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

Disparities in Surgical Care Have Multilevel, Interconnected Causes

Journal of the American College of Surgeons article proposes a thematic framework for studying surgical care disparities


CHICAGO (June 10, 2016): Surgeons and researchers, responding to the known prevalence of inequalities in U.S. surgical care, have taken the first steps toward eliminating surgical care disparities by grouping their causes into themes and identifying modifiable contributing factors.  The new article, including a comprehensive review of the medical literature on health care disparities, is published online as an “article in press” on the Journal of the American College of Surgeons website in advance of print publication later this year.

Health care disparities encompass differential access, care, and outcomes due to factors such as minority group and socioeconomic status.

“Disparities are a huge problem at all stages of surgical care,” said  principal investigator, Adil Haider, MD, MPH, FACS, Kessler Director of the Center for Surgery and Public Health, a joint initiative of Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston.

“As surgeons, we have a long way to go to make sure that all patients have equal access to high-quality surgical care and postoperative care,” Dr. Haider said.  “However, we have raised awareness of the problem, which is step one to developing studies and interventions that will make a real difference for surgical patients.”

The authors’ work, in collaboration with leaders at the American College of Surgeons and the National Institutes of Health (NIH), led to the NIH’s National Institute on Minority Health and Health Disparities recently launching a research program to address disparities in surgical care.

For this investigation, the authors evaluated 328 U.S. studies of health care disparities published between January 2008 and February 2015.  The researchers identified five common major themes from the causes of surgical disparities.

Previously, Dr. Haider and his colleagues1 identified three themes of factors that contribute to surgical disparities: patient-, provider-, and health care systems-level factors.  In this new article, the researchers added two additional themes.

The first new theme is clinical care and quality at the hospital level, which includes how variation in the quality of care across hospitals affects surgical results, complications, and hospital readmissions.  The second new theme, postoperative care and rehabilitation, addresses how access to high-quality postoperative care and rehabilitative services can contribute to long-term recovery and outcomes.

Dr. Haider called postoperative care “an important but largely unexplored area of health care disparities research.”

Together these five themes make up a conceptual framework that Dr. Haider said will allow researchers to more manageably evaluate factors contributing to surgical disparities by their related causes and/or impact.  In turn, he noted, this process may speed development of effective interventions designed to improve access to optimal surgical care.

The themes reflect that surgical disparities are multilevel and often interconnected, the authors write.  Hospital-level factors, for instance, sometimes explain why racial-ethnic minorities (a patient factor) fare worse than white patients do after operations. 

Key hospital characteristics associated with improved surgical outcomes, according to the article, include use of quality improvement strategies, application of clinical guidelines and surgical protocols, use of supportive technology such as electronic health records, and a patient-centered culture that focuses on patient satisfaction and shared decision making.

Examples of disparities in clinical care and quality that affect racial-ethnic minorities and poor patients include the following:

  • Hospitals that treat the most uninsured patients—so-called safety net hospitals—tend to have worse surgical outcomes than hospitals with a better insurance payer mix, partly because they usually cannot afford to invest in quality improvement programs, Dr. Haider said.  Many minority patients use safety net hospitals.
  • Patients who live in financially disadvantaged regions are likelier to use hospitals that perform a low volume of operations.  Numerous studies2 show low volume is associated with worse outcomes for many surgical procedures, because the surgeons do not get enough practice.

Among the factors that can affect disparities in postoperative care and rehabilitation are the timing, duration, and quality of rehabilitation, as well as whether patients even receive rehabilitative care postoperatively.

  • Race/ethnicity and insurance status affect whether trauma and joint replacement patients receive rehabilitation and how intensive it is, and rural residence makes getting rehabilitation more difficult for joint replacement patients.3
  • Women are less likely than men to be referred for cardiac rehab after angioplasty, as are nonwhites.4

Inadequate follow-up with the surgeon may contribute to delays in patients receiving rehabilitation, according to Dr. Haider. 

“Surgeons should go the extra mile to make sure their patients get the best possible postoperative rehabilitation when needed,” he suggested.

The other authors include Maya J. Torain, BS; Allysha C. Maragh-Bass, PhD, MPH; Elizabeth J. Lilley, MD, MPH; Peter Najjar, MD, MBA; Navin R. Changoor, MD; John A. Rose Jr, MD, MPH; Cheryl K. Zogg, MSPH, MHS, from the Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston; Butool Hisam, MD, formerly from the Center for Surgery and Public Health and now with Dow University of Health Sciences Medical College, Karachi, Pakistan; Lisa M. Kodadek, MD, Johns Hopkins University School of Medicine, Baltimore; and L.D. Britt, MD, MPH, FACS, Eastern Virginia Medical School, Norfolk. Co-authors from the National Institutes of Health included Irene Dankwa-Mullen, MD, MPH, and Yvonne T. Maddox, PhD.

“FACS” designates that a surgeon is a Fellow of the American College of Surgeons.

The study findings were presented in part May 7-8, 2015, at the National Institutes of Health-American College of Surgeons Symposium on Health Care Disparities in Bethesda, Md., which was funded by both organizations ( Research priorities identified at the symposium were published online March 16, 2016, in JAMA Surgery.

Citation: Surgical Disparities: A Comprehensive Review and New Conceptual Framework, Journal of the American College of Surgeons.  


  1. Haider AH, Scott VK, Rehman KA, et al. Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors. J Am Coll Surg. 2013;216(3):482-492.
  2. References 47 to 51 in the article by Torain et al.
  3. Englum BR, Villegas C, Bolorunduro O, et al. Racial, ethnic, and insurance status disparities in use of posthospitalization care after trauma. J Am Coll Surg. 2011;213:699-708.  Meagher AD, Beadles CA, Doorey J, Charles AG. Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury. J Neurosurg. 2015;122:595-601.  Asemota AO, George BP, Cumpsty-Fowler CJ, et al. Race and insurance disparities in discharge to rehabilitation for patients with traumatic brain injury. J Neurotrauma. 2013;30:2057-2065. Freburger JK, Holmes GM, Ku LJ, Cutchin MP, Heatwole-Shank K, Edwards LJ. Disparities in post-acute rehabilitation care for joint replacement. Arthritis Care Res. 2011 Jul;63(7):1020-1030.
  4. Aragam KG, Moscucci M, Smith DE, et al. Trends and disparities in referral to cardiac rehabilitation after percutaneous coronary intervention. Am Heart J. 2011 Mar;161(3):544-551.

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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit


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