference: 21/PR/0345). Approval was also granted by North Bristol NHS Trust to undertake quality improvement work (reference: Q80008) overseen by the Consent and SDM Programme Board and reporting to an Executive Assurance Committee.

TRIAL REGISTRATION NUMBER

ISRCTN17951423; Pre-results.

Treatment Disparities Partially Mediate Socioeconomic- and Race/Ethnicity-Based Survival Disparities in Stage I-II Hepatocellular Carcinoma

BACKGROUND

Low socioeconomic status (SES) patients with early-stage hepatocellular carcinoma (HCC) receive procedural treatments less often and have shorter survival. Little is known about the extent to which these survival disparities result from treatment-related disparities versus other causal pathways. We aimed to estimate the proportion of SES-based survival disparities that are mediated by treatment- and facility-related factors among patients with stage I-II HCC.

METHODS

We analyzed patients aged 18-75 years diagnosed with stage I-II HCC in 2008-2016 using the National Cancer Database. Inverse odds weighting mediation analysis was used to calculate the proportion mediated by three mediators: procedure type, facility volume, and facility procedural interventions offered. Intersectional analyses were performed to determine whether treatment disparities played a larger role in survival disparities among Black and Hispanic patients.

RESULTS

Among 46,003 patients, 15.0% had low SES, 71.6% had middle SES, and 13.4% had high SES. Five-year overall survival was 46.9%, 39.9%, and 35.7% among high, middle, and low SES patients, respectively. Procedure type mediated 45.9% (95% confidence interval [CI] 31.1-60.7%) and 36.7% (95% CI 25.7-47.7%) of overall survival disparities for low and middle SES patients, respectively, which was more than was mediated by the two facility-level mediators. Procedure type mediated a larger proportion of survival disparities among low-middle SES Black (46.6-48.2%) and Hispanic patients (92.9-93.7%) than in White patients (29.5-29.7%).

CONCLUSIONS

SES-based disparities in use of procedural interventions mediate a large proportion of survival disparities, particularly among Black and Hispanic patients. Initiatives aimed at attenuating these treatment disparities should be pursued.

Social determinants of health and race are independent predictors of reduced rotator cuff surgery rates in the Medicare population

BACKGROUND

Racial disparities have been shown to influence rates of surgery for patients with rotator cuff disease. Some individuals have attributed adverse social determinants of health (SDOHs) as potential confounders of this relationship between race and surgery rate. However, there is a paucity of literature observing whether adverse SDOHs and race independently influence rotator cuff surgery rates. Therefore, the purpose of this study was to determine whether adverse SDOHs and race are independent predictors of rotator cuff surgery rates for Medicare beneficiaries.

METHODS

A retrospective analysis was conducting using the Medicare Standard Analytic Files (SAF) data set of the PearlDiver database, observing 211,340 patients with rotator cuff pathology. Univariate and multivariable regression analyses were performed to observe whether race and adverse SDOHs were independent variables associated with rotator cuff surgery rates. To determine whether adverse SDOHs significantly influenced racial disparities, stratified analyses of patients with ≥1 adverse SDOH and those without adverse SDOHs were conducted to compare the odds ratios (ORs) and 95% confidence intervals (CIs) of racial disparities.

RESULTS

Among patients with rotator cuff disease, 21,679 (10.26%) were of nonwhite race and 21,835 (10.33%) had ≥1 adverse SDOH. The variables of nonwhite race (OR, 0.622; 95% CI, 0.599-0.668; P < .001) and having ≥1 adverse SDOH (OR, 0.715; 95% CI, 0.501-0.814; P < .001) were independent predictors of not undergoing surgery. On stratified analysis, there was no significant difference in racial disparities in patients with ≥1 adverse SDOH (OR, 0.620; 95% CI, 0.440-0.875) and those without adverse SDOHs (0.635; 95% CI, 0.601-0.671) based on overlapping 95% CIs.

DISCUSSION

This study demonstrated that among Medicare beneficiaries, adverse SDOHs and race are independent predictors of lower rotator cuff surgery rates, emphasizing the need to address disparities based on race alone.

Nationwide Estimates of Gender-Affirming Chest Reconstruction in the United States, 2016-2019

BACKGROUND

Section 1557 of the Affordable Care Act, introduced in 2016, increased access to gender-affirming surgeries for transgender and gender diverse individuals. Masculinizing chest reconstruction (e.g., mastectomy) and feminizing chest reconstruction (e.g., augmentation mammaplasty), often outpatient procedures, are the most frequently performed gender-affirming surgeries. However, there is a paucity of information about the demographics of patients who undergo gender-affirming chest reconstruction.

OBJECTIVES

The authors sought to investigate the incidence, demographics, and spending for ambulatory gender-affirming chest reconstruction utilizing nationally representative data from 2016 to 2019.

METHODS

Employing the Nationwide Ambulatory Surgery Sample, the authors identified patients with an International Classification of Diseases diagnosis code of gender dysphoria who underwent chest reconstruction between 2016 and 2019. Demographic and clinical characteristics were recorded for each encounter.

RESULTS

A weighted estimate of 21,293 encounters for chest reconstruction were included (17,480 [82.1%] masculinizing and 3813 [27.9%] feminizing). Between 2016 and 2019, the number of chest surgeries per 100,000 encounters increased by 143.2% from 27.3 to 66.4 (P < 0.001). A total 12,751 (59.9%) chest surgeries were covered by private health insurance, 6557 (30.8%) were covered by public health insurance, 1172 (5.5%) were self-pay, and 813 (3.8%) had other means of payment. The median total charges were $29,887 (IQR, $21,778-$43,785) for chest reconstruction overall. Age, expected primary payer, patient location, and median income varied significantly by race (P < 0.001).

CONCLUSIONS

Gender-affirming chest reconstructions are on the rise, and surgeons must understand the background and needs of transgender and gender diverse patients who require and choose to undergo surgical transitions.

LEVEL OF EVIDENCE: 3

Neighborhood socioeconomic status and low-value breast cancer care

BACKGROUND

The objective of this study is to examine the association between neighborhood socioeconomic status (nSES) and receipt of low-value breast cancer procedures.

METHODS

Patients with breast cancer diagnosed between 2010 and 2016 were identified in the Surveillance, Epidemiology, and End Results (SEER) Program. Low value procedures included: (1) axillary lymph node dissection (ALND) for patients with limited nodal disease receiving breast conservation therapy (BCT); (2) contralateral prophylactic mastectomies (CPM); and (3) sentinel lymph node biopsies (SLNB) in patients ≥70 years old with clinically node negative early-stage hormone-positive breast cancer. The cohort was divided by nSES. Univariable and multivariable logistic regression analysis compared the groups.

RESULTS

The study included 412 959 patients. Compared to patients in high nSES areas, residing in neighborhoods with low nSES (odd ratio [OR] 2.20, 95% confidence interval [CI] 2.0-2.42) and middle nSES (OR 1.42, 95% CI 1.20-1.56) was associated with a higher probability of undergoing low value ALND. Conversely, patients in low SES neighborhoods were less likely to receive low value SLNB (OR 0.89, 95% CI 0.85-0.94) or CPM than (low nSES OR 0.75, 95% CI 0.73-0.77); middle nSES OR 0.91 (0.89-0.92) those in high SES neighborhoods.

CONCLUSION

In the SEER Program, low nSES was associated with a lower probability of low value procedures except for ALND utilization.