American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Racial gaps in outcomes and access persist, as do questions about their cause

OCTOBER 26, 2017
Clinical Congress Daily Highlights, Thursday Edition

Studies of racial disparities have found some encouraging signs of progress, but gaps remain. Furthermore, the reasons for these differences have been difficult to identify. A number of studies presented on Thursday shed light on the current extent and nature of racial disparities.

1.) One study found “reassuring evidence” that minority groups do not suffer higher rates of inpatient mortality in the perioperative period for gastrointestinal (GI) cancer surgeries, a category including cancers of the esophagus, stomach, pancreas, colon, and rectum.

Researchers led by John Bliton of Montefiore Medical Center, Bronx, NY,  examined a nationally representative sample from the Nationwide Inpatient Sample’s GI cancer database for 2008-2012 (102,621 subjects), to reach that conclusion. The poorest outcomes were observed for those with higher Charlson comorbidity score, lower income, males, and those without private insurance. Differences in perioperative mortality were predominantly driven by comorbidities. Researchers called for future work to identify disparities in other areas such as cancer screening, patient selection, social-economic factors, and access to care.

2.) A study led by Adam C. Sheka, MD, University of Minnesota, Minneapolis, MN, found that African Americans have poorer short-term outcomes after bariatric surgery than European Americans. Measures included increased readmission rates after Roux-en-Y gastric bypass (RYGB) surgery and increased reoperation, readmission, and mortality rates after sleeve gastrectomy (SG) surgeries.

The researchers queried the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for patients undergoing SG or RYGB procedures.  Univariate and multivariate analyses examined patient characteristics and 30-day outcomes for 108,198 patients stratified by race.

The authors note that further data is required to understand the reasons for these disparities. The study occurs in the context of an obesity epidemic in the United States that disproportionately affects African Americans. Blacks have a higher prevalence of obesity-related diseases than whites, including type 2 diabetes mellitus and cardiovascular disease. Despite the proven efficacy of bariatric surgery, African Americans are less likely to undergo bariatric procedures.

A greater gender disparity in surgery rate was found among blacks than among whites, with black women undergoing surgery 6.25 times more often than black men. Among whites, women were operated on 3.46 times more often than white men.

3.) African Americans who underwent colon cancer surgery in 2010 had higher odds of dying from major complications than whites, a study of 39,789 cases drawn from the National Inpatient Sample revealed. The disparity existed regardless of age, gender, comorbid conditions, and insurance status, Viraj Pandit, MD, and colleagues at the University of Arizona, Tucson, AZ, report. Major complications were defined as myocardial infarction, stroke, pulmonary embolism, ARDS, sepsis, and anastomotic leak. Overall, major complication rate was 10.2 percent, mortality rate 7.2 percent and failure-to-rescue (FTR) rate 5.2 percent. Patients in the FTR group were more likely to be African-American than white (7.4 percent vs. 4.6 percent). The authors call for further study of racial disparities to identify potential modifying risk factors.

4.) A 10-year national database review found a closing racial gap in surgical mortality rates across a broad range of procedures, with most improvement occurring within versus between hospitals.

Researchers at Massachusetts General Hospital in Boston, MA, analyzed Medicare inpatient claims data from 2005 to 2014 for seven procedures: coronary artery bypass graft, pulmonary lobectomy, abdominal aortic aneurysm repair, appendectomy, cholecystectomy, hip and knee repair, and colectomy. Across procedures and separately, Winta Mehtsun, MD, and colleagues examined trends in 30-day surgical mortality rates among African-American and white patients.

For the first year of data, African Americans had a composite mortality rate of 3.86 percent compared with 3.24 percent for white patients. Overall mortality trends subsequently decreased significantly for both groups, and the difference between African American and white patients narrowed at a rate of 0.03 percentage points annually. The majority of improvement was concentrated in hospitals with high baseline mortality rates.

5.) Racial disparities in utilization and time to treatment for early-stage breast cancer persisted in a national 10-year study of 628,104 patients in the National Cancer Database (NCDB). The study, led by Barbara A. Wexelman, MD, of Trihealth Cancer Institute, Cincinnati, OH, follows prior research demonstrating racial disparities in breast cancer treatment. Such disparities are commonly attributed to more advanced stage at presentation or aggressive tumor biology, but this study identified racial disparities in the treatment of Stage 1 breast cancer (T1N0).

All T1N0 breast cases from 2004-2014 NCDB of the American College of Surgeons were analyzed for differences by race in utilization and time to treatment. African-American women in the sample were younger (59.0 vs 61.8 years) and resided in poor counties (27.9 percent vs 7.4 percent of whites). Significant comorbidities were rare. ER-negative tumors were more common in black women (24.9 percent vs 13.2 percent white) and neoadjuvant chemotherapy was infrequent in both groups.

Black women lived closer to treating facilities than whites (14.7 vs 23.3 miles), but their time to treatment (surgery, chemotherapy, radiation, endocrine therapy) was significantly longer. When patients with private insurance were analyzed, time to care decreased (1.5 days) but racial differences remained statistically significant.

Based on their findings, the authors conclude that early detection alone will not resolve racial disparities in breast cancer treatment.

Additional Information:
These Scientific Forums were presented October 26 at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at FACS.org/clincon2017.

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