Racial disparities in comorbid conditions among patients undergoing thyroidectomy for Graves' disease: An ACS-NSQIP analysis

Outcome Disparities in Total Knee and Total Hip Arthroplasty among Native American Populations

BACKGROUND

No prior racial disparities studies in total knee arthroplasty (TKA) and total hip arthroplasty (THA) have specifically evaluated outcomes among American Indian or Alaska Native (AIAN) patients. We hypothesized that AIAN patients have worse outcomes than White patients after controlling for demographics and comorbidities.

METHODS

This was a retrospective cohort study comparing White and AIAN patients undergoing primary TKA/THA from 2012-2019 using the American College of Surgeons National Surgical Quality Improvement Program. Race, demographics, and comorbidities were analyzed for correlations with 30-day outcomes and complications using multivariable logistic and linear regression analyses.

RESULTS

Comparing 422,215 White and 2,676 AIAN patients, AIAN patients had higher American Society of Anesthesiologist (ASA) classifications, body mass index (BMI), and were younger at the time of surgery. AIAN patients more often stayed inpatient > 2 days (49.4% vs 36.2%, p < 0.001), underwent reoperation (2.1% vs 1.4%, p < 0.01), and were discharged home (91.4% vs 81.7%, p < 0.01). Regression analyses controlling for age, BMI, sex, ASA classification, and functional status found that AIAN race was significantly positively correlated with a length of stay > 2 days (OR 1.6), reoperation (OR 1.4), and discharging home (OR 2.0).

CONCLUSION

AIAN patients undergoing TKA/THA present with a greater comorbidity burden compared to White patients and experience multiple worse outcome metrics including increased hospital length of stay and reoperation rates. Interestingly, AIAN patients were more likely to discharge home, representing a unique racial disparity which warrants further study.

Trends in thyrotoxicosis-related mortality in the United States from 1999 to 2020

PURPOSE

Thyrotoxicosis is defined as a condition caused by excessive thyroid hormone concentrations, with the main cause being inappropriately increased thyroid hormone production. Existing literature indicates a correlation between thyrotoxicosis and mortality. Thus, this descriptive analysis was conducted to assess the demographic and regional trends of thyrotoxicosis-related mortality in the United States.

METHODS

Death certificates from the Center of Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC-WONDER) from 1999 to 2020 were retrieved for thyrotoxicosis-related mortality in the United States. The crude and age-adjusted mortality rates (AAMRs) per 1,000,000 population and annual percentage change (APCs) were calculated.

RESULTS

There were 33,253 thyrotoxicosis-related deaths from 1999 to 2020. Initially, the AAMR increased from 1999 to 2003 (APC: 3.09; 95% CI 0.83 to 8.16), followed by a steep decline from 2003 to 2008 (APC: -4.28; 95% CI -7.46 to -2.47), followed by a marginal decline from 2008 to 2018 (APC: -0.71; 95% CI -1.70 to 0.95), and concluded by a significant increase from 2018 to 2020 (APC: 11.72; 95% CI 5.06 to 15.32). Non-Hispanic (NH) Black or African American, Hispanic or Latino, and NH White populations demonstrated a significant rise in thyrotoxicosis-related mortality during 2018 to 2020. In contrast, the NH Asian or Pacific Islander population did not denote any significant variations within the included study timeframe. States including West Virginia, the District of Columbia, Vermont, California, and Montana were in the top 10th percentile of thyrotoxicosis-related mortality.

CONCLUSION

After an extended period of decline, the recent increments in thyrotoxicosis-related mortality rates are concerning. Further consideration is urged with respect to thyroid screening, especially among females, in order to reduce the overall thyrotoxicosis-related mortality.

Emergency department use after outpatient thyroidectomy across three states

BACKGROUND

Although outpatient thyroidectomy has become common, few large-scale studies have examined post-thyroidectomy emergency department use, readmission, and encounters not resulting in readmission, known as "treat-and-release" encounters. We evaluated post-outpatient thyroidectomy emergency department use and readmission and characterized associated factors.

METHODS

Using the Healthcare Cost and Utilization Project databases, we identified adult outpatient (same-day or <24-hour discharge) thyroidectomies performed in Florida, Maryland, and New York from 2016 to 2017. We identified the procedures linked with emergency department treat-and-release encounters and readmissions within 30 days postoperatively and the factors associated with post-thyroidectomy emergency department use and readmission.

RESULTS

Of the 17,046 patients who underwent outpatient thyroidectomy at 374 facilities, 7.5% had emergency department treat-and-release encounters and 2.3% readmissions. The most common reasons for emergency department treat-and-release encounters (9.9%) and readmissions (22.2%) were hypocalcemia-related diagnoses. Greater odds of treat-and-release were associated with identifying as non-Hispanic Black (adjusted odds ratio: 1.5, 95% confidence interval: 1.3-1.8) or Hispanic race/ethnicity (adjusted odds ratio: 1.4, 95% CI: 1.1-1.6), having Medicaid insurance (adjusted odds ratio: 2.7, 95% CI: 2.3-3.2), and living in non-metropolitan areas (adjusted odds ratio: 1.6, 95% CI: 1.1-2.2). We observed no associations between these factors and the odds of readmission.

