Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors

Outcomes After Damage Control Laparotomy Among White, American Indian, and Alaska Native Populations

BackgroundAmerican Indian and Alaska Native (AIAN) populations have been shown to have severe health disparities, with increased 30-day mortality rates and surgical complications. They continue to represent a population that has the worst outcomes, however, still underrepresented within the medical literature. Further research into AIAN is critical to start to determine why these differences exist.MethodsA retrospective review of patients undergoing damage control laparotomies (DCLs) between 2015 and 2024 was conducted. Logistic regression was used to compare variables (age, race, gender, ASA, APACHE II, ICU admission, ventilation, number of operations, and time until abdominal closure).ResultsA total of 502 patients were included in the analysis. 10% of these were AIAN. The AIANs undergoing DCL had a mean age of 47.5 years, whereas White patients had a mean age of 62.1 years (P < 0.0001). There were no statistically significant differences in mortality rates. Non-mortality complications were equally distributed between the 2 groups. Logistic regression analysis identified age, APACHE II score, and procedure count as significant predictors of mortality.ConclusionsAmerican Indians are presenting at notably younger ages compared to their White counterparts (62 vs 48 years old). Despite comparable outcomes between the groups, this highlights a distinct age-related gap within our AIAN population, underscoring the necessity for heightened care in this specific patient demographic.

Racial and ethnic disparities in conversion to mastectomy following lumpectomy

PURPOSE

Advances in contemporary breast cancer care (e.g., early detection, increased use of preoperative chemotherapy, and updated SSO-ASTRO margin guidelines) have the collective potential to influence successful breast conservation. We evaluated contemporary trends in conversion to mastectomy (lumpectomy followed by definitive mastectomy) among women with breast cancer undergoing initial lumpectomy.

METHODS

Women with unilateral clinical stage 0-III breast cancer were identified from the National Cancer Database (2009-2019). Treatment sequence was categorized into surgery first or neoadjuvant chemotherapy (NACT) followed by surgery. We used a multivariable logistic regression model to calculate the predicted probability of conversion to mastectomy across diagnosis year and race and ethnicity, controlling for socio-demographic and clinical factors. We then calculated the relative change in conversion to mastectomy over time for each race and ethnic group.

RESULTS

The study included N = 1,543,702 women. Approximately 9.2% received NACT. Conversion to mastectomy differed significantly between those who underwent surgery first (10.6%) versus women who received NACT (6.1%, p < 0.0001). For those who underwent surgery first, success of breast conservation differed significantly by race/ethnicity. During the study period, White women had a relative decrease of 7.6% (95% CI - 10.58, - 4.59), while Black women had a relative increase of 8.9% (95% CI 1.53, 16.19) in predicted probability of conversion to mastectomy.

CONCLUSION

Over the past decade, Black women deemed candidates for initial lumpectomy were more likely to be converted to mastectomy when compared to White women. A greater understanding of contributing factors is needed to improve disparities in successful breast conservation.

The importance of multiculturalism in medical education: a global comparison of perspectives from medical and health professions students at 21 universities

Objectives

This study aims to quantitatively assess the baseline level of self-perceived cultural competency preparedness and skillfulness among medical and health professions students from 21 universities around the world utilizing a previously validated and standardized testing tool.

Design

Cross-sectional study.

Setting

The International Collaboration and Exchange Program (ICEP), a global exchange initiative for junior medical and health professions students spanning 21 universities across four continents.

Participants

A total of 753 students from the 2021 and 2022 ICEP cohorts.

Main Outcome Measures

Students self-evaluated their cultural competency skills on a 5-point Likert-type scale encompassing different areas of competency. Multiple linear regression was performed to identify contributors to cultural competency levels.

Results

Upon rating how skillful they are at interacting with culturally diverse patients, North American students reported the highest scores with a mean of 3.22, while Australian students showed the lowest score of 2.82. When analyzing students' stages of study, those in clinical years of medical schools scored the highest at 3.29. Significant variations were observed in the cultural competency self-rating scores among students based on their respective regions (p < .005) and program types/stages (p < .05). Notably, students in their clinical years of school consistently rated themselves higher compared to their preclinical counterparts (p < .05). Furthermore, students from Europe displayed elevated self-ratings compared to the other regions (p < .005).

