November 16, 2010
This statement was developed by the ACS Committee on Diversity Issues and was approved by the Board of Governors and Board of Regents in June 2010.
Nationally, disparities in surgical care are a combination of complex patient, social, and institutional factors. The relative contributions of access and timeliness of surgical care to these disparities is not clear. For some conditions such as cancer, disadvantaged populations may present with more advanced disease. For example, African-Americans, Native Americans, Hawaiians, Indians and Pakistanis, Mexicans, South and Central Americans, and Puerto Ricans are 1.4 to 3.6 times more likely to present with advanced (stage IV) breast cancer than non-Hispanic whites. In addition to clinical presentation as an explanatory variable for outcome differences, access to specialists, such as surgeons, may also contribute. For example, in the Community Tracking Study Physician Survey, P. B. Bach, MD, MAPP, and colleagues found that clinicians caring for African-American patients were less likely to report access to high-quality subspecialists, high-quality diagnostic imaging, high-quality ancillary services, and non-emergency hospital admission.* These results indicate that race and ethnicity may dictate the quality of patient care as far as it is determined by location and access to providers.
In the American College of Surgeons’ (ACS) ongoing effort to improve the quality of care overall, focusing on disparities may be a fruitful target for interventions, as the overall quality of care will improve if we eliminate health care inequities.
In addition to issues of access, outcomes are affected by factors such as race, ethnicity, primary language, and culture. Surgeons are increasingly concerned about patients’ outcomes, especially as public reporting and pay for performance initiatives promulgate. Traditionally, surgical procedures are viewed as discrete, episodic interventions in which all patients are treated equally. However, racial and ethnic disparities in outcomes have been reported. Some studies have suggested that race is an independent predictor of poor outcomes following surgery. Using Medicare data on eight major cardiovascular and cancer procedures, John Birkmeyer, MD, FACS, and colleagues found that the African-American race was associated with an increased risk of death in seven out of eight procedures, even when adjusting for severity of illness. The effect of race on outcomes, however, was attenuated, when the effect of the hospitals at which patients were treated were controlled.† The structure of the hospitals in which disadvantaged populations receive care may lead to some of these outcome differences. The mitigation of health care disparities will be an important step to improve the overall quality of care in the U.S.
Given the complexity of the health care disparities, we believe that a multi-pronged approach to eliminate surgical disparities in care, from access to outcomes, is necessary. Strategies on the national and local level will certainly differ. As there is an increasing focus on patient safety and the quality of surgical care, now is the time to address the issue of disparities in surgical care, as this reflects a defect in the overall quality of care.
Therefore, the ACS believes that ethnic and racial health care disparities have no role in a humane and just society, and are ethically and morally antithetical to the practice of medicine and surgery.
The College further promotes the principle that all patients deserve to be treated with respect and compassion, regardless of race, gender, creed, or religious beliefs. The ACS urges the Centers for Medicare & Medicaid Services and other agencies to include the factors of race, socioeconomic background, and educational level of patients into existing and future risk-adjustment methodologies for mortality and morbidity adjustment.
* Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med. 2004; 351(6):575-584.
† Lucas FL, Stukel TA, Morris AM, Siewers AE, Birkmeyer JD. Race and surgical mortality in the United States. Ann Surg. 2006; 243(2):281-286. PMID: 16432363.
Reprinted from Bulletin of the American College of Surgeons
Vol. 95, No. 11, November 2010