CONCLUSION

Emergency department use after outpatient thyroidectomy is common. Racial, ethnic, socioeconomic, and geographic disparities are associated with treat-and-release encounters but not readmissions. Standardization of perioperative care pathways, focusing on identifying and addressing specific issues in vulnerable populations, could improve care, reduce disparities, and improve patient experience by avoiding unnecessary emergency department visits after outpatient thyroidectomy.

Parathyroidectomy outcomes for Asians in the United States: Implications for resident surgical education

Introduction

Outcomes for Asian patients in the United States are often overlooked in the surgical literature. Surgical education includes little emphasis on reporting outcomes for Asian patients in the United States. Our null hypothesis (H0) is that there is no difference in surgical complications following parathyroid surgery between Asians and all other ethnicities in the United States. Our alternate hypothesis (H1) is that Asians have more incidences of certain complications (possibly due to culture and language barriers).

Methods

Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for parathyroidectomy and patient race. Complications within 30 days of surgery were extracted.

Results

Among, White, Black, Asian, Pacific Islanders, Native Americans, and Hispanic patients of the United States the Asians (p = 0.018) and Blacks (p = 0.003) had increased operative time for parathyroid surgery compared to other groups. Hispanics had the most surgical complications (p = 0.025). Blacks had statistically significant longer hospital stay (p < 0.0001).

Discussion/conclusion

United States Asian patient data is not typically analyzed separately for complications. We found that in the United States Asians have increased operative time for parathyroidectomy. Future studies of healthcare inequities should include analysis of data for Asian surgical data in the United States as this may help prevent future surgical complications.

Racial Disparities in Tympanoplasty Surgery: A 30-Day Morbidity and Mortality National Cohort Study

OBJECTIVES

To assess the impact of race and ethnicity on 30-day complications after tympanoplasty surgery.

METHODS

The National Surgical Quality Improvement Program database was queried for tympanoplasty procedures from 2005 to 2019. Demographic, comorbidity, and postoperative complication data were compared according to race using univariate and binary logistic regression analyses.

RESULTS

A total of 11,701 patients were included, consisting of 80.3% White, 3.0% Black, 7.7% Asian, 5.7% Hispanic, 2.5% American Indian/Alaska Native, and 0.8% other. Binary logistic regression model indicated that Black patients had increased odds of unplanned readmittance (p = 0.033; odds ratio [OR], 3.110) and deep surgical site infections (p = 0.008; OR, 6.292). American Indian/Alaska Native patients had increased odds of reoperation (p = 0.022; OR, 6.343), superficial surgical site infections (p < 0.001; OR, 5.503), urinary tract infections (p < 0.001; OR, 18.559), surgical complications (p < 0.001; OR, 3.820), medical complications (p = 0.001; OR, 10.126), and overall complications (p < 0.001; OR, 4.545).

CONCLUSION

Although Black and American Indian/Alaskan Native patients were more likely to have complications after tympanoplasty surgery after adjusting for comorbidities, age, and sex, these results are tempered by an overall low rate of complications. Future studies should be devoted to understanding the drivers of these health inequities in access to otologic care and surgical treatment to improve outcomes and achieve equitable care.

Disparities in Thyroid Care

Thyroid disease affects an estimated 20 million Americans, with 1 in 8 women developing a thyroid disorder during her lifetime. Although most patients with thyroid cancer have a good prognosis and effective treatments for benign thyroid disease are available, disparities exist in thyroid care and result in worse outcomes for racial and ethnic minorities. Inequities in the diagnosis and treatment of thyroid disease are due to the complex interplay of systems-, physician-, and patient-level factors. Thus, innovative strategies that take an ecological approach to addressing racial disparities are needed to achieve equitable care for all patients with thyroid disease.

Thyroidectomy for Graves' Disease Predicts Postoperative Neck Hematoma and Hypocalcemia: A North American cohort study

Objective:

Examine the association of Graves’ disease with the development of postoperative neck hematoma.

Design:

A cohort of patients participating in the Thyroid Procedure-Targeted Database of the National Surgical Quality Improvement Program from January 1, 2016 to December 31, 2018.

Setting:

A North American surgical cohort study.

Methods:

17 906 patients who underwent thyroidectomy were included. Propensity score matching was performed to adjust for differences in baseline covariates. Multivariate logistic regression was used to ascertain the association between thyroidectomy for Graves’ disease and risk of postoperative adverse events within 30 days of surgery. The primary outcome was postoperative hematoma. Secondary outcomes were postoperative hypocalcemia and recurrent laryngeal nerve injury.

Results:

One-to-three propensity score matching yielded 1207 patients with mean age (SD) of 42.6 (14.9) years and 1017 (84.3%) female in the group with Graves’ disease and 3621 patients with mean age (SD) of 46.7 (15.0%) years and 2998 (82.8%) female in the group with indications other than Graves’ disease for thyroidectomy. The cumulative 30-day incidence of postoperative hematoma was 3.1% (38/1207) in the Graves’ disease group and 1.9% (70/3621) in other patients. The matched cohort showed that Graves’ disease was associated with higher odds of postoperative hematoma (OR 1.65, 95% CI 1.10-2.46) and hypocalcemia (OR 2.04, 95% CI 1.66-2.50) compared with other indications for thyroid surgery. There was no difference in recurrent laryngeal nerve injury among the 2 groups.

Conclusions:

Patients with Graves’ disease undergoing thyroidectomy are more likely to suffer from postoperative hematoma and hypocalcemia compared to patients undergoing surgery for other indications.