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Rahmani A, Najand B, Maharlouei N, Zare H, Assari S. COVID-19 Pandemic as an Equalizer of the Health Returns of Educational Attainment for Black and White Americans. J Racial Ethn Health Disparities 2024; 11:1223-1237. [PMID: 37490210 PMCID: PMC11101502 DOI: 10.1007/s40615-023-01601-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND COVID-19 pandemic has immensely impacted the social and personal lives of individuals around the globe. Marginalized-related diminished returns (MDRs) theory suggests that educational attainment shows a weaker protective effect for health and behavioral outcomes for Black individuals compared to White individuals. Previous studies conducted before the COVID-19 pandemic demonstrated diminished returns of educational attainment for Black individuals compared to White individuals. OBJECTIVES The study has three objectives: First, to test the association between educational attainment and cigarette smoking, e-cigarette vaping, presence of chronic medical conditions (CMC), self-rated health (SRH), depressive symptoms, and obesity; second, to explore racial differences in these associations in the USA during the COVID-19 pandemic; and third, to compare the interaction of race and return of educational attainment pre- and post-COVID-19 pandemic. METHODS This study utilized data from the Health Information National Trends Survey (HINTS) 2020. Total sample included 1313 adult American; among them, 77.4% (n = 1017) were non-Hispanic White, and 22.6% (n = 296) were non-Hispanic Black. Educational attainment was the independent variable operationalized as years of education. The main outcomes were cigarette smoking, e-cigarette vaping, CMC, SRH, depressive symptoms, and obesity. Age, gender, and baseline physical health were covariates. Race/ethnicity was an effect modifier. RESULTS Educational attainment was significantly associated with lower CMC, SRH, depressive symptoms, obesity, cigarette smoking, and e-cigarette vaping. Educational attainment did not show a significant interaction with race on any of our outcomes, suggesting that the health returns of education is similar between non-Hispanic White and non-Hispanic Black individuals. CONCLUSION COVID-19 may have operated as an equalizer of the returns of educational attainment. This observation may be because White may have more to lose; Black communities may be more resilient or have economic and social policies that buffered unemployment and poverty regardless of historical anti-Black oppression.
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Affiliation(s)
- Arash Rahmani
- Marginalized-Related Diminished Returns (MDRs) Center, Los Angeles, CA, USA
| | - Babak Najand
- Marginalized-Related Diminished Returns (MDRs) Center, Los Angeles, CA, USA
| | - Najmeh Maharlouei
- Marginalized-Related Diminished Returns (MDRs) Center, Los Angeles, CA, USA
| | - Hossein Zare
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
- School of Business, University of Maryland Global Campus (UMGC), Adelphi, 20783, USA
| | - Shervin Assari
- Marginalized-Related Diminished Returns (MDRs) Center, Los Angeles, CA, USA.
- Department of Family Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA.
- Department of Urban Public Health, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA.
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Banks KC, Wei J, Morales LM, Islas ZA, Alcasid NJ, Susai CJ, Sun A, Burapachaisri K, Patel AR, Ashiku SK, Velotta JB. Differences in outcomes by race/ethnicity after thoracic surgery in a large integrated health system. Surg Open Sci 2024; 19:118-124. [PMID: 38655068 PMCID: PMC11035076 DOI: 10.1016/j.sopen.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/26/2024] Open
Abstract
Background Disparities exist throughout surgery. We aimed to assess for racial/ethnic disparities among outcomes in a large thoracic surgery patient population. Methods We reviewed all thoracic surgery patients treated at our integrated health system from January 1, 2016-December 31, 2020. Post-operative outcomes including length of stay (LOS), 30-day return to the emergency department (30d-ED), 30-day readmission, 30- and 90-day outpatient appointments, and 30- and 90-day mortality were compared by race/ethnicity. Bivariate analyses and multivariable logistic regression were performed. Our multivariable models adjusted for age, sex, body mass index, Charlson Comorbidity Index, surgery type, neighborhood deprivation index, insurance, and home region. Results Of 2730 included patients, 59.4 % were non-Hispanic White, 15.0 % were Asian, 11.9 % were Hispanic, 9.6 % were Black, and 4.1 % were Other. Median (Q1-Q3) LOS (in hours) was shortest among non-Hispanic White (37.3 (29.2-76.1)) and Other (36.5 (29.3-75.4)) patients followed by Hispanic (46.8 (29.9-78.1)) patients with Asian (51.3 (30.7-81.9)) and Black (53.7 (30.6-101.6)) patients experiencing the longest LOS (p < 0.01). 30d-ED rates were highest among Hispanic patients (21.3 %), followed by Black (19.2 %), non-Hispanic White (18.1 %), Asian (13.4 %), and Other (8.0 %) patients (p < 0.01). On multivariable analysis, Hispanic ethnicity (Odds Ratio (OR) 1.43 (95 % CI 1.03-1.97)) and Medicaid insurance (OR 2.37 (95 % CI 1.48-3.81)) were associated with higher 30d-ED rates. No racial/ethnic disparities were found among other outcomes. Conclusions Despite parity across multiple surgical outcomes, disparities remain related to patient encounters within our system. Health systems must track such disparities in addition to standard clinical outcomes. Key message While our large integrated health system has been able to demonstrate parity across many major surgical outcomes among our thoracic surgery patients, race/ethnicity disparities persist including in the number of post-operative return trips to the emergency department. Tracking outcome disparities to a granular level such as return visits to the emergency department and number of follow up appointments is critical as health systems strive to achieve equitable care.
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Affiliation(s)
- Kian C. Banks
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Julia Wei
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Leyda Marrero Morales
- University of California, San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - Zeuz A. Islas
- Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Nathan J. Alcasid
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Cynthia J. Susai
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Angela Sun
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Katemanee Burapachaisri
- University of California, San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - Ashish R. Patel
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Simon K. Ashiku
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Jeffrey B. Velotta
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
- University of California, San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S Los Robles Ave, Pasadena, CA 91101, USA
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Burton BN, Adeola JO, Do VM, Milam AJ, Cannesson M, Norris KC, Lopez NE, Gabriel RA. Differences in the Receipt of Regional Anesthesia Based on Race and Ethnicity in Colorectal Surgery. Jt Comm J Qual Patient Saf 2024; 50:416-424. [PMID: 38433070 DOI: 10.1016/j.jcjq.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 12/19/2023] [Accepted: 01/02/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Health equity in pain management during the perioperative period continues to be a topic of interest. The authors evaluated the association of race and ethnicity with regional anesthesia in patients who underwent colorectal surgery and characterized trends in regional anesthesia. METHODS Using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2020, the research team identified patients who underwent open or laparoscopic colorectal surgery. Associations between race and ethnicity and use of regional anesthesia were estimated using logistic regression models. RESULTS The final sample size was 292,797, of which 15.6% (n = 45,784) received regional anesthesia. The unadjusted rates of regional anesthesia for race and ethnicity were 15.7% white, 15.1% Black, 12.8% Asian, 29.6% American Indian or Alaska Native, 16.3% Native Hawaiian or Pacific Islander, and 12.4% Hispanic. Black (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.96, p < 0.001) and Asian (OR 0.76, 95% CI 0.71-0.80, p < 0.001) patients had lower odds of regional anesthesia compared to white patients. Hispanic patients had lower odds of regional anesthesia compared to non-Hispanic patients (OR 0.72, 95% CI 0.68-0.75, p < 0.001). There was a significant annual increase in regional anesthesia from 2015 to 2020 for all racial and ethnic cohorts (p < 0.05). CONCLUSION There was an annual increase in the use of regional anesthesia, yet Black and Asian patients (compared to whites) and Hispanics (compared to non-Hispanics) were less likely to receive regional anesthesia for colorectal surgery. These differences suggest that there are racial and ethnic differences in regional anesthesia use for colorectal surgery.
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Zil-E-Ali A, Alamarie B, Paracha AW, Samaan F, Aziz F. Systematic Review and Meta-Analysis to Assess the Racial Disparities in the Outcomes of Carotid Endarterectomy in the United States. J Vasc Surg 2024:S0741-5214(24)01213-8. [PMID: 38782214 DOI: 10.1016/j.jvs.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/30/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Race-based disparities in healthcare have been related to a myriad of prevailing factors among minorities in the United States. This study aims to study the race-based differences in the outcomes of carotid endarterectomy (CEA). METHODS The PROSPERO database registered the review protocol (CRD42023428253). A systematic English literature review was performed using literature databases PubMed and Scopus from inception till June 2023. The review was designed on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included studies reporting mortality, stroke or composite outcome of mortality and stroke after CEA for carotid artery disease, regardless of any degree of stenosis including both symptomatic and asymptomatic patients. The risk of bias was evaluated utilizing the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for the overall mortality was computed, and a p-value of <0.05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I2 statistics. RESULTS Twelve studies were identified which included a total of 574,055 patients, who underwent CEA from 1998 to 2022. 11 out of 12 studies reported 30-day mortality as an outcome for patients undergoing CEA in which 52,4708 (92.5%) patients were white and 42797 (7.5%) were non-white. The overall pooled OR indicated a statistical significance in 30-day mortality between white and non-white patients undergoing CEA (OR: 1.73 [1.37-2.18], p=0.011) with substantial heterogeneity (I2 = 56.3%). 11 out of 12 studies reported stroke as an outcome for patients undergoing CEA in which 52,4708 (92.5%) patients were white and 42,801 (7.5%) were non-white. The overall pooled OR indicated no statistical significance in stroke between white and non-white patients undergoing CEA (OR:1.46 [1.28, 1.65], p = 0.111) with moderate heterogeneity (I2 = 35.9%). 5 out of 12 studies reported composite mortality or stroke as an outcome for patients undergoing CEA. The overall pooled OR indicated no statistical significance in composite mortality or stroke between white and non-white patients undergoing CEA (OR: 1.40 [1.24-1.59], p = 0.467) with no heterogeneity (I2 = 0.0%). CONCLUSION Non-White patients have a relatively higher risk of mortality; however no significant difference was observed between the racial groups in terms of stroke or a composite outcome of mortality or stroke. The odds of mortality in Non-White patients have been persistent throughout recent studies.
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Affiliation(s)
- Ahsan Zil-E-Ali
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center.
| | - Billal Alamarie
- Office of Medical Education, Penn State College of Medicine, Penn State University
| | - Abdul Wasay Paracha
- Office of Medical Education, Penn State College of Medicine, Penn State University
| | - Fadi Samaan
- Office of Medical Education, Penn State College of Medicine, Penn State University
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center
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Bishay AE, Hughes NC, Zargari M, Paulo DL, Bishay S, Lyons AT, Morkos MN, Ball TJ, Englot DJ, Bick SK. Disparities in Access to Deep Brain Stimulation for Parkinson's Disease and Proposed Interventions: A Literature Review. Stereotact Funct Neurosurg 2024; 102:179-194. [PMID: 38697047 DOI: 10.1159/000538748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/28/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND Deep brain stimulation (DBS) is an effective therapy for Parkinson's disease (PD), but disparities exist in access to DBS along gender, racial, and socioeconomic lines. SUMMARY Women are underrepresented in clinical trials and less likely to undergo DBS compared to their male counterparts. Racial and ethnic minorities are also less likely to undergo DBS procedures, even when controlling for disease severity and other demographic factors. These disparities can have significant impacts on patients' access to care, quality of life, and ability to manage their debilitating movement disorders. KEY MESSAGES Addressing these disparities requires increasing patient awareness and education, minimizing barriers to equitable access, and implementing diversity and inclusion initiatives within the healthcare system. In this systematic review, we first review literature discussing gender, racial, and socioeconomic disparities in DBS access and then propose several patient, provider, community, and national-level interventions to improve DBS access for all populations.
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Affiliation(s)
- Anthony E Bishay
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA,
| | - Natasha C Hughes
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Michael Zargari
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Danika L Paulo
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Steven Bishay
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Mariam N Morkos
- Arizona College of Osteopathic Medicine, Glendale, Arizona, USA
| | - Tyler J Ball
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dario J Englot
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Sarah K Bick
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Wang HE, Weiner JP, Saria S, Kharrazi H. Evaluating Algorithmic Bias in 30-Day Hospital Readmission Models: Retrospective Analysis. J Med Internet Res 2024; 26:e47125. [PMID: 38422347 PMCID: PMC11066744 DOI: 10.2196/47125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 12/28/2023] [Accepted: 02/27/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The adoption of predictive algorithms in health care comes with the potential for algorithmic bias, which could exacerbate existing disparities. Fairness metrics have been proposed to measure algorithmic bias, but their application to real-world tasks is limited. OBJECTIVE This study aims to evaluate the algorithmic bias associated with the application of common 30-day hospital readmission models and assess the usefulness and interpretability of selected fairness metrics. METHODS We used 10.6 million adult inpatient discharges from Maryland and Florida from 2016 to 2019 in this retrospective study. Models predicting 30-day hospital readmissions were evaluated: LACE Index, modified HOSPITAL score, and modified Centers for Medicare & Medicaid Services (CMS) readmission measure, which were applied as-is (using existing coefficients) and retrained (recalibrated with 50% of the data). Predictive performances and bias measures were evaluated for all, between Black and White populations, and between low- and other-income groups. Bias measures included the parity of false negative rate (FNR), false positive rate (FPR), 0-1 loss, and generalized entropy index. Racial bias represented by FNR and FPR differences was stratified to explore shifts in algorithmic bias in different populations. RESULTS The retrained CMS model demonstrated the best predictive performance (area under the curve: 0.74 in Maryland and 0.68-0.70 in Florida), and the modified HOSPITAL score demonstrated the best calibration (Brier score: 0.16-0.19 in Maryland and 0.19-0.21 in Florida). Calibration was better in White (compared to Black) populations and other-income (compared to low-income) groups, and the area under the curve was higher or similar in the Black (compared to White) populations. The retrained CMS and modified HOSPITAL score had the lowest racial and income bias in Maryland. In Florida, both of these models overall had the lowest income bias and the modified HOSPITAL score showed the lowest racial bias. In both states, the White and higher-income populations showed a higher FNR, while the Black and low-income populations resulted in a higher FPR and a higher 0-1 loss. When stratified by hospital and population composition, these models demonstrated heterogeneous algorithmic bias in different contexts and populations. CONCLUSIONS Caution must be taken when interpreting fairness measures' face value. A higher FNR or FPR could potentially reflect missed opportunities or wasted resources, but these measures could also reflect health care use patterns and gaps in care. Simply relying on the statistical notions of bias could obscure or underplay the causes of health disparity. The imperfect health data, analytic frameworks, and the underlying health systems must be carefully considered. Fairness measures can serve as a useful routine assessment to detect disparate model performances but are insufficient to inform mechanisms or policy changes. However, such an assessment is an important first step toward data-driven improvement to address existing health disparities.