Conclusions

Though these participants represent a highly motivated subgroup of students, potentially limiting result generalizability, the findings emphasize that regional differences exist. Given the multifaceted nature of cultural competency, the results suggest that factors such as educational stage, age, and region may influence students' perceived competency levels.

Demographic Factors Associated with Postoperative Complications in Primary Bariatric Surgery: A Rapid Review

BACKGROUND

Bariatric surgery is highly effective for the management of severe obesity, but its safety profile is not completely understood. This review aimed to synthesise evidence linking demographic factors to postoperative complications and mortality following primary bariatric surgery.

METHODS

We searched Medline for observational studies of adult patients linking demographic factors to postoperative complications of primary bariatric surgery published from 2017 to 2022. Risk ratios (RR) with 95% confidence intervals (95% CI) were calculated and pooled using random effect meta-analysis. Heterogeneity was quantified using the I2 statistic and tested for statistical significance using the Q-statistic. Sensitivity analyses were used to explore potential sources of heterogeneity.

RESULTS

A total of 71 observational studies (69 cohort, 2 case-control) were reviewed and appraised. Older age was consistently associated with increased risks of postoperative mortality (RR = 2.62, 95% CI 1.63-4.23, I2 = 42.04%), serious complications (RR = 1.76, 95% CI 1.09-2.82, I2 = 93.24%), anastomotic leak (RR = 1.64, 95% CI 1.04-2.58, I2 = 61.09%), and haemorrhage (RR = 1.44, 95% CI 1.07-1.94, I2 = 45.25%). Male sex was associated with increased anastomotic leak (RR = 1.39, 95% CI 1.04-1.87, I2 = 72.36%). Sensitivity analyses did not identify sources of bias. Socioeconomic factors, including Black/African American race, low financial status, and marital status (mixed results), were linked to higher complication risks in some studies.

CONCLUSIONS

Older age and certain demographic factors (male sex, Black/African American race, low financial status, marital status) were associated with increased risks of postoperative complications following primary bariatric surgery.

Epidemiology and disparities of gender-affirming surgery in the United States

BACKGROUND

Several advances have been made to increase access to gender-affirming procedures across the country, yet it remains unknown whether these benefits are experienced disproportionately across demographics. The purpose of this study was to investigate the epidemiologic trends of gender-affirming surgery across the country over the past six years, as well as to analyze the racial and ethnic disparities in immediate postoperative complications for patients undergoing gender-affirming surgery nationwide.

METHODS

Retrospective cohort study was conducted of gender-affirming procedures performed in the United States between 2015 and 2020 across 719 hospitals participating in the National Surgical Quality Improvement Program. Age at surgery, type of reconstruction, and postoperative complications were compared across demographic groups.

RESULTS

During the study interval, 4491 patients underwent gender-affirming surgery, including 71.1% (n=3221) masculinizing procedures and 28.3% (n=1270) feminizing procedures. Over the last five years, there has been a fourfold increase in gender-affirming surgery, from 299 per million to 1029 per million cases performed in the United States (p<.001). Transmasculine patients were ten years younger than transfeminine patients (p<.001). While masculinizing procedures were the most common across all demographics, Black and Hispanic patients were significantly more likely to undergo feminizing procedures than White patients (p<.001). Black patients were significantly older than White patients at the time of surgery. Black patients were significantly more likely than White patients to experience postoperative surgical complications (p=.039).

CONCLUSIONS

Racial and ethnic disparities exist in gender-affirming surgery preference, timing, and postoperative outcomes.

Study protocol for investigating racial disparities in pain care: a comprehensive integration of patient-level and provider-level mechanisms with dyadic communication processes using a mixed-methods research design

INTRODUCTION

Although many efforts have been made to reduce racial pain disparities over decades, the pain of black patients is still undertreated. Previous work has identified a host of patient and provider factors that contribute to racial disparities in healthcare in general, and consequently, may contribute to disparities in pain care in particular. That said, there has been limited clinically meaningful progress in eliminating these disparities. This lack of progress is likely because prior research has investigated the influence of patient and provider factors in isolation, rather than examining their interaction. Successful pain care requires constructive patient-provider communication, and constructive communication is both dyadic and dynamic. One well-accepted operationalisation of such dyadic processes is behavioural coordination. We hypothesise that the pain of black patients continues to be undertreated because black patients are more likely than white patients to participate in racially discordant medical interactions (ie, seeing other-race providers) and experience disruptions in behavioural coordination. We further hypothesise that disruptions in behavioural coordination will reflect patient and provider factors identified in prior research. We propose to test these hypotheses in the planned surgical context.