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Affiliation(s)
- H Echo Wang
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Jonathan P Weiner
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
- Johns Hopkins Center for Population Health Information Technology, Baltimore, MD, United States
| | - Suchi Saria
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Hadi Kharrazi
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
- Johns Hopkins Center for Population Health Information Technology, Baltimore, MD, United States
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Singh V, Jayne CS, Cuero KJ, Thomas J, Rozell JC, Schwarzkopf R, Macaulay W, Davidovitch RI. Are We Moving in the Right Direction? Demographic and Outcome Trends in Same-day Total Hip Arthroplasty From 2015 to 2020. J Am Acad Orthop Surg 2024; 32:346-353. [PMID: 38194641 DOI: 10.5435/jaaos-d-23-00762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/27/2023] [Indexed: 01/11/2024] Open
Abstract
INTRODUCTION Understanding the trends among patients undergoing same-day discharge (SDD) total hip arthroplasty (THA) is imperative to highlight the progression of outpatient surgery and the criteria used for enrollment. The purpose of this study was to identify trends in demographic characteristics and outcomes among patients who participated in an academic hospital SDD THA program over 6 years. METHODS We retrospectively reviewed all patients who enrolled in our institution's SDD THA program from January 2015 to October 2020. Patient demographics, failure-to-launch rate, as well as readmission and revision rates were evaluated. Trends for continuous variables were analyzed using analysis of variance, and categorical variables were analyzed using chi-square tests. RESULTS In total, 1,334 patients participated in our SDD THA program between 2015 and 2020. Age (54.82 to 57.94 years; P < 0.001) and mean Charlson Comorbidity Index (2.15 to 2.90; P < 0.001) significantly differed over the 6-year period. More African Americans (4.3 to 12.3%; P = 0.003) and American Society of Anesthesiology class III (3.2% to 5.8%; P < 0.001) patients enrolled in the program over time. Sex ( P = 0.069), BMI ( P = 0.081), marital status ( P = 0.069), and smoking status ( P = 0.186) did not statistically differ. Although the failure-to-launch rate (0.0% to 12.0%; P < 0.001) increased over time, the 90-day readmissions ( P = 0.204) and 90-day revisions ( P = 0.110) did not statistically differ. CONCLUSION More African Americans, older aged individuals, and patients with higher preexisting comorbidity burden enrolled in the program over this period. Our findings are a reflection of a more inclusive selection criterion for participation in the SDD THA program. These results highlight the potential increase in the number of patients and surgeons interested in SDD THA, which is paramount in the current incentivized and value-based healthcare environment. LEVEL EVIDENCE III, Retrospective Review.
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Affiliation(s)
- Vivek Singh
- From the Department of Orthopedic Surgery, NYU Langone Health, New York, NY (Dr. Singh, Mr. Thomas, Dr. Rozell, Dr. Schwarzkopf, Dr. Macaulay, and Dr. Davidovitch), and the Department of Orthopaedic Surgery, Dignity Health St. Joseph's Medical Center, Stockton, CA (Dr. Singh, Dr. Jayne, and Dr. Cuero)
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Birmingham TB, Primeau CA, Shariff SZ, Reid JNS, Marsh JD, Lam M, Dixon SN, Giffin JR, Willits KR, Litchfield RB, Feagan BG, Fowler PJ. Incidence of Total Knee Arthroplasty After Arthroscopic Surgery for Knee Osteoarthritis: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e246578. [PMID: 38635272 DOI: 10.1001/jamanetworkopen.2024.6578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Importance It is unclear whether arthroscopic resection of degenerative knee tissues among patients with osteoarthritis (OA) of the knee delays or hastens total knee arthroplasty (TKA); opposite findings have been reported. Objective To compare the long-term incidence of TKA in patients with OA of the knee after nonoperative management with or without additional arthroscopic surgery. Design, Setting, and Participants In this ad hoc secondary analysis of a single-center, assessor-blinded randomized clinical trial performed from January 1, 1999, to August 31, 2007, 178 patients were followed up through March 31, 2019. Participants included adults diagnosed with OA of the knee referred for potential arthroscopic surgery in a tertiary care center specializing in orthopedics in London, Ontario, Canada. All participants from the original randomized clinical trial were included. Data were analyzed from June 1, 2021, to October 20, 2022. Exposures Arthroscopic surgery (resection or debridement of degenerative tears of the menisci, fragments of articular cartilage, or chondral flaps and osteophytes that prevented full extension) plus nonoperative management (physical therapy plus medications as required) compared with nonoperative management only (control). Main Outcomes and Measures Total knee arthroplasty was identified by linking the randomized trial data with prospectively collected Canadian health administrative datasets where participants were followed up for a maximum of 20 years. Multivariable Cox proportional hazards regression models were used to compare the incidence of TKA between intervention groups. Results A total of 178 of 277 eligible patients (64.3%; 112 [62.9%] female; mean [SD] age, 59.0 [10.0] years) were included. The mean (SD) body mass index was 31.0 (6.5). With a median follow-up of 13.8 (IQR, 8.4-16.8) years, 31 of 92 patients (33.7%) in the arthroscopic surgery group vs 36 of 86 (41.9%) in the control group underwent TKA (adjusted hazard ratio [HR], 0.85 [95% CI, 0.52-1.40]). Results were similar when accounting for crossovers to arthroscopic surgery (13 of 86 [15.1%]) during follow-up (HR, 0.88 [95% CI, 0.53-1.44]). Within 5 years, the cumulative incidence was 10.2% vs 9.3% in the arthroscopic surgery group and control group, respectively (time-stratified HR for 0-5 years, 1.06 [95% CI, 0.41-2.75]); within 10 years, the cumulative incidence was 23.3% vs 21.4%, respectively (time-stratified HR for 5-10 years, 1.06 [95% CI, 0.45-2.51]). Sensitivity analyses yielded consistent results. Conclusions and Relevance In this secondary analysis of a randomized clinical trial of arthroscopic surgery for patients with OA of the knee, a statistically significant association with delaying or hastening TKA was not identified. Approximately 80% of patients did not undergo TKA within 10 years of nonoperative management with or without additional knee arthroscopic surgery. Trial Registration ClinicalTrials.gov Identifier: NCT00158431.
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Affiliation(s)
- Trevor B Birmingham
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
| | - Codie A Primeau
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
| | - Salimah Z Shariff
- Bone and Joint Institute, University of Western Ontario, London, Canada
- ICES Western, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Arthur Labatt Family School of Nursing, Faculty of Health Sciences, University of Western Ontario, London, Canada
| | - Jennifer N S Reid
- ICES Western, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Jacquelyn D Marsh
- School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
| | - Melody Lam
- ICES Western, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Stephanie N Dixon
- ICES Western, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - J Robert Giffin
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Kevin R Willits
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Robert B Litchfield
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Brian G Feagan
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Peter J Fowler
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
- Bone and Joint Institute, University of Western Ontario, London, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
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Mani K, Kleinbart E, Schlumprecht A, Golding R, Akioyamen N, Song H, De La Garza Ramos R, Eleswarapu A, Yang R, Geller D, Hoang B, Fourman MS. Association of Socioeconomic Status With Worse Overall Survival in Patients With Bone and Joint Cancer. J Am Acad Orthop Surg 2024; 32:e346-e355. [PMID: 38354415 DOI: 10.5435/jaaos-d-23-00718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 12/25/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases. METHODS This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals. RESULTS A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients. DISCUSSION Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.
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Affiliation(s)
- Kyle Mani
- From the Albert Einstein College of Medicine (Mani, Kleinbart, Golding, and Song), the Department of Neurological Surgery, Montefiore Einstein (Schlumprecht, and De La Garza Ramos), and the Department of Orthopaedic Surgery, Montefiore Einstein, Bronx, NY (Akioyamen, Eleswarapu, Yang, Geller, Hoang, and Fourman)
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10
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Abla H, Collins RA, Dhanasekara CS, Shrestha K, Dissanaike S. Using the Social Vulnerability Index to Analyze Statewide Health Disparities in Cholecystectomy. J Surg Res 2024; 296:135-141. [PMID: 38277949 DOI: 10.1016/j.jss.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/27/2023] [Accepted: 12/25/2023] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Addressing the effects of social determinants of health in surgery has become a national priority. We evaluated the utility of the Social Vulnerability Index (SVI) in determining the likelihood of receiving cholecystectomy for cholecystitis in Texas. METHODS A retrospective study of adults with cholecystitis in the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Data Public Use Data File from 2016 to 2019. Patients were stratified into SVI quartiles, with the lowest quartile as low vulnerability, the middle two as average vulnerability, and the highest as high vulnerability. The relative risk (RR) of undergoing surgery was calculated using average vulnerability as the reference category and subgroup sensitivity analyses. RESULTS A total of 67,548 cases were assessed, of which 48,603 (72.0%) had surgery. Compared with the average SVI groups, the low vulnerability groups were 21% more likely to undergo cholecystectomy (RR = 1.21, 95% confidence interval [CI] 1.18-1.24), whereas the high vulnerability groups were 9% less likely to undergo cholecystectomy (RR = 0.91, 95% CI 0.88-0.93). The adjusted model showed similar results (RR = 1.05, 95% CI 1.04-1.06 and RR = 0.97, 95% CI 0.96-0.99, for low and high vulnerability groups, respectively). These results remained significant after stratifying for age, sex, ethnicity, and insurance status. However, the differences between low, average, and high vulnerability groups diminished in rural settings, with lower surgery rates in all groups. CONCLUSIONS Patients with higher SVI were less likely to receive an elective cholecystectomy. SVI is an effective method of identifying social determinants impacting access to and receipt of surgical care.
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Affiliation(s)
- Habib Abla
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | - Reagan A Collins
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas.
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11
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Borowsky PA, Yoon K, Eroraha A, Bonsu JM, Kington D, Lawani PE, Smith RN, Bliton JN. General surgery textbooks and surgical disparities. J Natl Med Assoc 2024; 116:145-152. [PMID: 38245468 DOI: 10.1016/j.jnma.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/23/2023] [Indexed: 01/22/2024]
Abstract
INTRODUCTION Some academic textbooks have previously disseminated simplistic or even incorrect conceptions of race. Propagation of such ideas in General Surgery could contribute to gaps in quality of care received by minority patients. This study aims to determine whether General Surgery textbooks provide a thorough understanding of racial disparities. METHODS General Surgery texts were drawn from Doody's list, an industry-standard list of textbooks for medical education. Technical guides, atlases, and books for non-General Surgery professionals were excluded. Passages mentioning medical differences amongst racial and ethnic groups were extracted. Six binary classifications were made, based on whether passages (a) described interventions to alleviate difference; (b) addressed environmental mediators of difference; (c) described the contribution of racism or discrimination; (d) used causal language to connect race to difference; (e) referred to known, heritable genetic mechanisms; and (f) directly provided a reference. Types of intervention were also extracted. A heuristic scale was calculated granting one point each for classifications a-c and losing one point for classification d. Three authors performed classifications, and raw agreement and Cohen's kappa were used to assess inter-rater reliability. RESULTS Thirteen textbooks from Doody's list contained 511 passages discussing medical differences among racial/ethnic groups. Among passages, 25% discussed white people, 22% Black people/African Americans, 19% Asians, 9% Latinos, 4% Jewish/Ashkenazi people, 3% Native Americans, and 18% other. Fifteen passages (2.9%) used language indicating race was the cause of medical difference, and only two explicitly discussed racism or discrimination. Most passages (370, 72.3%) received a scale of 0. 120 (23.5%) received a scale of 1, eight (1.2%) received a scale of 2, and zero received a scale of 3. The mean passage scale was 0.24 and is not changing with time (regression coefficient -0.006/year, p = 0.538). Agreement was 91.2% across all categories and overall Kappa was 0.62. CONCLUSIONS General Surgery textbooks do not provide readers with scientifically thorough understanding of health disparities. Teaching more comprehensive conceptions, including systemic causes and the role of racism, may prevent reflexive association of minority patients with poor outcomes. Future editions should include these details where disparities are discussed in an independent, comprehensive section.
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Affiliation(s)
- Peter A Borowsky
- Wellstar Kennestone Regional Medical Center, Department of Surgery, Marietta, GA, United States
| | | | | | - Janice M Bonsu
- Emory University School of Medicine, Department of ORthopaedic Surgery, Atlanta GA, United States
| | - Daniella Kington
- Wellstar Kennestone Regional Medical Center, Department of Surgery, Marietta, GA, United States
| | - Phyllis E Lawani
- NewYork-Presbyterian Brooklyn Methodist Hospital, Department of Women's Health, Brooklyn, NY, United States
| | - Randi N Smith
- Emory University School of Medicine, Department of Acute Care Surgery, Atlanta GA, United States
| | - John N Bliton
- Jamaica Hospital Medical Center, Department of Surgery, Queens, NY, United States.
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12
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Fonteh CN, Patnaik JL, Grove NC, Lynch AM, Pantcheva MB, Christopher KL. Refractive outcomes using Barrett formulas and patient characteristics of cataract surgery patients with and without prior LASIK/PRK. Graefes Arch Clin Exp Ophthalmol 2024:10.1007/s00417-024-06456-3. [PMID: 38558260 DOI: 10.1007/s00417-024-06456-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 03/07/2024] [Accepted: 03/16/2024] [Indexed: 04/04/2024] Open
Abstract
PURPOSE The goal of this study is to describe characteristics of cataract surgery patients who previously underwent laser in situ keratomileusis/photorefractive keratectomy (LASIK/PRK) in comparison to non-LASIK/PRK cataract surgery patients including psychiatric comorbidities, as well as describe refractive prediction error after cataract surgery while accounting for axial length (AL) using the Barrett True-K and Barrett Universal II formulas. METHODS This was a retrospective study of patients from the University of Colorado Cataract Outcomes Registry. The primary outcomes were refraction prediction error (RPE), mean absolute RPE, and median absolute RPE. Outcomes were stratified by five axial length groups. Univariate and multivariate models for RPE were stratified by the AL group. RESULTS Two hundred eighty-one eyes with prior LASIK/PRK and 3101 eyes without are included in the study. Patients with prior LASIK/PRK were significantly younger: 67.0 vs 69.9 years, p < 0.0001. The LASIK/PRK group had significantly better mean pre-operative BCVA in comparison to the non-LASIK group, logMAR 0.204 vs logMAR 0.288, p = 0.003. The LASIK/PRK group had significantly lower rates of cardiovascular disease (18.5% vs 29.3%, p < 0.001), hypertension (49.1% vs 59.3%, p < 0.012), and type 2 diabetes (10.7% vs 26.0%, p < 0.001), and no significant difference in psychiatric disease. The absolute RPE was higher for the LASIK group for all ALs, but only significantly higher for eyes with AL less than 25 mm. CONCLUSION Patient eyes with prior LASIK/PRK surgery undergoing cataract surgery were significantly younger, had significantly less comorbidities, and a significantly better pre-operative BCVA. Using the Barrett formulas, absolute prediction error for eyes with longer ALs was not significantly worse for LASIK/PRK eyes than those without and the difference was smaller for eyes with longer AL.