METHODS AND ANALYSIS

Using a convergent mixed methods research design, we will collect data from at least 15 surgeons and their 150 patients (approximately equal number of black and white patients per surgeon). The data sources will include one surgeon survey, four patient surveys, video- and/or audio-recordings of preoperative consultations and medical chart reviews. The recorded preoperative consultations will be analysed both qualitatively and quantitatively to assess the magnitude and pattern of behavioural coordination between patients and surgeons. Those data will be linked to survey data and data from medical chart reviews to test our hypotheses.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Virginia Commonwealth University Institutional Review Board (HM20023574). Findings will be disseminated through presentations at scientific conferences, publications in peer-reviewed journals and speaking engagements with clinician stakeholders. We will also share the main findings from this project with patients via a newsletter on completion of the entire project.

Racial disparities in anterior cervical discectomy and fusion: an analysis of 67,621 patients

BACKGROUND CONTEXT

Racial disparities have been demonstrated in the analysis of perioperative outcomes in minority populations in the field of spine surgery when compared to nonminorities. However, there are limited studies investigating the role of racial disparities in cervical spine surgery in a recent, large patient sample.

PURPOSE

We assessed race and ethnicity as an independent risk factor in outcome disparities following anterior cervical discectomy and fusion (ACDF) among Black or African American (AA), Asian or Pacific Islander (AP), Hispanic (HA), and Native American or Alaska Native (NA) patients compared to White or Caucasian (CA) patients.

STUDY DESIGN/SETTING

A retrospective cohort, large multicenter database study.

PATIENT SAMPLE

The American College of Surgeons National Surgical Quality Improvement Program database was queried for ACDFs from 2011 to 2021 by Common Procedural Terminology codes (22551, 22552, 22585, and 22554). Patients were categorized into five cohorts based on race and ethnicity: Asian American or Pacific Islander, Black or African American, Hispanic, Native American or Alaskan Native, and White or Caucasian.

OUTCOME MEASURES

The outcome measures for this study were surgical complications, perioperative, and postoperative outcomes within 30-days postoperative.

METHODS

Baseline characteristics were analyzed using analysis of variance (ANOVA) for continuous variables or chi-squared test for categorical variables with Bonferroni correction. Controlling for racial demographic and comorbidity differences via model selection by Akaike information criterion by backward stepwise regression, race and ethnicity were isolated as possible independent risk factors for short-term patient outcomes.

RESULTS

67621 patients (54679 CA, 7358 AA, 1429 AP, 399 NA, and 3756 HA) were included in this study. AA race was an independent risk factor for medical complications (OR: 1.330, 95% CI [1.137-1.549], p < .001), operative time (β: 12.162 minutes, 95% CI [10.565-13.758], p < .001), length of stay (β: 0.514 days, 95% CI [0.431-0.597], p < .001), postoperative discharge time (β: 0.439 days, 95% CI [0.388-0.491], p < 0.001), 30-day reoperation (OR: 1.379, 95% CI [1.142-1.654], p < .001), and a nonhome discharge destination (OR: 2.256, 95% CI [2.022-2.514], p < .001). AP race was an independent risk factor for operative time (β: 14.293 minutes, 95% CI [10.854-17.732], p < .001). HA ethnicity was an independent risk factor for a nonhome discharge destination (OR: 1.395, 95% CI [1.171-1.652], p < .001).

CONCLUSIONS

Compared to CA patients, AA, AP, HA, and NA ACDF patients experience greater comorbidity burden and/or unfavorable 30-day surgical outcomes. These findings support the need for the exploration of interdisciplinary care focused on addressing known causes of disparities in minority patients. Future studies should account for social determinants of health by race and ethnicity to identify additional factors that may contribute to higher rates of complications.

Patient-surgeon racial and ethnic concordance and outcomes of older adults operated on by California licensed surgeons: an observational study

OBJECTIVE

To examine the association of patient-surgeon racial and ethnic concordance with postoperative outcomes among older adults treated by surgeons with California medical licences.