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Affiliation(s)
- Cheryl N Fonteh
- Department of Ophthalmology, University of Colorado School of Medicine, Mail Stop F731, 1675 Aurora Court, Aurora, CO, USA.
| | - Jennifer L Patnaik
- Department of Ophthalmology, University of Colorado School of Medicine, Mail Stop F731, 1675 Aurora Court, Aurora, CO, USA
| | - Nathan C Grove
- Department of Ophthalmology, University of Colorado School of Medicine, Mail Stop F731, 1675 Aurora Court, Aurora, CO, USA
| | - Anne M Lynch
- Department of Ophthalmology, University of Colorado School of Medicine, Mail Stop F731, 1675 Aurora Court, Aurora, CO, USA
| | - Mina B Pantcheva
- Department of Ophthalmology, University of Colorado School of Medicine, Mail Stop F731, 1675 Aurora Court, Aurora, CO, USA
| | - Karen L Christopher
- Department of Ophthalmology, University of Colorado School of Medicine, Mail Stop F731, 1675 Aurora Court, Aurora, CO, USA
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13
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Peterman NJ, Pagani N, Mann R, Li RL, Gasienica J, Naik A, Sun D. Disparities in Access to Robotic Knee Arthroplasty: A Geospatial Analysis. J Arthroplasty 2024; 39:864-870. [PMID: 37852446 DOI: 10.1016/j.arth.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND The utilization of robotic knee arthroplasty (RKA) continues to increase across the United States. The aim of this geospatial analysis was to elucidate if RKA is distributed uniformly across the United States or if disparities exist in patient access. METHODS Publicly available provider-finding functions for 5 major manufacturers of RKA systems were used to obtain the practice locations of surgeons performing RKA along with their associated RKA system manufacturer. The average travel distance for each county to the nearest RKA surgeon was calculated and Moran's index clustering analysis was used to find hotspots and coldspots of RKA access. A logistic regression model was used to identify the predictive odds ratios between robotic hotspots and coldspots with county-level sociodemographic variables. Of the 34,216 currently practicing orthopedic surgeons in 2022, 2,571 have access to robotic assistance for knee arthroplasty. RESULTS Hotspots of increased travel time were predominantly in West South Central and West North Central census regions. Hotspots were significantly more rural and consisted of predominantly White populations, with lower median income and health insurance coverage. CONCLUSIONS The results of the current study align with existing literature, demonstrating absolute geographic access disparities for rural and economically disadvantaged populations. Additionally, relative access disparities persist for minority populations and individuals with high comorbidity burdens residing in urban areas.
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Affiliation(s)
- Nicholas J Peterman
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Nicholas Pagani
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Rachel Mann
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Richard L Li
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Jacob Gasienica
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois
| | - Daniel Sun
- Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts
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Gillis A, Chen H, Wang TS, Dream S. Racial and Ethnic Disparities in the Diagnosis and Treatment of Thyroid Disease. J Clin Endocrinol Metab 2024; 109:e1336-e1344. [PMID: 37647887 PMCID: PMC10940267 DOI: 10.1210/clinem/dgad519] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 09/01/2023]
Abstract
CONTEXT There are differences in diagnosis, treatment, and outcomes for thyroid between racial and ethnic groups that contribute to disparities. Identifying these differences and their causes are the key to understanding and reducing disparities in presentation and outcomes in endocrine disorders. EVIDENCE ACQUISITION The present study reviews original studies identifying and exploring differences between benign and malignant thyroid diseases. A PubMed, Web of Science, and Scopus search was conducted for English-language studies using the terms "thyroid," "thyroid disease," "thyroid cancer," "race," "ethnicity," and "disparities" from inception to December 31, 2022. EVIDENCE SYNTHESIS Many racial and ethnic disparities in the diagnosis, presentation, treatment, and outcomes of thyroid disease were found. Non-White patients are more likely to have a later time to referral, to present with more advanced disease, to have more aggressive forms of thyroid cancer, and are less likely to receive the appropriate treatment than White patients. Overall and disease-specific survival rates are lower in Black and Hispanic populations when compared to White patients. CONCLUSIONS Extensive disparities exist in thyroid disease diagnosis, treatment, and outcomes that may have been overlooked. Further work is needed to identify the causes of these disparities to begin to work toward equity in the care of thyroid disease.
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Affiliation(s)
- Andrea Gillis
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53266, USA
| | - Sophie Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53266, USA
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15
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Tandon P, Chhibba T, Natt N, Singh Brar G, Malhi G, Nguyen GC. Significant Racial and Ethnic Disparities Exist in Health Care Utilization in Inflammatory Bowel Disease: A Systematic Review and Meta-analysis. Inflamm Bowel Dis 2024; 30:470-481. [PMID: 36975373 DOI: 10.1093/ibd/izad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Indexed: 03/29/2023]
Abstract
BACKGROUND The incidence of inflammatory bowel disease (IBD) is rising worldwide, though the differences in health care utilization among different races and ethnicities remains uncertain. We aimed to better define this through a systematic review and meta-analysis. METHODS We explored the impact of race or ethnicity on the likelihood of needing an IBD-related surgery, hospitalization, and emergency department visit. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated with I2 values reporting heterogeneity. Differences in IBD phenotype and treatment between racial and ethnic groups of IBD were reported. RESULTS Fifty-eight studies were included. Compared with White patients, Black patients were less likely to undergo a Crohn's disease (CD; OR, 0.69; 95% CI, 0.50-0.95; I2 = 68.0%) or ulcerative colitis (OR, 0.58; 95% CI, 0.40-0.83; I2 = 85.0%) surgery, more likely to have an IBD-hospitalization (OR, 1.54; 95% CI, 1.06-2.24; I2 = 77.0%), and more likely to visit the emergency department (OR, 1.74; 95% CI, 1.32-2.30; I2 = 0%). There were no significant differences in disease behavior or biologic exposure between Black and White patients. Hispanic patients were less likely to undergo a CD surgery (OR, 0.57; 95% CI, 0.48-0.68; I2 = 0%) but more likely to be hospitalized (OR, 1.38; 95% CI, 1.01-1.88; I2 = 37.0%) compared with White patients. There were no differences in health care utilization between White and Asian or South Asian patients with IBD. CONCLUSIONS There remain significant differences in health care utilization among races and ethnicities in IBD. Future research is required to determine factors behind these differences to achieve equitable care for persons living with IBD.
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Affiliation(s)
- Parul Tandon
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Tarun Chhibba
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Navneet Natt
- Department of Medicine, Northern Ontario School of Medicine, Ontario, Canada
| | - Gurmun Singh Brar
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gurpreet Malhi
- Department of Medicine, Western University, London, Ontario, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology and Hepatology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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16
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Malapati SH, Edelen MO, Kaur MN, Zeng C, Ortega G, McCleary NJ, Hubbell H, Meyers P, Bryant AS, Sisodia RC, Pusic AL. Social Determinants of Health Needs and Health-related Quality of Life Among Surgical Patients: A Retrospective Analysis of 8512 Patients. Ann Surg 2024; 279:443-449. [PMID: 37800351 DOI: 10.1097/sla.0000000000006117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To assess associations between social determinants of health (SDOH) needs and health-related quality of life (HRQOL) among surgical patients. BACKGROUND Despite the profound impact of SDOH on health outcomes, studies examining the effect of SDOH needs on HRQOL among surgical patients are limited. METHODS A retrospective study was conducted using responses from the SDOH needs assessment and the Patient-Reported Outcomes Measurement Information Systems Global Health instrument of adults seen in surgical clinics at a single institution. Patient characteristics including socioeconomic status (insurance type, education level, and employment status) were extracted. Stepwise multivariable logistic regression analyses were performed to identify independent predictors of global health scores. RESULTS A total of 8512 surgical patients (mean age: 55.6±15.8 years) were included. 25.2% of patients reported one or more SDOH needs. The likelihood of reporting at least one SDOH need varied by patient characteristics and socioeconomic status variables. In fully adjusted regression models, food insecurity [odds ratio (OR), 1.53; 95% CI, 1.38-1.70 and OR, 1.49; 95% CI, 1.22-1.81, respectively], housing instability (OR, 1.27; 95% CI, 1.12-1.43 and OR, 1.39; 95% CI, 1.13-1.70, respectively) lack of transportation (OR, 1.46; 95% CI, 1.27-1.68 and OR, 1.25; 95% CI, 1.00-1.57, respectively), and unmet medication needs (OR, 1.31; 95% CI, 1.13-1.52 and OR, 1.61; 95% CI, 1.28-2.03, respectively) were independent predictors of poor physical and mental health. CONCLUSIONS SDOH needs are independent predictors of poor patient-reported physical and mental health among surgical patients. Assessing and addressing SDOH needs should be prioritized in health care settings and by policymakers to improve HRQOL.
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Affiliation(s)
- Sri Harshini Malapati
- The Patient-Reported Outcome, Value and Experience Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Maria O Edelen
- The Patient-Reported Outcome, Value and Experience Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Manraj N Kaur
- The Patient-Reported Outcome, Value and Experience Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Chengbo Zeng
- The Patient-Reported Outcome, Value and Experience Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gezzer Ortega
- The Patient-Reported Outcome, Value and Experience Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nadine J McCleary
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Harrison Hubbell
- Office of the Chief Medical Officer, Mass General Brigham, Boston, MA
| | - Peter Meyers
- Office of the Chief Medical Officer, Mass General Brigham, Boston, MA
| | - Allison S Bryant
- Office of the Chief Medical Officer, Mass General Brigham, Boston, MA
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Rachel C Sisodia
- Office of the Chief Medical Officer, Mass General Brigham, Boston, MA
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrea L Pusic
- The Patient-Reported Outcome, Value and Experience Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Charubhumi V, Chepla KJ. Discussion: An Analysis of Treatment Choices among White and African American Medicaid Patients with Carpal Tunnel Syndrome. Plast Reconstr Surg 2024; 153:656-657. [PMID: 38385722 DOI: 10.1097/prs.0000000000010948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Affiliation(s)
| | - Kyle J Chepla
- Division of Plastic Surgery, MetroHealth Medical Center
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18
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Myers S, Kenzik K, Allee L, Dechert T, Theodore S, Jaffe A, Sanchez SE. Social Determinants of Health Associated With the Need for Urgent Versus Elective Cholecystectomy at an Urban, Safety-Net Hospital. Surg Infect (Larchmt) 2024; 25:101-108. [PMID: 38301176 DOI: 10.1089/sur.2023.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Background: Benign gallstone disease is the most frequent indication for cholecystectomy in the United States. Many patients present with complicated disease requiring urgent interventions, which increases morbidity and mortality. We investigated the association between individual and population-level social determinants of health (SDoH) with urgent versus elective cholecystectomy. Patients and Methods: All patients undergoing cholecystectomy (2014-2021) for benign gallstone disease were included. Demographic and clinical data were linked to population-level SDoH characteristics using census tracts. Data were analyzed using descriptive and inferential statistics. Results: A total of 3,197 patients met inclusion criteria; 1,913 (59.84%) underwent urgent cholecystectomy, 1,204 (37.66%) underwent emergent cholecystectomy, and 80 (2.5%) underwent interval cholecystectomy. On multinomial logistic regression, patients who were older (relative risk [RR], 1.010; p < 0.001), black (RR, 1.634; p = 0.008), and living in census tracts with a higher percent of poverty (RR, 0.017; p = 0.021) had a higher relative risk of presenting for urgent cholecystectomy. Patients who were female (RR, 0.462; p < 0.001), had a primary care provider (PCP; RR, 0.821; p = 0.018), and lived in census tracts with low supermarket access (RR, 0.764; p = 0.038) had a lower relative risk of presenting for urgent cholecystectomy. Only age (RR, 1.066; p < 0.001), female gender (RR, 0.227; p < 0.001), and having a PCP (RR, 1.984; p = 0.034) were associated with presentation for interval cholecystectomy. Conclusions: Patients who were older, black, and living in census tracts with high poverty levels had a higher relative risk of presenting for urgent cholecystectomy at our institution, whereas females and patients with PCPs were more likely to undergo elective cholecystectomy. Improved access to primary care and surgical clinics for all patients at safety-net hospitals may result in improved outcomes in the management of benign gallstone disease by increasing diagnosis and treatment in the elective setting.
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Affiliation(s)
- Sara Myers
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Kelly Kenzik
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Lisa Allee
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Tracey Dechert
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sheina Theodore
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Abraham Jaffe
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
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19
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Hooper RC, Tong Y, Sanders HM, Wang L, Chung KC. An Analysis of Treatment Choices among White and African American Medicaid Patients with Carpal Tunnel Syndrome. Plast Reconstr Surg 2024; 153:649-655. [PMID: 37184528 DOI: 10.1097/prs.0000000000010640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is the most common compressive neuropathy and has severe long-term effects on hand function if surgery is delayed significantly following diagnosis. The authors investigated the timespan between diagnosis and surgical intervention for carpal tunnel syndrome among African American and White patients on Medicaid. METHODS Using the MarketScan Truven Database Medicaid Supplement 2009 to 2020, the authors identified patients with CTS. Demographic data and time intervals between diagnosis and treatment were collected and analyzed using chi-square test and regression models. RESULTS A total of 361,942 African American and White Medicaid patients with a diagnosis of CTS were included in the study. Overall, 21.4% of White patients compared with 13.6% of African American patients chose surgery as their first and only option ( P < 0.001). A greater proportion of White patients underwent surgery less than 6 months after diagnosis compared with African Americans (75.5% and 67.7%, respectively; P < 0.001). African American women underwent surgery at a significantly lower rate compared with White women (13.8% and 21.8%, respectively); P < 0.001). Despite the increase in rates of surgery among both groups, the gap in use of surgery widened from a 6.6% difference in 2009 to a difference of 9.5% in 2020 between racial groups. CONCLUSIONS African American race and female sex are significantly correlated with choice of treatment and time to surgery among Medicaid patients with CTS. Identification of the relationship between health care disparities and the decision to undergo surgery is the first step in the development of strategies to mitigate underuse of this quality-of-life-improving procedure.