DESIGN

Retrospective cohort study.

SETTING

US acute care and critical access hospitals in 2016-2019.

PARTICIPANTS

100% Medicare fee-for-service beneficiaries aged 65-99 years who underwent one of 14 common surgical procedures (abdominal aortic aneurysm repair, appendectomy, coronary artery bypass grafting, cholecystectomy, colectomy, cystectomy, hip replacement, hysterectomy, knee replacement, laminectomy, liver resection, lung resection, prostatectomy and thyroidectomy), who were operated on by surgeons with self-reported race and ethnicity (21.4% of surgeons) in the Medical Board of California database. We focused our primary analysis on black and Hispanic beneficiaries.

PRIMARY OUTCOMES MEASURE

The outcomes assessed included (1) patient postoperative 30-day mortality, defined as death within 30 days after surgery including during the index hospitalisation, (2) 30-day readmission and (3) length of stay. We adjusted for patient, physician and hospital characteristics.

RESULTS

Among 1858 black and 4146 Hispanic patients treated by 746 unique surgeons (67 black, 98 Hispanic and 590 white surgeons; includes surgeons who selected multiple backgrounds), 977 (16.3%) patients were treated by a racially or ethnically concordant surgeon. Hispanic patients treated by concordant surgeons had lower 30-day readmission (adjusted readmission rate, 4.2% for concordant vs 6.6% for discordant dyad; adjusted risk difference, -2.4 percentage points (pp); 95% CI, -4.3 to -0.5 pp; p=0.014) and length of stay (adjusted length of stay, 4.1 d vs 4.6 days (d); adjusted difference, -0.5 d; 95% CI, -0.8 to -0.2 d; p=0.003) than those treated by discordant surgeons. We found no evidence that patient-surgeon racial and ethnic concordance was associated with surgical outcomes among black patients or mortality among Hispanic patients.

CONCLUSIONS

Patient-surgeon racial and ethnic concordance was associated with a lower postoperative readmission rate and length of stay for Hispanic patients. Increasing Hispanic surgeon representation may contribute to narrowing of racial and ethnic disparities in surgical outcomes.

Black-vs-white racial disparities in 30-day outcomes following primary and revisional metabolic and bariatric surgery: a MBSAQIP database analysis

BACKGROUND

Previous studies have demonstrated Black-vs-White disparities in postoperative outcomes following primary metabolic and bariatric surgery (MBS). With the rising prevalence of MBS, it is important to examine racial disparities using quality indicators in primary and revisional procedures. This study explores Black-vs-White disparities in postoperative outcomes following primary and revisional MBS.

METHODS

We performed an observational cohort study using the 2015-2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database of adults who underwent primary or revisional Roux-en-Y gastric bypass, sleeve gastrectomy, duodenal switch, or one-anastomosis gastric bypass. Black and White patients were 1:1 matched using propensity scores across 19 covariates for primary and revisional MBS groups. McNemar's tests were used to compare 11 postoperative outcomes from the MBSAQIP semi-annual report and death, between matched cohorts.

RESULTS

We identified 112,495 Black and 434,266 White primary MBS and 10,838 Black and 37,075 White revisional MBS patients. A total of 219,114 primary and 21,314 revisional patients were matched. Following primary MBS, Black patients had higher rates of death (0.1% vs. 0.06%, p < 0.001), all occurrences morbidity (5.6% vs. 4.7%, p < 0.001), serious events (2.2% vs. 1.9%, p < 0.001), and all cause and related reoperations (1.2% vs. 1.1%, p = 0.006; 0.2% vs. 0.1%, p = 0.01), readmissions (4.6% vs. 3.4%, p < 0.001; 2.8% vs. 1.9%, p < 0.001), and interventions (1.4% vs. 1.1%, p < 0.001; 0.8% vs. 0.6%, p < 0.001) compared to White patients. In contrast, there were no significant Black-vs-White disparities in death, morbidity, serious events, reoperations, interventions, and bleeding following revisional MBS. Interestingly, Black patients had higher rates of all cause and related readmissions (7.4% vs. 6.2%, p = 0.005; 4.4% vs. 3.6%, p = 0.01), but lower surgical site infection rates (1.6% vs. 2.1%, p = 0.04).