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Affiliation(s)
- Rachel C Hooper
- From the Department of Surgery, Division of Plastic Surgery, Michigan Medicine
| | | | | | - Lu Wang
- Department of Biostatistics, University of Michigan
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
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Elsamadicy AA, Sayeed S, Sherman JJZ, Craft S, Reeves BC, Hengartner AC, Koo AB, Larry Lo SF, Shin JH, Mendel E, Sciubba DM. Racial/Ethnic Disparities Among Patients Undergoing Anterior Cervical Discectomy and Fusion or Posterior Cervical Decompression and Fusion for Cervical Spondylotic Myelopathy: A National Administrative Database Analysis. World Neurosurg 2024; 183:e372-e385. [PMID: 38145651 DOI: 10.1016/j.wneu.2023.12.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/18/2023] [Indexed: 12/27/2023]
Abstract
INTRODUCTION The aim of this study was to investigate the impact of racial disparities on surgical outcomes for cervical spondylotic myelopathy (CSM). METHODS Adult patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) for CSM were identified from the 2016 to 019 National Inpatient Sample Database using the International Classification of Diseases codes. Patients were categorized based on approach (ACDF or PCDF) and race/ethnicity (White, Black, Hispanic). Patient demographics, comorbidities, operative characteristics, adverse events, and health care resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS), nonroutine discharge (NRD), and exorbitant costs. RESULTS A total of 46,500 patients were identified, of which 36,015 (77.5%) were White, 7465 (16.0%) were Black, and 3020 (6.5%) were Hispanic. Black and Hispanic patients had a greater comorbidity burden compared to White patients (P = 0.001) and a greater incidence of any postoperative complication (P = 0.001). Healthcare resource utilization were greater in the PCDF cohort than the ACDF cohort and greater in Black and Hispanic patients compared to White patients (P < 0.001). Black and Hispanic patient race were significantly associated with extended hospital LOS ([Black] odds ratio [OR]: 2.24, P < 0.001; [Hispanic] OR: 1.64, P < 0.001) and NRD ([Black] OR: 2.33, P < 0.001; [Hispanic] OR: 1.49, P = 0.016). Among patients who underwent PCDF, Black race was independently associated with extended hospital LOS ([Black] OR: 1.77, P < 0.001; [Hispanic] OR: 1.47, P = 0.167) and NRD ([Black] OR: 1.82, P < 0.001; [Hispanic] OR: 1.38, P = 0.052). CONCLUSIONS Our study suggests that patient race may influence patient outcomes and healthcare resource utilization following ACDF or PCDF for CSM.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Sumaiya Sayeed
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Josiah J Z Sherman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samuel Craft
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sheng-Fu Larry Lo
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ehud Mendel
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
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Venkatraman V, Futch BG, Bode Padron KJ, Yang LZ, Lee HJ, Seas A, Parente B, Shofty B, Lad SP, Williamson TL, Rahimpour S. Disparities in the treatment of movement disorders using deep brain stimulation. J Neurosurg 2024:1-11. [PMID: 38306639 PMCID: PMC10898494 DOI: 10.3171/2023.11.jns23882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 11/16/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is a well-established treatment for Parkinson's disease (PD) and essential tremor (ET). Although the prevalence of PD and ET can vary by sex and race, little is known about the accessibility of neurosurgical treatments for these conditions. In this nationwide study, the authors aimed to characterize trends in the use of DBS for the treatment of PD and ET and to identify disparities in the neurosurgical treatment of these diseases based on ethnic, racial, sex, insurance, income, hospital, and geographic factors. METHODS Using the dates January 1, 2012, to December 31, 2019, the authors queried the National Inpatient Sample database for all discharges with an ICD-9 or ICD-10 diagnosis of PD or ET. Among these discharges, the DBS rates were reported for each subgroup of race, ethnicity, and sex. To develop national estimates, all analyses were weighted. RESULTS Among 2,517,639 discharges with PD, 29,820 (1.2%) received DBS, and among 652,935 discharges with ET, 11,885 (1.8%) received DBS. Amid the PD cases, Black patients (n = 405 [0.2%], OR 0.16, 95% CI 0.12-0.20) were less likely than White patients (n = 23,975 [1.2%]) to receive DBS treatment, as were Hispanic patients (n = 1965 [1.1%], OR 0.76, 95% CI 0.65-0.88), whereas Asian/Pacific Islander patients (n = 855 [1.5%]) did not statistically differ from White patients. Amid the ET cases, Black (n = 230 [0.8%], OR 0.39, 95% CI 0.27-0.56), Hispanic (n = 215 [1.0%], OR 0.39, 95% CI 0.28-0.55), and Asian/Pacific Islander (n = 55 [1.0%], OR 0.51, 95% CI 0.28-0.93) patients were less likely than White patients (n = 10,440 [1.9%]) to receive DBS. Females were less likely than males to receive DBS for PD (OR 0.69, p < 0.0001) or ET (OR 0.70, p < 0.0001). CONCLUSIONS The authors describe significant racial and sex-based differences in the utilization of DBS for the treatment of PD and ET. Further research is required to ascertain the causes of these disparities, as well as any differences in access to specialty neurosurgical care and referral for neuromodulation approaches.
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Affiliation(s)
| | | | | | - Lexie Z Yang
- 2Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Hui-Jie Lee
- 2Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | | | | | - Ben Shofty
- 3Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah; and
| | | | - Theresa L Williamson
- 4Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Shervin Rahimpour
- 3Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah; and
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22
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Dixit AA, Sekeres G, Mariano ER, Memtsoudis SG, Sun EC. Association of Patient Race and Hospital with Utilization of Regional Anesthesia for Treatment of Postoperative Pain in Total Knee Arthroplasty: A Retrospective Analysis Using Medicare Claims. Anesthesiology 2024; 140:220-230. [PMID: 37910860 PMCID: PMC10872475 DOI: 10.1097/aln.0000000000004827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND Regional anesthesia for total knee arthroplasty has been deemed high priority by national and international societies, and its use can serve as a measure of healthcare equity. The association between utilization of regional anesthesia for postoperative pain and (1) race and (2) hospital in patients undergoing total knee arthroplasty was estimated. The hypothesis was that Black patients would be less likely than White patients to receive regional anesthesia, and that variability in regional anesthesia would more likely be attributable to the hospital where surgery occurred than race. METHODS This study used Medicare fee-for-service claims for patients aged 65 yr or older who underwent primary total knee arthroplasty between January 1, 2011, and December 31, 2016. The primary outcome was administration of regional anesthesia for postoperative pain, defined as any peripheral (femoral, lumbar plexus, or other) or neuraxial (spinal or epidural) block. The primary exposure was self-reported race (Black, White, or Other). Clinical significance was defined as a relative difference of 10% in regional anesthesia administration. RESULTS Data from 733,406 cases across 2,507 hospitals were analyzed: 90.7% of patients were identified as White, 4.7% as Black, and 4.6% as Other. Median hospital-level prevalence of use of regional anesthesia was 51% (interquartile range, 18 to 79%). Black patients did not have a statistically different probability of receiving a regional anesthetic compared to White patients (adjusted estimates: Black, 53.3% [95% CI, 52.5 to 54.1%]; White, 52.7% [95% CI, 52.4 to 54.1%]; P = 0.132). Findings were robust to alternate specifications of the exposure and outcome. Analysis of variance revealed that 42.0% of the variation in block administration was attributable to hospital, compared to less than 0.01% to race, after adjusting for other patient-level confounders. CONCLUSIONS Race was not associated with administration of regional anesthesia in Medicare patients undergoing primary total knee arthroplasty. Variation in the use of regional anesthesia was primarily associated with the hospital where surgery occurred. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Anjali A Dixit
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Gabriel Sekeres
- Stanford Institute for Economic Policy Research, Stanford University, Stanford, California
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Stavros G Memtsoudis
- Departments of Anesthesiology and Public Health, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine and Department of Health Policy, Stanford University, Stanford, California
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23
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Zheng M, Wandell GM, Maxin AJ, Gomez-Castillo LA, Giliberto JP, Bhatt NK. Sociodemographic Disparities in Tracheostomy Timing and Outcomes. Laryngoscope 2024; 134:582-587. [PMID: 37584408 DOI: 10.1002/lary.30872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/30/2023] [Accepted: 06/25/2023] [Indexed: 08/17/2023]
Abstract
OBJECTIVE Tracheostomies are commonly performed in critically ill patients requiring prolonged mechanical ventilation. Although early tracheostomy has been associated with improved outcomes, the reasons for delayed tracheostomy are complex. We examined the impact of sociodemographic factors on tracheostomy timing and outcomes. METHODS Medical records were retrospectively reviewed of ventilator-dependent adult patients who underwent tracheostomy from 2021 to 2022. Tracheostomy timing was defined as routine (<21 days) versus late (21 days or more). Sociodemographic variables were compared between cohorts using univariate and multivariate models. Secondary outcomes included hospital length of stay (LOS), decannulation, tracheostomy-related complications, and inhospital mortality. RESULTS One hundred forty-two patients underwent tracheostomy after initial intubation: 74.7% routine (n = 106) and 25.4% late (n = 36). In a multivariate model adjusted for age, race, surgical service, tracheostomy technique, and time between consultation and surgery, non-English speaking patients and women were more likely to receive a late tracheostomy compared with English speaking patients and men, respectively (odds ratio [OR] 3.18, 95% confidence interval [CI] 1.03, 9.81, p < 0.05), (OR 3.15, 95% CI 1.18, 8.41, p < 0.05). Late tracheostomy was associated with longer median hospital LOS (62 vs. 52 days, p < 0.05). Tracheostomy timing did not significantly impact mortality, decannulation or tracheostomy-related complications. CONCLUSION Despite an association between earlier tracheostomy and shorter LOS, non-English speaking patients and female patients are more likely to receive a late tracheostomy. Standardized protocols for tracheostomy timing may address bias in the referral and execution of tracheostomy and reduce unnecessary hospital days. LEVEL OF EVIDENCE 4 Laryngoscope, 134:582-587, 2024.
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Affiliation(s)
- Melissa Zheng
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Grace M Wandell
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Anthony J Maxin
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
- School of Medicine, Creighton University, Omaha, Nebraska, U.S.A
| | - Luis A Gomez-Castillo
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - John P Giliberto
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Neel K Bhatt
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
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24
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Rullán PJ, Emara AK, Zhou G, Pasqualini I, Klika AK, Koroukian S, Barsoum WK, Piuzzi NS. National Inpatient Datasets May No Longer Be Appropriate for Overall Total Hip and Knee Arthroplasties Projections after Removal from Inpatient-Only Lists. J Knee Surg 2024; 37:214-219. [PMID: 36807103 DOI: 10.1055/a-2037-6323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
It is unknown if the National Inpatient Sample (NIS) remains suitable to conduct projections for total knee arthroplasty (TKA) and total hip arthroplasty (THA), after their removal from "inpatient-only lists" in 2018 and 2020, respectively. We aimed to: (1) quantify primary THA and TKA volume from 2008 to 2018; (2) project estimates of future volume of THA and TKA until 2050; and (3) compare projections based on NIS data from 2008 to 2018 and 2008 to 2017, respectively. We identified all primary THA and TKA performed from 2008 to 2018 from the NIS. The projected volumes of THA and TKA were modeled using negative binomial regression models while incorporating log-transformed population data from the Centers for Disease Control and Prevention. Annual volume increased by 26% for THA and 11% for TKA (2008/2018: THA: 360,891/465,559; TKA:592,352/657,294). Based on 2008 to 2018 data, THA volume is projected to grow 120%, to 1,119,942 THAs by 2050. While, based on 2008 to 2017 data, THA volume is projected to grow 136%, to 1,219,852 THAs by 2050. Based on 2008 to 2018 data, TKA volume is projected to grow 4%, to 794,852 TKAs by 2050. While, based on 2008 to 2017 data, TKA volume is projected to grow 28%, to 1,037,474 TKAs by 2050. Projections based on 2008 to 2017 data estimated up to 240,000 (23%) more annual TKAs by 2050, compared with projections based on 2008 to 2018 data. The largest discrepancy among THA projections was an 8.2% difference (99,000 THAs) for 2050. After 2018 for TKA, and potentially 2020 for THA, projections based on the NIS will have to be interpreted with caution and may only be appropriate to estimate future inpatient volume. Level of evidence is prognostic level II.
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Affiliation(s)
- Pedro J Rullán
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmed K Emara
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Guangjin Zhou
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Ignacio Pasqualini
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alison K Klika
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Siran Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Wael K Barsoum
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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25
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Ikram M, Shen C, Pameijer CR. Racial and Socioeconomic Differences and Surgical Outcomes in Pancreaticoduodenectomy Patients: A Systematic Review of High- Versus Low-Volume Hospitals in the United States. Am Surg 2024; 90:292-302. [PMID: 37941362 DOI: 10.1177/00031348231211040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is associated with better outcomes in high-volume hospitals. However, it is unknown whether and to what extent the improved performance of high-volume hospitals may be associated with racial and socioeconomic factors, which have been shown to impact operative and postoperative outcomes in major surgeries. This review aims to identify the differences in racial and socioeconomic characteristics of patients who underwent PD surgery in high- and low-volume hospitals. METHODS PubMed, Cochrane, and Web of Science were systematically searched between May 1, 2023 and May 7, 2023 without any time restriction on publication date. Studies that were conducted in the United States and had a direct comparison between high- and low-volume hospitals were included. RESULTS A total of 30 observational studies were included. When racial proportions were compared by hospital volume, thirteen studies reported that compared to high-volume hospitals, a higher percentage of racial minorities underwent PD in low-volume hospitals. Disparities in traveling distance, education levels, and median income at baseline between high- and low-volume hospitals were reported by four, three, and two studies, respectively. CONCLUSION A racial difference at baseline between high- and low-volume hospitals was observed. Socioeconomic factors were less frequently included in existing literature. Future studies are needed to understand the socioeconomic differences between patients receiving PD surgery in high- and low-volume hospitals.
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Affiliation(s)
- Mohammad Ikram
- Department of Surgery, Division of Outcomes Research and Quality, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Chan Shen
- Department of Surgery, Division of Outcomes Research and Quality, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
- Department of Public Health Sciences, Division of Health Services and Behavioral Research, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Colette R Pameijer
- Department of Surgery, Division of Surgical Oncology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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26
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Klein E, Saheed M, Irvin N, Balhara KS, Badaki-Makun O, Poleon S, Kelen G, Cosgrove SE, Hinson J. Racial and Socioeconomic Disparities Evident in Inappropriate Antibiotic Prescribing in the Emergency Department. Ann Emerg Med 2024:S0196-0644(23)01426-9. [PMID: 38260931 DOI: 10.1016/j.annemergmed.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/21/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024]
Abstract
STUDY OBJECTIVE Inappropriate antibiotic prescribing for acute respiratory tract infections is a common source of low-value care in the emergency department (ED). Racial and socioeconomic disparities have been noted in episodes of low-value care, particularly in children. We evaluated whether prescribing rates for acute respiratory tract infections when antibiotics would be inappropriate by guidelines differed by race and socioeconomics. METHODS A retrospective cross-sectional analysis of adult and pediatric patient encounters in the emergency department (ED) between 2015 and 2023 at 5 hospitals for acute respiratory tract infections that did not require antibiotics by guidelines. Multivariable regression was used to calculate the risk ratio between race, ethnicity, and area deprivation index and inappropriate antibiotic prescribing, controlling for patient age, sex, and relevant comorbidities. RESULTS A total of 147,401 ED encounters (55% pediatric, 45% adult) were included. At arrival, 4% patients identified as Asian, 50% as Black, 5% as Hispanic, and 23% as White. Inappropriate prescribing was noted in 7.6% of overall encounters, 8% for Asian patients, 6% for Black patients, 5% for Hispanic patients, and 12% for White patients. After adjusting for age, sex, comorbidities, and area deprivation index, White patients had a 1.32 (95% confidence interval, 1.26 to 1.38) higher likelihood of receiving a prescription compared with Black patients. Patients residing in areas of greater socioeconomic deprivation, regardless of race and ethnicity, had a 0.74 (95% confidence interval, 0.70 to 0.78) lower likelihood of receiving a prescription. CONCLUSION Our results suggest that although overall inappropriate prescribing was relatively low, White patients and patients from wealthier areas were more likely to receive an inappropriate antibiotic prescription.
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Affiliation(s)
- Eili Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; OneHealthTrust, Washington, DC.
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nathan Irvin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kamna S Balhara
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Oluwakemi Badaki-Makun
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeremiah Hinson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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27
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West E, Jackson L, Greene H, Lucas DJ, Gadbois KD, Choi PM. Race Does Not Affect Rates of Surgical Complications at Military Treatment Facility. Mil Med 2024:usad502. [PMID: 38241780 DOI: 10.1093/milmed/usad502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/02/2023] [Accepted: 12/19/2023] [Indexed: 01/21/2024] Open
Abstract
INTRODUCTION Racial minorities have been found to have worse health care outcomes, including perioperative adverse events. We hypothesized that these racial disparities may be mitigated in a military treatment facility, where all patients have a military service connection and are universally insured. MATERIALS AND METHODS This is a single institution retrospective review of American College of Surgeons National Surgical Quality Improvement Program data for all procedures collected from 2017 to 2020. The primary outcome analyzed was risk-adjusted 30-day postoperative complications compared by race. RESULTS There were 6,941 patients included. The overall surgical complication rate was 6.9%. The complication rate was 7.3% for White patients, 6.5% for Black patients, 12.6% for Asian patients, and 3.4% for other races. However, after performing patient and procedure level risk adjustment using multivariable logistic regression, race was not independently associated with surgical complications. CONCLUSIONS Risk-adjusted surgical complication rates do not vary by race at this military treatment facility. This suggests that postoperative racial disparities may be mitigated within a universal health care system.
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Affiliation(s)
- Erin West
- Department of General Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Laurinda Jackson
- Department of General Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Howard Greene
- Clinical Investigation Department, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Kyle D Gadbois
- Department of General Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Pamela M Choi
- Division of Pediatric Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
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28
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Juarez JJ, Khalid MU, Ulloa BA, Romero CM, Maruthi R, Shah D, Chang E, Shafi I, Lakhter V, Zhao H, Rodriquez EJ, Pérez-Stable EJ, Bashir R. Racial and ethnic disparities in inferior vena cava filter placement for deep vein thrombosis in the United States. J Vasc Surg Venous Lymphat Disord 2024; 12:101683. [PMID: 37708935 DOI: 10.1016/j.jvsv.2023.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/30/2023] [Accepted: 08/28/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE We sought to determine whether racial and ethnic disparities existed in inferior vena cava (IVC) filter (IVCF) placement rates among Black and Latino patients for the treatment of acute proximal lower extremity (LE) deep vein thrombosis (DVT) in the United States from 2016 to 2019. METHODS We performed a retrospective review of National Inpatient Sample data to identify adult patients with a primary discharge diagnosis of acute proximal LE DVT from January 2016 to December 2019, including self-reported patient race and ethnicity. IVCF placement rates were identified using International Classification of Diseases, 10th revision, codes. Weighted multivariable logistic regression was used to compare IVCF use by race and ethnicity. The regression model was adjusted for patient demographics (ie, sex, primary payer, quartile classification of household income), hospital information (ie, region, location, teaching status, bed size), weekend admission, and clinical characteristics (ie, modified Charlson comorbidity index, hypertension, atrial fibrillation, diabetes mellitus type 2, congestive heart failure, dyslipidemia, coronary artery disease, smoking, obesity, alcohol abuse, chronic kidney disease, pulmonary embolism, malignancy, contraindications to anticoagulation, including other major bleeding). RESULTS Of 134,499 acute proximal LE DVT patients, 18,909 (14.1%) received an IVCF. Of the patients who received an IVCF, 12,733 were White (67.3%), 3563 were Black (18.8%), and 1679 were Latino (8.9%). IVCF placement decreased for all patient groups between 2016 and 2019. After adjusting for the U.S. population distribution, the IVCF placement rates were 11 to 12/100,000 persons for Black patients, 7 to 8/100,000 persons for White patients, and 4 to 5/100,000 persons for Latino patients. The difference in IVCF placement rates was statistically significant between patient groups (Black patients vs White patients, P < .05; Black patients vs Latino patients, P < .05; Latino patients vs White patients, P < .05). CONCLUSIONS This nationwide study showed that Black patients have higher IVCF placement rates compared with White and Latino patients. Given the known long-term complications and uncertain benefits of IVCFs, coupled with the 2010 U.S. Food and Drug Administration safety warning regarding adverse patient events for these devices, proactive measures should be taken to address this disparity among the Black patient population to promote health equity. Future work should assess whether clinician bias might be perpetuating this disparity.
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Affiliation(s)
- Jordan J Juarez
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA; Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Muhammad U Khalid
- Department of Vascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Bianca A Ulloa
- Medical Scientist Training Program, Albert Einstein College of Medicine, Bronx, NY
| | - Carlos M Romero
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Rohit Maruthi
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Devrat Shah
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Eric Chang
- Division of Cardiovascular Diseases, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Irfan Shafi
- Division of Cardiovascular Medicine, Wayne State University, Detroit Medical Center, Detroit, MI
| | - Vladimir Lakhter
- Division of Cardiovascular Diseases, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Huaqing Zhao
- Center for Biostatistics and Epidemiology, Department of Biomedical Education and Data Science, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Erik J Rodriquez
- Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Eliseo J Pérez-Stable
- Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; Office of the Director, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD
| | - Riyaz Bashir
- Division of Cardiovascular Diseases, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.
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Pang JC, Nguyen TV, Dilley KK, Mundo ZDD, Abiri A, Hsu FPK, Kuan EC. Racial and ethnic disparities in the presentation size and timing of pituitary adenomas resected via endoscopic endonasal approach. Int Forum Allergy Rhinol 2023; 13:2252-2255. [PMID: 37317699 DOI: 10.1002/alr.23214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 06/16/2023]
Abstract
KEY POINTS In a single-center cohort of pituitary adenoma patients, non-White race independently predicted larger tumor size at initial presentation. Uninsured patients suffered a significantly higher rate of pituitary apoplexy at initial presentation. Geographically distant care appeared to present a greater barrier for non-White and Hispanic patients relative to their White and non-Hispanic counterparts.
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Affiliation(s)
- Jonathan C Pang
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Theodore V Nguyen
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Katelyn K Dilley
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Zena D Del Mundo
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Arash Abiri
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Edward C Kuan
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, Orange, California, USA
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
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Al-Mansour MR, Gabriel KH, Neal D. Gender, racial, and socioeconomic disparity of preoperative optimization goals in ventral hernia repair. Surg Endosc 2023; 37:9399-9405. [PMID: 37658198 DOI: 10.1007/s00464-023-10365-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/30/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Preoperative optimization cut-offs are frequently utilized to determine eligibility for elective ventral hernia repair. Our objective was to assess the relationship between gender, race, and socioeconomic status and preoperative optimization goals. METHODS We queried our institutional database for adults with ventral hernia diagnoses between 2016 and 2021. Demographics, comorbidities, laboratory, and operative data were collected and analyzed. The following cut-offs were used to determine eligibility for elective repair: body mass index (BMI) < 40 kg/m2, no active smoking, and glycated hemoglobin (HbA1c) < 8%. Socioeconomic status was assessed using the Distressed Communities Index. RESULTS A total of 5638 patients were included [Whites = 4321 (77%), Blacks = 794 (14%), Hispanics = 318 (6%), and other/unknown 205 (4%)]. Median age was 61 years and 50% were male. Most common hernia types were umbilical (36%) and incisional (20%). 10% had BMI > 40 kg/m2, 9% were active smokers and 4% had HbA1c > 8%. 21% of all patients did not meet the preoperative optimization cut-offs at time of diagnosis and those were less likely to undergo hernia repair during the study timeframe compared to those who did (OR 0.50; 95% CI [0.42-0.60]). There was a higher proportion of females (21%) and Blacks (22%) with BMI > 40 kg/m2 compared to males (11%) and other races (11-15%), p = 0.002. As the level of socioeconomic distress increased, there was a corresponding increase in the proportion of patients who did not meet preoperative optimization cut-offs from 16% in prosperous communities to 25% in distressed communities (p < 0.0001). CONCLUSION Nearly 1 of 5 patients with ventral hernias is affected by commonly used arbitrary preoperative optimization cut-offs. These cut-offs disproportionately impact females, Black patients and those with higher socioeconomic distress. These disparities need to be considered when planning preoperative optimization protocols and resource allocation to ensure equitable access to elective ventral hernia repair.
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Affiliation(s)
- Mazen R Al-Mansour
- Department of Surgery, University of Florida, Gainesville, FL, USA.
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA.
| | | | - Dan Neal
- Department of Surgery, University of Florida, Gainesville, FL, USA
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Welter M, Grosh K, Jose J, Khalil S, Muharraq A, Elian A, Munene G, Sawyer R, Shebrain S. Are There Racial Differences in the Rate of Surgical Site Infection Based on Surgical Subspecialty? Surg Infect (Larchmt) 2023; 24:860-868. [PMID: 38011334 DOI: 10.1089/sur.2023.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Background: Surgical site infection (SSI) is a common, morbid post-operative complication. We hypothesized the presence of racial differences in SSI rates, comparing black/African American (BAA) to white non-Hispanic (WNH) patients. Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), BAA and WNH surgery patients across 10 surgical specialties were identified: general surgery (GS), vascular surgery (VS), cardiac surgery (CS), thoracic surgery (TS), orthopedics (OS), neurosurgery (NS), urology (US), otolaryngology (ENT), plastic surgery (PS), and gynecology (GYN). The primary outcome was SSI rate (superficial, deep incisional, or organ/space). The secondary outcome was rate of non-surgical infection. Pearson χ2 and Fisher exact tests were used to test group differences of categorical variables. Continuous variables were tested with the Student t-test, or Mann-Whitney U test, with statistical significance set at a value of p < 0.05. Multivariable logistic regression models were conducted to analyze the association between race/ethnicity and the infection outcomes. Results: A total of 740,144 patients were included: 99,425 (13.4%) BAA and 640,749 (86.6%) WNH, distributed as follows; 32,2976 GS, 17,6175 OS, 44,383 VS, 2,227 CS, 9,645 TS, 42,298 NS, 42,726 US, 18,518 ENT, 20,709 PS, and 60,517 GYN cases. Surgical site infection rates were higher among WNH in GS (4.4% vs. 4.1%; p = 0.003) and TS (3.1% vs. 1.7%; p = 0.015); lower in VS (3.2% vs. 4.4%; p < 0.001), OS (1.2% vs.1.6%; p < 0.001), and GYN (2.4% vs. 3%; p < 0.001); and similar between WNH and BAA in ENT (1.8% vs 1.8%; p = 0.76), and US (1.9% vs. 1.9%; p = 0.90). Non-surgical infection was higher in BAA in NS (3.2% vs. 2.5%; p = 0.003), and higher in WNH in GYN (2.6% vs. 2%; p < 0.001), OS (1.7% vs. 1.1%; p < 0.001), US (4.4% vs. 3.6%; p = 0.014), and VS (3.4% vs. 2.6%; p < 0.001). Conclusions: Variation exists in SSI rates between WNH and BAA patients among surgical subspecialties. Further research is required to understand these differences and address racial disparities in outcomes.
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Affiliation(s)
- Matthew Welter
- Department of Surgery, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Kent Grosh
- Department of Surgery, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Joslyn Jose
- Department of Surgery, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Sarah Khalil
- Department of Surgery, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Afnan Muharraq
- Biostatistics Department, Western Michigan University, Kalamazoo, Michigan, USA
| | - Alain Elian
- Department of Surgery, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Gitonga Munene
- Department of Surgery, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Robert Sawyer
- Department of Surgery, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Saad Shebrain
- Department of Surgery, Homer Stryker M.D. School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
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Goldhaber NH, Matson J, Luo W, Thareja N, Lopez N, Clary BM, Mekeel KL. Case Bias Case Basis: Expanding Morbidity and Mortality Conference to Examine the Impact of Disparities in Surgical Care. JOURNAL OF SURGICAL EDUCATION 2023; 80:1755-1761. [PMID: 37978011 DOI: 10.1016/j.jsurg.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/04/2023] [Accepted: 10/07/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Originally designed as a forum to discuss adverse patient events, Surgery Morbidity & Mortality Conference (M&M) has evolved into an integral tool within surgical education where trainees at all levels are taught to critically examine decision-making. Others have expanded the scope of subsets of M&M conferences to include additional factors that influence patient outcomes, such as social determinants of health, implicit bias and structural policies that contribute to health disparities. In this study, we implemented a disparities-based discussion into our surgical department's weekly M&M conference and examined the effect(s) on participants' understanding and perceptions of key disparities in access to surgical care. METHODS An anonymous electronic survey was sent to attendees of the Department of Surgery's M&M conference including faculty, residents and medical students prior to implementation of the intervention. The survey queried perceptions of the presence and impact of disparities in access to surgical care and how these are addressed at the study institution. The standard presenter slide template was updated to include a "Disparities Factors" section within the "Reasons for Complication" slide. After over 1 year, a postintervention survey was sent to conference attendees that included the same questions as the initial survey, as well as new questions related to the intervention. Descriptive statistics were performed on survey results, and comparisons were made for paired pre-post items. RESULTS Eighty conference attendees completed the pre-intervention survey, and 70 completed the postintervention survey (22 [27.5%]; 22 [31.4%] attendings, 24 [30.0%]; 21 [30.0%] residents, 34 [42.5%]; 27 [38.6%] medical students respectively). Socioeconomics and language were most commonly identified both pre- and postintervention as the most important factors contributing to disparities in care experienced by patients at the study institution. Respondents agreed disparities in access significantly impact surgical care, and there was an increase in the number of respondents who reported feeling that disparities are being addressed postintervention. A total of 69% (n = 48) of respondents thought that integrating discussion of disparities in access to surgical care into M&M improved their understanding of the role these disparities play, 66% (n = 46) felt that their own thinking or practice changed regarding patient disparities, 84% (n = 59) reported integrating these discussions of disparities into M&M has been helpful overall. CONCLUSION The inclusion of a disparities discussion in weekly M&M conference has led to positive change at the study institution, fostering a more comprehensive and socially conscious dialogue within the Department of Surgery. Survey respondents agreed that disparities exist in access to surgical care, and that the intervention improved their perceptions of how the study institution addresses disparities. Respondents felt that the integration of a disparities discussion was overall helpful, improved their knowledge of disparities in access to surgical care, and impacted their plans to address disparities in their own practices.
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Affiliation(s)
- Nicole H Goldhaber
- Department of Surgery, University of California, San Diego Health, La Jolla, California.
| | - Jared Matson
- Department of Surgery, University of California, San Diego Health, La Jolla, California
| | - William Luo
- School of Medicine, University of California, San Diego, La Jolla, California
| | - Nikita Thareja
- School of Medicine, University of California, San Diego, La Jolla, California
| | - Nicole Lopez
- Department of Surgery, University of California, San Diego Health, La Jolla, California
| | - Bryan M Clary
- Department of Surgery, University of California, San Diego Health, La Jolla, California
| | - Kristin L Mekeel
- Department of Surgery, University of California, San Diego Health, La Jolla, California
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LaPorte ZL, Cherian NJ, Eberlin CT, Dean MC, Torabian KA, Dowley KS, Martin SD. Operative management of rotator cuff tears: identifying disparities in access on a national level. J Shoulder Elbow Surg 2023; 32:2276-2285. [PMID: 37245619 DOI: 10.1016/j.jse.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/09/2023] [Accepted: 04/12/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND The purpose of this study was to identify nationwide disparities in the rates of operative management of rotator cuff tears based on race, ethnicity, insurance type, and socioeconomic status. METHODS Patients diagnosed with a full or partial rotator cuff tear from 2006 to 2014 were identified in the Healthcare Cost and Utilization Project's National Inpatient Sample database using International Classification of Diseases, Ninth Revision diagnosis codes. Bivariate analysis using chi-square tests and adjusted, multivariable logistic regression models were used to evaluate differences in the rates of operative vs. nonoperative management for rotator cuff tears. RESULTS This study included 46,167 patients. When compared with white patients, adjusted analysis showed that minority race and ethnicity were associated with lower rates of operative management for Black (adjusted odds ratio [AOR]: 0.31, 95% confidence interval [CI]: 0.29-0.33; P < .001), Hispanic (AOR: 0.49, 95% CI: 0.45-0.52; P < .001), Asian or Pacific Islander (AOR: 0.72, 95% CI: 0.61-0.84; P < .001), and Native American patients (AOR: 0.65, 95% CI: 0.50-0.86; P = .002). In comparison to privately insured patients, our analysis also found that self-payers (AOR: 0.08, 95% CI: 0.07-0.10; P < .001), Medicare beneficiaries (AOR: 0.76, 95% CI: 0.72-0.81; P < .001), and Medicaid beneficiaries (AOR: 0.33, 95% CI: 0.30-0.36; P < .001) had lower odds of receiving surgical intervention. Additionally, relative to those in the bottom income quartile, patients in all other quartiles experienced nominally higher rates of operative repair; these differences were statistically significant for the second quartile (AOR: 1.09, 95% CI: 1.03-1.16; P = .004). CONCLUSION There are significant nationwide disparities in the likelihood of receiving operative management for rotator cuff tear patients of differing race/ethnicity, payer status, and socioeconomic status. Further investigation is needed to fully understand and address causes of these discrepancies to optimize care pathways.
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Affiliation(s)
- Zachary L LaPorte
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Nathan J Cherian
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA.
| | - Christopher T Eberlin
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Michael C Dean
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Kaveh A Torabian
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Kieran S Dowley
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
| | - Scott D Martin
- Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Mass General Brigham, Boston, MA, USA
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Akinsola O, Klausner AP, Vince R, Scarpato KR. The Other Pandemic, Racism, in Urology. Urol Clin North Am 2023; 50:525-530. [PMID: 37775211 DOI: 10.1016/j.ucl.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
Racism is deeply ingrained in our society with lasting effects within medicine. The COVID-19 pandemic further highlighted racial disparities in the medical field, including in the field of Urology. This has led to investigation regarding the effects of racism on education, patient care, and research within Urology. This article aims to review current literature on the "other pandemic," structural racism, within medicine and specifically urology and provide ways to combat its impact.
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Affiliation(s)
- Olutiwa Akinsola
- Department of Urology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA.
| | - Adam P Klausner
- Division of Urology, Department of Surgery, Virginia Commonwealth University School of Medicine, 1200 East Broad Street, 7th Floor East Wing, Richmond, VA 23298, USA
| | - Randy Vince
- Case Western Reserve University, University Hospital Urology Institute, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Kristen R Scarpato
- Department of Urology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
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Barry K, Mekkawy KL, Nayar SK, Oni JK. Racial Disparities in Short-Stay and Outpatient Total Hip and Knee Arthroplasty: 13-year Trend in Utilization Rates and Perioperative Morbidity Using a National Database. J Am Acad Orthop Surg 2023; 31:e788-e797. [PMID: 37205876 DOI: 10.5435/jaaos-d-22-00803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/11/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND The objective of this study was to assess racial and ethnic disparities in short-stay (< 2-midnight length of stay) and outpatient (same-day discharge) total joint arthroplasties (TJAs). We aimed to determine (1) whether there are differences in postoperative outcomes between short-stay Black, Hispanic, and White patients and (2) the trend in utilization rates of short-stay and outpatient TJA across these racial groups. METHODS This was a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Short-stay TJAs done between 2008 and 2020 were identified. Patient demographics, comorbidities, and 30-day postoperative outcomes were assessed. Multivariate regression analysis was used to assess differences between racial groups in minor and major complication rates, as well as readmission and revision surgery rates. RESULTS Of a total of 191,315 patients, 88% were White, 8.3% were Black, and 3.9% were Hispanic. Minority patients were younger and had greater comorbidity burden when compared with Whites. Black patients had greater rates of transfusions and wound dehiscence when compared with White and Hispanic patients ( P < 0.001, P = 0.019, respectively). Black patients had lower adjusted odds of minor complications (odds ratio [OR], 0.87; confidence interval [CI], 0.78 to 0.98), and minorities had lower revision surgery rates in comparison with Whites (OR, 0.70; CI, 0.53 to 0.92, and OR, 0.84; CI, 0.71 to 0.99, respectively). The utilization rate for short-stay TJA was most pronounced for Whites. CONCLUSION There continues to persist marked racial disparities in demographic characteristics and comorbidity burden in minority patients undergoing short-stay and outpatient TJA procedures. As outpatient-based TJA becomes more routine, opportunities to address these racial disparities will become increasingly more important to optimize social determinants of health. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Kawsu Barry
- From the From the Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Barry, Dr. Mekkawy, and Dr. Oni), and the From the Department of Orthopedic Surgery (Dr. Nayar), Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Zea-Vera R, Asokan S, Shah RM, Ryan CT, Chatterjee S, Wall MJ, Coselli JS, Rosengart TK, Kayani WT, Jneid H, Ghanta RK. Racial/ethnic differences persist in treatment choice and outcomes in isolated intervention for coronary artery disease. J Thorac Cardiovasc Surg 2023; 166:1087-1096.e5. [PMID: 35248359 PMCID: PMC11092967 DOI: 10.1016/j.jtcvs.2022.01.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/10/2021] [Accepted: 01/23/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Studies have noted racial/ethnic disparities in coronary artery disease intervention strategies. We investigated trends and outcomes of coronary artery disease treatment choice (coronary artery bypass grafting or percutaneous coronary intervention) stratified by race/ethnicity. METHODS We queried the National Inpatient Sample for patients who underwent isolated coronary artery bypass grafting or percutaneous coronary intervention (2002-2017). Outcomes were stratified by race/ethnicity (White, African American, Hispanic, Asian). Multivariable logistic regression evaluated associations between race/ethnicity and receiving coronary artery bypass grafting versus percutaneous coronary intervention, in-hospital mortality, and costs. RESULTS Over the 15-year period, 2,426,917 isolated coronary artery bypass grafting surgeries and 7,184,515 percutaneous coronary interventions were performed. Compared with White patients, African American patients were younger (62 [interquartile range, 53-70] vs 66 [interquartile range, 57-75] years), were more likely to have Medicaid insurance (12.2% vs 4.4%), and had more comorbidities (Charlson-Deyo index, 1.9 ± 1.6 vs 1.7 ± 1.6) (all P < .01). After adjustment for patient comorbidities, presence of acute myocardial infarction, insurance status, and geography, African Americans were the least likely of all racial/ethnic groups to undergo coronary artery bypass grafting (odds ratio, 0.76; P < .01), a consistent trend throughout the study. African American patients had higher risk-adjusted mortality after coronary artery bypass grafting (odds ratio, 1.09; P < .01). Race/ethnicity was not associated with increased mortality after percutaneous coronary intervention. African American patients had higher hospitalization costs for coronary artery bypass grafting (+$5816; P < .01) and percutaneous coronary intervention (+$856; P < .01) after controlling for confounders. CONCLUSIONS In this contemporary national analysis, risk-adjusted frequency of coronary artery bypass grafting versus percutaneous coronary intervention for coronary artery disease differed by race/ethnicity. African American patients had lower odds of undergoing coronary artery bypass grafting and worse outcomes. Reasons for these differences merit further investigation to identify opportunities to reduce potential disparities.
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Affiliation(s)
- Rodrigo Zea-Vera
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Sainath Asokan
- Department of Surgery, Boston University School of Medicine, Boston, Mass
| | - Rohan M Shah
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Christopher T Ryan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Matthew J Wall
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Todd K Rosengart
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Waleed T Kayani
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, Tex
| | - Hani Jneid
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, Tex
| | - Ravi K Ghanta
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
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Tornberg H, Kleinbart EP, Martin K, Hunter K, Gentile PM, Rivera-Pintado C, Kleiner MT, Miller LS, Fedorka CJ. Disparities in arthroplasty utilization for rotator cuff tear arthropathy. J Shoulder Elbow Surg 2023; 32:1981-1987. [PMID: 37230288 DOI: 10.1016/j.jse.2023.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 03/26/2023] [Accepted: 04/05/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Rotator cuff tear arthropathy (CTA) carries a significant symptomatic burden for patients. Reverse shoulder arthroplasty (RSA) is an effective treatment intervention for CTA. Disparities in musculoskeletal medicine are well documented; however, there is a paucity of literature on how social determinants of health affect utilization rates. The purpose of this study is to determine how social determinants of health affect the utilization rates of RSA. METHODS A single-center retrospective review was conducted for adult patients diagnosed with CTA between 2015 and 2020. Patients were divided by those who underwent RSA and those who were offered RSA but did not undergo surgery. Each patient's zip code was used to determine the most specific median household income in the US Census Bureau database and compared to the multistate metropolitan statistical area median income. Income levels were defined by the US Department of Housing and Urban Development's (HUD's) 2022 Income Limits Documentation System and the Federal Reserve's (FED's) Community Reinvestment Act. Because of numeric restrictions, patients were grouped into racial cohorts of Black, White, and all other races. RESULTS Patients of other races had significantly lower odds of continuing to surgery compared with White patients in models controlled for median household income (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.18-0.81, P = .01), HUD's 3 income levels (OR 0.36, 95% CI 0.18-0.74, P = .01), and FED's income levels (OR 0.37, 95% CI 0.17-0.79, P = .01). There was no significantly different odds of going on to surgery between FED income levels and median household income levels, but when compared with those with low HUD income, those below median had significantly lower odds of going on to surgery (OR 0.43, 95% CI 0.23-0.80, P = .01). CONCLUSION Although contradictory to reported health care utilization for Black patients, our study supports reported disparities in utilization for other ethnic minorities. These findings may suggest that improvements in utilization efforts targeted Black-identifying patients but not necessarily other ethnic minorities. The findings of this study can help providers understand how social determinants of health play a role in the utilization of care for CTA and direct mitigation efforts to reduce disparities in access to adequate orthopedic care.
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Affiliation(s)
- Haley Tornberg
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA; Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Emily P Kleinbart
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA
| | - Kelsey Martin
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA
| | - Krystal Hunter
- Cooper Medical School of Rowan University, Camden, NJ, USA; Cooper Research Institute, Cooper University Health Care, Camden, NJ, USA
| | - Pietro M Gentile
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA
| | | | - Matthew T Kleiner
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA; Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Lawrence S Miller
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA; Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Catherine J Fedorka
- Department of Orthopaedic Surgery, Cooper University Health Care, Camden, NJ, USA; Cooper Medical School of Rowan University, Camden, NJ, USA.
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Sarica C, Conner CR, Yamamoto K, Yang A, Germann J, Lannon MM, Samuel N, Colditz M, Santyr B, Chow CT, Iorio-Morin C, Aguirre-Padilla DH, Lang ST, Vetkas A, Cheyuo C, Loh A, Darmani G, Flouty O, Milano V, Paff M, Hodaie M, Kalia SK, Munhoz RP, Fasano A, Lozano AM. Trends and disparities in deep brain stimulation utilization in the United States: a Nationwide Inpatient Sample analysis from 1993 to 2017. LANCET REGIONAL HEALTH. AMERICAS 2023; 26:100599. [PMID: 37876670 PMCID: PMC10593574 DOI: 10.1016/j.lana.2023.100599] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 10/26/2023]
Abstract
Background Deep brain stimulation (DBS) is an approved treatment option for Parkinson's Disease (PD), essential tremor (ET), dystonia, obsessive-compulsive disorder and epilepsy in the United States. There are disparities in access to DBS, and clear understanding of the contextual factors driving them is important. Previous studies aimed at understanding these factors have been limited by single indications or small cohort sizes. The aim of this study is to provide an updated and comprehensive analysis of DBS utilization for multiple indications to better understand the factors driving disparities in access. Methods The United States based National Inpatient Sample (NIS) database was utilized to analyze the surgical volume and trends of procedures based on indication, using relevant ICD codes. Predictors of DBS use were analyzed using a logistic regression model. DBS-implanted patients in each indication were compared based on the patient-, hospital-, and outcome-related variables. Findings Our analysis of 104,356 DBS discharges from 1993 to 2017 revealed that the most frequent indications for DBS were PD (67%), ET (24%), and dystonia (4%). Although the number of DBS procedures has consistently increased over the years, radiofrequency ablation utilization has significantly decreased to only a few patients per year since 2003. Negative predictors for DBS utilization in PD and ET cohorts included age increase and female sex, while African American status was a negative predictor across all cohorts. Significant differences in patient-, hospital-, and outcome-related variables between DBS indications were also determined. Interpretation Demographic and socioeconomic-based disparities in DBS use are evident. Although racial disparities are present across all indications, other disparities such as age, sex, wealth, and insurance status are only relevant in certain indications. Funding This work was supported by Alan & Susan Hudson Cornerstone Chair in Neurosurgery at University Health Network.
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Affiliation(s)
- Can Sarica
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Christopher R. Conner
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kazuaki Yamamoto
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Andrew Yang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Melissa M. Lannon
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Nardin Samuel
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael Colditz
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Brendan Santyr
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Clement T. Chow
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - David H. Aguirre-Padilla
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Neurosurgery, Medical School, Universidad de Chile, Santiago, Chile
| | - Stefan Thomas Lang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Artur Vetkas
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Neurosurgery, Tartu University Hospital, University of Tartu, Tartu, Estonia
| | - Cletus Cheyuo
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ghazaleh Darmani
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Oliver Flouty
- Department of Neurosurgery, University of South Florida, Tampa, FL, United States
| | - Vanessa Milano
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Michelle Paff
- Department of Neurosurgery, University of California Irvine, Orange, CA, United States
| | - Mojgan Hodaie
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada
| | - Suneil K. Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada
- KITE, University Health Network, Toronto, ON, Canada
| | - Renato P. Munhoz
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Division of Neurology, Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Alfonso Fasano
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada
- KITE, University Health Network, Toronto, ON, Canada
- Division of Neurology, Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Andres M. Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada
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Dhanjani SA, Schmerler J, Wenzel A, Gomez G, Oni J, Hegde V. Racial and Socioeconomic Disparities in Risk and Reason for Revision in Total Joint Arthroplasty. J Am Acad Orthop Surg 2023; 31:e815-e823. [PMID: 37276485 DOI: 10.5435/jaaos-d-22-01124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/11/2023] [Indexed: 06/07/2023] Open
Abstract
INTRODUCTION Data regarding racial/ethnic and socioeconomic differences in revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) have been inconsistent. This study examined racial/ethnic and socioeconomic disparities in comorbidity-adjusted risk and reason for rTHA and rTKA. METHODS Patients who underwent rTHA or rTKA between 2006 and 2014 in the National Inpatient Sample were identified. Multivariable logistic regression models adjusted for payer status, hospital geographic setting, and patient characteristics (age, sex, and Elixhauser Comorbidity Index) were used to examine the effect of race/ethnicity and socioeconomic status on trends in annual risk of rTHA/rTKA and causes of rTHA/rTKA. RESULTS Black patients were less likely to undergo rTHA and more likely to undergo rTKA while Hispanic patients were more likely to undergo rTHA and less likely to undergo rTKA ( P < 0.001 for all) compared with White patients. Patients residing in areas of lower income quartiles were more likely to undergo rTHA and rTKA compared with those in the highest quartile ( P < 0.001), and these disparities persisted and widened over time. Black, Hispanic, and Asian patients were less likely to undergo rTHA/rTKA because of dislocation compared with White patients ( P < 0.001 for all). Patients from areas of lower income quartiles were more likely to undergo rTHA because of septic complications and less likely to require both rTHA and rTKA because of mechanical complications ( P < 0.001 for all). DISCUSSION Racial/ethnic and socioeconomic disparities exist in risk and cause of rTHA and rTKA. Increasing awareness and a focus on minimizing variability in hospital quality may help mitigate these disparities.
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Affiliation(s)
- Suraj A Dhanjani
- From the Johns Hopkins University School of Medicine, Baltimore, MD (Dhanjani, Schmerler, and Gomez), and the Department of Orthopaedic Surgery, (Dr. Wenzel, Dr. Oni, Dr. Hegde), The Johns Hopkins University School of Medicine, Baltimore, MD (Wenzel, Oni, and Hegde)
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Joo PY, Halperin SJ, Dhodapkar MM, Adeclat GJ, Elaydi A, Wilhelm C, Grauer JN. Racial Disparities in Surgical Versus Nonsurgical Management of Distal Radius Fractures in a Medicare Population. Hand (N Y) 2023:15589447231198267. [PMID: 37737570 DOI: 10.1177/15589447231198267] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND As racial/ethnic disparities in management of distal radius fractures (DRFs) have not been well elucidated in the literature, this study sought to evaluate the correlation of race/ethnicity on surgical versus nonsurgical management of DRFs in a Medicare population. METHODS The PearlDiver Standard Analytical Files Medicare claims database was used to identify patients ≥65 years old with isolated DRF. Patients with polytrauma or surgery performed for upper extremity neoplasm were excluded. Surgical versus nonsurgical management was compared based on demographics, comorbidity (Elixhauser Comorbidity Index, ECI), race/ethnicity, and whether the fracture was open or closed. Univariate and multivariable analyses were used to assess for independent predictors. RESULTS Of 54 564 isolated DRFs identified, surgery was performed for 20 663 (37.9%). On multivariable analysis, patients were independently less likely to receive surgical management if they were: older (relative to 65- to 69-year-olds, incrementally decreasing by age bracket up to >85 years where odds ratio [OR] was 0.27, P < .001), higher ECI (per 2 increase OR: 0.96, P < .001), and closed fractures (OR: 0.35, P < .001). For race/ethnicity: black (OR: 0.64, P < .001), Hispanic (OR: 0.71, P < .001), and Asian (OR: 0.60, P < .001) patients were less likely to undergo surgery. CONCLUSIONS While age, comorbidities, and fracture type are known to affect surgical decision-making for DRF, race/ethnicity has not previously been reported, and its independent prediction of nonsurgical management for several groups points to a disparity in surgical decision-making/access to care. This highlights the need for increased attention to initiatives that seek to provide equitable care to all patients. LEVEL OF EVIDENCE Level III-Retrospective review of national database.
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Affiliation(s)
| | | | | | | | - Ali Elaydi
- Yale School of Medicine, New Haven, CT, USA
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Ling K, Leatherwood W, Fassler R, Burgan J, Komatsu DE, Wang ED. Disparities in postoperative total shoulder arthroplasty outcomes between Black and White patients. JSES Int 2023; 7:842-847. [PMID: 37719829 PMCID: PMC10499855 DOI: 10.1016/j.jseint.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background Despite the rise in surgical volume for total shoulder arthroplasty (TSA) procedures, racial disparities exist in outcomes between White and Black populations. The purpose of this study was to compare 30-day postoperative complication rates between Black and White patients following TSA. Methods The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for all patients who underwent TSA between 2015 and 2019. Patient demographics and comorbidities were compared between cohorts using bivariate analysis. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between Black or African American race and postoperative complications. Results A total of 19,733 patients were included in the analysis, 18,669 (94.6%) patients in the White cohort and 1064 (5.4%) patients in the Black or African American cohort. Demographics and comorbidities that were significantly associated with Black or African American race were age 40-64 years (P < .001), body mass index ≥40 (P < .001), female gender (P < .001), American Society of Anesthesiologists classification ≥3 (P < .001), smoking status (P < .001), non-insulin and insulin dependent diabetes mellitus (P < .001), hypertension requiring medication (P < .001), disseminated cancer (P = .040), and operative duration ≥129 minutes (P = .002). Multivariate logistic regression identified Black or African American race to be independently associated with higher rates of readmission (odds ratio: 1.42, 95% confidence interval: 1.05-1.94; P = .025). Conclusion Black or African American race was independently associated with higher rates of 30-day readmission following TSA.
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Affiliation(s)
- Kenny Ling
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | | | - Richelle Fassler
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Jane Burgan
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - David E. Komatsu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Edward D. Wang
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
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Adeola JO, Wall PV, Mehdipour S, Macias AA, Gabriel RA. Racial and Ethnic Differences in the Use of Regional Anesthesia for Patients Undergoing Total Knee Arthroplasty. J Arthroplasty 2023; 38:1663-1667. [PMID: 36924860 DOI: 10.1016/j.arth.2023.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/05/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND There is an increasing body of evidence that suggests racial and ethnic disparities exist in medical care. In the field of anesthesiology, few studies have investigated the association of race and ethnicity with the provision of regional anesthesia for patients undergoing total knee arthroplasty. This analysis queried a large national surgical database to determine whether there were racial or ethnic differences in the administration of peripheral nerve blocks for patients undergoing total knee arthroplasty. METHODS In this retrospective cohort study, data were collected from a large national database during the years 2017-2019. Multivariable logistic regressions were used to measure the association of race and ethnicity with utilization of regional anesthesia. The participants for the study were patients 18 years or older undergoing total knee arthroplasty. RESULTS Our primary finding was that among patients undergoing total knee arthroplasty, Black patients had lower odds (adjusted odds ratio [aOR]: 0.93, 99% confidence interval [CI]: 0.89-0.98) of receiving regional anesthesia than White patients. Also, Hispanic patients had lower odds (aOR: 0.88, 99% CI: 0.83-0.94) of receiving regional anesthesia than non-Hispanic patients. Native Hawaiian/Pacific Islander patients had increased odds (aOR: 2.04, 99% CI: 1.66-2.51) of receiving regional anesthesia. CONCLUSION This study demonstrated that there might be racial and ethnic differences in the provision of regional anesthesia for patients undergoing total knee arthroplasty. These differences underscore the need for more studies aimed at equitable access to high quality and culturally competent health care.
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Affiliation(s)
- Janet O Adeola
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School/Brigham & Women's Hospital, Boston, Massachusetts
| | - Pelle V Wall
- Division of Regional Anesthesia, Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Soraya Mehdipour
- Division of Regional Anesthesia, Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Alvaro A Macias
- Division of Regional Anesthesia, Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Rodney A Gabriel
- Division of Regional Anesthesia, Department of Anesthesiology, University of California San Diego, San Diego, California; Division of Perioperative Informatics, Department of Anesthesiology, University of California San Diego, San Diego, California; Department of Biomedical Informatics, University of California San Diego, San Diego, California
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Daniel D, Maillie L, Dhamoon M. Provider care segregation and hospital-region racial disparities for carotid interventions in the USA. J Neurointerv Surg 2023:jnis-2023-020656. [PMID: 37525446 DOI: 10.1136/jnis-2023-020656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/22/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Reasons for racial disparities in the utilization and outcomes of carotid interventions (carotid endarterectomy (CEA) and carotid artery stenting (CAS)) are not well understood, especially segregation of care associated with carotid intervention. We examined patterns of geographic and provider care segregation in carotid interventions and outcomes. METHOD We used de-identified Medicare datasets to identify CEA and CAS interventions between January 1, 2016 and December 31, 2019 using validated ICD-10 codes. For patients who underwent carotid intervention, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for carotid intervention cases. We examined associations between measures of segregation and outcomes. RESULTS Despite higher proportions of Black patients in counties with hospitals that provide carotid intervention, lower proportions of Black patients received intervention. The difference in the proportion of White patients comparing CEA patients to the county race distribution was 0.143 (SD 0.297) at the hospital level (for CAS, 0.174 (0.315)). The dissimilarity index for CEA providers was high, with mean (SD) 0.387 (0.274) averaged across all hospitals and higher among CAS providers at 0.472 (0.288). Black patients receiving CEA and CAS (compared with Whites) had reduced odds of discharge home. Better outcomes (inpatient mortality and 30-day mortality) were independently associated with higher proportion of White CAS patients. CONCLUSION In this national study with contemporary data on carotid intervention, we found evidence for segregation of care of both CEA and CAS.
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Affiliation(s)
- David Daniel
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luke Maillie
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mandip Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Dahl V, Lee Y, Wagner JD, Moore M, Pretell-Mazzini J. Epidemiology and survival factors for sarcoma patients in minority populations: a SEER-retrospective study. Rep Pract Oncol Radiother 2023; 28:370-378. [PMID: 37795400 PMCID: PMC10547403 DOI: 10.5603/rpor.a2023.0041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 06/05/2023] [Indexed: 10/06/2023] Open
Abstract
Background Epidemiologic studies have demonstrated race as a predictor of worse oncological outcomes. To better understand the effect of race on oncological outcomes, we utilized the Surveillance, Epidemiology, and End Results (SEER) database to determine what treatment courses are provided to minority patients and how this impacts survival. Materials and methods A retrospective review of bone and soft tissue sarcoma cases was performed using the SEER database for a minimum 5-year survival rate (SR) using Kaplan-Meier curves. Categorical variables were compared using Pearson's χ2 test and Cramer V. Kaplan-Meier curves were used to determine survival rates (SR) and Cox regression analysis was used to determine hazard ratios (HRs). Results Races that had an increased risk of death included Native American/Alaska Native (NA/AN) [hazard ratio (HR): 1.36, 95% confidence interval (CI): 1.049-1.761, p = 0.020) and Black (HR = 1.17, 95% CI: 1.091-1.256, p < 0.001). NA/AN individuals had the lowest SR (5-year SR = 70.9%, 95% CI: 63.8-78.0%, p < 0.001). The rate of metastasis at diagnosis for each race was 13.07% - Hispanic, 10.62% - NA/AN, 12.77% - Black, 10.61% - Asian/Pacific Islander (A/PI), and 9.02% - White individuals (p < 0.001). There were increases in the rate of metastasis at diagnosis and decreases in rates of surgical excision for Hispanic and Black patients (p < 0.001). Conclusion Race is determined to be an independent risk factor for death in NA/AN and Black patients with sarcomas of the extremities. Access to healthcare and delay in seeking treatment may contribute to higher rates of metastasis upon diagnosis for minority patients, and decreased rates of surgical excision could be associated with poor follow up and lack of resources.
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Affiliation(s)
- Victoria Dahl
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, Florida, United States
| | - Yonghoon Lee
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, Florida, United States
| | - Jaxon D. Wagner
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, Florida, United States
| | - Maya Moore
- Department of Education, The University of Miami Leonard M. Miller School of Medicine, Miami, Florida, United States
| | - Juan Pretell-Mazzini
- Musculoskeletal Oncology Surgeon, Chief of Musculoskeletal Oncology Division, Miami Cancer Institute, Baptist Health System, Miami, Florida, United States
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Solarczyk JK, Roberts HJ, Wong SE, Ward DT. Healthcare Disparities in Orthopaedic Surgery: A Comparison of Anterior Cruciate Ligament Reconstruction Incidence Proportions With US Census-Derived Demographics. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202307000-00002. [PMID: 37410658 PMCID: PMC10328594 DOI: 10.5435/jaaosglobal-d-22-00271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/11/2023] [Accepted: 04/24/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Disparities exist and affect outcomes after anterior cruciate ligament (ACL) injury. The purpose of this study was to investigate the association between race, ethnicity, and insurance type on the incidence of ACL reconstruction in the United States. METHODS The Healthcare Cost and Utilization Project database was used to determine demographics and insurance types for those undergoing elective ACL reconstruction from 2016 to 2017. The US Census Bureau was used to obtain demographic and insurance data for the general population. RESULTS Non-White patients undergoing ACL reconstruction with commercial insurance were more likely to be younger, male, less burdened with comorbidities including diabetes, and less likely to smoke. When we compared Medicaid patients who had undergone ACL reconstruction with all Medicaid recipients, there was an under-representation of Black patients and a similar percentage of White patients undergoing ACL reconstruction (P < 0.001). DISCUSSION This study suggests ongoing healthcare disparities with lower rates of ACL reconstruction for non-White patients and those with public insurance. Equal proportions of patients identifying as Black undergoing ACL reconstruction as compared with the underlying general population suggests a possible narrowing in disparities. More data are needed at numerous points of care between injury, surgery, and recovery to identify and address disparities.
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Affiliation(s)
- Justin K. Solarczyk
- From the University of California San Francisco School of Medicine, San Francisco, CA (Mr. Solarczyk); the Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN (Dr. Roberts); and the Department of Orthopaedic Surgery, University of California at San Francisco, Francisco, CA (Dr. Wong and Dr. Ward)
| | - Heather J. Roberts
- From the University of California San Francisco School of Medicine, San Francisco, CA (Mr. Solarczyk); the Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN (Dr. Roberts); and the Department of Orthopaedic Surgery, University of California at San Francisco, Francisco, CA (Dr. Wong and Dr. Ward)
| | - Stephanie E. Wong
- From the University of California San Francisco School of Medicine, San Francisco, CA (Mr. Solarczyk); the Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN (Dr. Roberts); and the Department of Orthopaedic Surgery, University of California at San Francisco, Francisco, CA (Dr. Wong and Dr. Ward)
| | - Derek T. Ward
- From the University of California San Francisco School of Medicine, San Francisco, CA (Mr. Solarczyk); the Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN (Dr. Roberts); and the Department of Orthopaedic Surgery, University of California at San Francisco, Francisco, CA (Dr. Wong and Dr. Ward)
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Frego N, D'Andrea V, Labban M, Trinh QD. An ecological framework for racial and ethnic disparities in surgery. Curr Probl Surg 2023; 60:101335. [PMID: 37316107 DOI: 10.1016/j.cpsurg.2023.101335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Nicola Frego
- Department of Urology, Istituto Clinico Humanitas IRCCS, Milan, Italy
| | - Vincent D'Andrea
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA
| | - Muhieddine Labban
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women's Hospital, Harvard Medical School, MA; Brigham and Women's Faulkner Hospital, Jamaica Plain, MA.
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Lasater KB, Rosenbaum PR, Aiken LH, Brooks-Carthon JM, Kelz RR, Reiter JG, Silber JH, McHugh MD. Explaining racial disparities in surgical survival: a tapered match analysis of patient and hospital factors. BMJ Open 2023; 13:e066813. [PMID: 37169502 PMCID: PMC10186454 DOI: 10.1136/bmjopen-2022-066813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 04/26/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVES Evaluate whether hospital factors, including nurse resources, explain racial differences in Medicare black and white patient surgical outcomes and whether disparities changed over time. DESIGN Retrospective tapered-match. SETTING 571 hospitals at two time points (Early Era 2003-2005; Recent Era 2013-2015). PARTICIPANTS 6752 black patients and three sets of 6752 white controls selected from 107 001 potential controls (Early Era). 4964 black patients and three sets of 4964 white controls selected from 74 108 potential controls (Recent Era). INTERVENTIONS Black patients were matched to white controls on demographics (age, sex, state and year of procedure), procedure (demographics variables plus 136 International Classification of Diseases (ICD)-9 principal procedure codes) and presentation (demographics and procedure variables plus 34 comorbidities, a mortality risk score, a propensity score for being black, emergency admission, transfer status, predicted procedure time). OUTCOMES 30-day and 1-year mortality. RESULTS Before matching, black patients had more comorbidities, higher risk of mortality despite being younger and underwent procedures at different percentages than white patients. Whites in the demographics match had lower mortality at 30 days (5.6% vs 6.7% Early Era; 5.4% vs 5.7% Recent Era) and 1-year (15.5% vs 21.5% Early Era; 12.3% vs 15.9% Recent Era). Black-white 1-year mortality differences were equivalent after matching patients with respect to presentation, procedure and demographic factors. Black-white 30-day mortality differences were equivalent after matching on procedure and demographic factors. Racial disparities in outcomes remained unchanged between the two time periods spanning 10 years. All patients in hospitals with better nurse resources had lower odds of 30-day (OR 0.60, 95% CI 0.46 to 0.78, p<0.010) and 1-year mortality (OR 0.77, 95% CI 0.65 to 0.92, p<0.010) even after accounting for other hospital factors. CONCLUSIONS Survival disparities among black and white patients are largely explained by differences in demographic, procedure and presentation factors. Better nurse resources (eg, staffing, work environment) were associated with lower mortality for all patients.
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Affiliation(s)
- Karen B Lasater
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul R Rosenbaum
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Linda H Aiken
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - J Margo Brooks-Carthon
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel R Kelz
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph G Reiter
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey H Silber
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Outcomes Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew D McHugh
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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48
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Li B, Ayoo K, Eisenberg N, Lindsay TF, Roche-Nagle G. The impact of race on outcomes following ruptured abdominal aortic aneurysm repair. J Vasc Surg 2023; 77:1413-1423. [PMID: 36702172 DOI: 10.1016/j.jvs.2023.01.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Racial differences in elective abdominal aortic aneurysm (AAA) repair outcomes have been previously reported; however, data on racial differences in ruptured AAA (rAAA) repair outcomes remain limited. This study assessed in-hospital and long-term mortality after rAAA repair in Black versus White patients. METHODS The Vascular Quality Initiative database was queried to identify all Black and White patients who underwent open or endovascular rAAA repair between 2003 and 2019. Baseline demographic and clinical characteristics were recorded, and independent t test and χ2 test were performed to assess differences between groups. In-hospital and 8-year mortality rates were the primary outcomes. Univariate and multivariate logistic regression and Cox proportional hazards analyses were conducted to analyze associations between race and outcomes. RESULTS Overall, 310 Black patients and 4679 White patients underwent rAAA repair. A greater proportion of Black patients underwent endovascular repair (73.2% vs 56.1%). Black patients had a lower mean age and were more likely to be female, with a greater proportion being Medicaid insured (9.7% vs 2.1%) or uninsured (4.8% vs 3.3%). Although Black patients were more likely to be current smokers and have hypertension, diabetes, and congestive heart failure, they were not more likely to receive risk reduction medications. The time from symptom onset to incision or access was higher for Black patients (median, 12.0 hours vs 7.0 hours). Similarly, the time from hospital admission to intervention was higher for Black patients (median, 2.8 hours vs 1.3 hours). In-hospital mortality was lower in Black patients (20.0% vs 28.6%; odds ratio [OR], 0.63; 95% confidence interval [CI], 0.47-0.83); however, this did not persist after adjusting for baseline characteristics (adjusted OR, 0.58; 95% CI, 0.30-1.07; P = .09). Furthermore, the 8-year survival was not different between groups (50.4% vs 46.6%; hazard ratio, 0.85; 95% CI, 0.57-1.26; P = .42), even when stratified by repair type. CONCLUSIONS This study identified racial differences in demographic, clinical, and procedural characteristics for patients undergoing rAAA repair. In particular, the door-to-intervention time for Black patients of 2.8 hours does not meet the Society for Vascular Surgery recommendation of 90 minutes. Despite these differences, the 8-year mortality is similar for Black and White patients. These differences should be investigated further, and there are opportunities to improve rAAA care for Black patients.
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Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kennedy Ayoo
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Joo PY, Wilhelm C, Adeclat G, Halperin SJ, Moran J, Elaydi A, Rubin LE, Grauer JN. Comparing Race/Ethnicity and Zip Code Socioeconomic Status for Surgical versus Nonsurgical Management of Proximal Humerus Fractures in a Medicare Population. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202305000-00011. [PMID: 37141180 PMCID: PMC10162786 DOI: 10.5435/jaaosglobal-d-22-00205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 01/24/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND This study evaluated the effect of race/ethnicity and socioeconomic status (SES) on surgical utilization after proximal humerus fractures in a large Medicare cohort. METHODS The PearlDiver Medicare claims database was used to identify patients aged 65years and older with isolated, closed proximal humerus fractures, for whom race/ethnicity data were available (65.5% of identified fractures). Patients with polytrauma or neoplasm were excluded. Patient demographic, race/ethnicity, comorbidity, and median household income were compared for surgical versus nonsurgical management. Univariate and multivariable logistic regressions were used to determine disparities of surgical utilization based on the abovementioned factors. RESULTS Of 133,218 patients with proximal humerus fracture identified, surgery was conducted for 4446 (3.3%). Those less likely to receive surgery were older (incrementally by increasing age bracket up to 85 years and older odds ratio [OR], 0.16, P < 0.001), male (OR, 0.79, P < 0.001), Black (OR, 0.51, P < 0.001) or Hispanic (0.61, P = 0.005), higher Elixhauser Comorbidity Index (per 2 increase OR, 0.86, P < 0.001), and low median household income (OR, 0.79, P < 0.001). CONCLUSIONS The independent significance of race/ethnicity and SES point to disparities in surgical decision making/access to care. These findings highlight the need for increased attention on initiatives and policies that seek to eliminate racial disparities and improve health equity independent of SES.
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Affiliation(s)
- Peter Y. Joo
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Christopher Wilhelm
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Giscard Adeclat
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Scott J. Halperin
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jay Moran
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Ali Elaydi
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Lee E. Rubin
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jonathan N. Grauer
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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50
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Anteby R, Blaszkowsky LS, Hong TS, Qadan M. Disparities in Receipt of Adjuvant Therapy After Upfront Surgical Resection for Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2023; 30:2473-2481. [PMID: 36585536 DOI: 10.1245/s10434-022-12976-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND A multimodal approach of surgery and chemotherapy, with or without radiation, is the mainstay of therapy with curative-intent for resectable pancreatic ductal adenocarcinoma (PDAC). This study compared utilization trends and outcomes of upfront surgery with and without adjuvant therapy. METHODS The National Cancer Database was queried for patients with a diagnosis of stage 1 or 2 PDAC who underwent upfront resection. Multivariable regression was applied to identify factors associated with initiation of adjuvant therapy. RESULTS Of the 39,128 patients in the study, 67% initiated adjuvant therapy after resection, whereas 33% received upfront surgery alone. Receipt of adjuvant multimodal therapy increased from 59% in 2006 to 69% in 2017 (P < 0.0001). Non-white race was associated with lower odds of receiving adjuvant therapy after adjustment for income status, education attainment, and other variables (Hispanic/Spanish [odds ratio {OR}, 0.77; 95% confidence interval {CI}, 0.69-0.86] and non-Hispanic black [OR 0.84; 95% CI 0.78-0.91 vs non-Hispanic white; P < 0.001). The variables that contributed to receipt of adjuvant therapy were place of residence in high versus low education attainment area (OR 1.30; 95% CI 1.18-1.44; P < 0.0001) and lower odds for initiation of adjuvant therapy with increasing distance from the treating facility (> 50 miles [OR 0.51; 95% CI 0.47-0.54] vs <12.5 miles; P < 0.0001). The median unadjusted overall survival (OS) time was 18.2 months (95% CI 17.7-18.8 months) for upfront surgery alone and 25.3 months (95% CI 24.9-25.8 months) for surgery with adjuvant therapy. CONCLUSIONS The patients who underwent upfront surgical resection for PDAC showed wide socioeconomic disparities in the use of adjuvant therapy independent of insurance status, facility type, or travel distance.
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Affiliation(s)
- Roi Anteby
- School of Public Health, Harvard University, Boston, MA, USA
- Department of Surgery, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA
| | - Lawrence S Blaszkowsky
- Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, Massachusetts, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital and Newton-Wellesley Hospital, Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA.
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