CONCLUSIONS

Our findings demonstrate a measurable contrast between racial disparities in postoperative outcomes following primary and revisional MBS. Equity-focused measures in national MBS assessments are needed to elucidate and address these disparities.

Differences in Surgical Cancer Care Delivery and Outcomes Between Safety-Net and Non-Safety-Net Hospitals in the United States: A Comprehensive Systematic Review

BACKGROUND

Studies evaluating the association of safety-net hospitals (SNHs) with outcomes of surgical care in cancer patients have demonstrated mixed results. We sought to systematically investigate the association of SNH status with measures of surgical cancer care delivery and outcomes.

METHODS

A comprehensive review of the literature identified from the MEDLINE/PubMed, Embase, Web of Science, and Cochrane databases was performed according to the PRISMA guidelines. Risk of bias assessment was conducted using the Joanna Briggs Institute's tool. The findings were synthesized qualitatively.

RESULTS

Of the 1749 records identified, 33 retrospective studies were included, 79% of which investigated national databases. Risk of bias assessment revealed average score of 78%. Among studies assessing each outcome, lower likelihood of receiving appropriate surgical interventions in SNH patients was reported by 85%; longer intervals to surgery by 100%; and prolonged hospital stays by 73%. Most studies reported no differences in survival (65%) or readmission (67%). Results were mixed regarding complications and mortality. Patient characteristics and shortage of resources and interdisciplinary teams were frequently proposed factors for observed disparities.

CONCLUSIONS

Cancer patients at SNHs may be less likely to undergo some surgical treatments and experience longer intervals to treatment but achieve largely comparable short- and long-term outcomes to non-SNH patients.

A National Analysis of Targeted Muscle Reinnervation following Major Upper Extremity Amputation

BACKGROUND

Postamputation pain is a debilitating sequela of upper extremity (UE) amputation. Targeted muscle reinnervation (TMR) is a relatively novel treatment that can help prevent pain and improve quality of life. The purpose of this study was to evaluate national trends in the application of immediate TMR following UE amputations.

METHODS

An analysis of the Nationwide Inpatient Sample database was conducted from 2016 to 2019. International Classification of Diseases, 10th Revision, codes were used to identify encounters involving UE amputation with and without TMR. Nationwide Inpatient Sample weights were used to estimate national estimates of incidence. Patient-specific and hospital-specific factors were analyzed to assess associations with use of TMR.

RESULTS

A total of 8945 weighted encounters underwent UE amputation, and of those, only 310 (3.5%) received TMR. The majority of TMR occurred in urban hospitals (>95%). Younger patients (47 years versus 54 years; P = 0.008) and patients located in New England were significantly more likely to undergo TMR. There was no difference in total cost of hospitalization among patients who underwent TMR ($55,241.0 versus $59,027.8; P = 0.683) but significantly shorter lengths of hospital stay when undergoing TMR versus other management (10.6 days versus 14.8 days; P = 0.012).

CONCLUSIONS

TMR has purported benefits of pain reduction, neuroma prevention, and increased prosthetic control. Access to this beneficial procedure following UE amputation varies by demographics and geographic region. Given that TMR has not been shown to increase cost while simultaneously decreasing patient length of stay, increased efforts to incorporate this procedure into training and practice will help to ensure equitable care for amputation patients.

Impact of Race and Social Determinants on Operative Management of Distal Radius Fractures in Medicare Patients

Background

Operative fixation of distal radius fractures (DRFs) in high-demand patients may provide functional benefit, particularly in the setting of significant displacement. Whether social determinants of health (SDOH) and race impact treatment remain unclear. The purpose of this study was to determine whether adverse SDOH modifiers and race are independent predictors of surgical intervention for DRF.

Methods

A retrospective analysis was conducted using the Medicare Standard Analytical Files of the PearlDiver database of patients with a DRF from 2007 to 2016. Univariate and multivariable regression analyses were performed to observe whether race and adverse SDOH variables were independent predictors of undergoing open reduction internal fixation (ORIF) within 3 weeks of a new diagnosis of DRF after controlling for age and fracture type.

Results

The average patient age was 76.3 years. A total of 10,697 (13.1%) patients underwent ORIF. Patients who underwent ORIF were less likely to have negative economic and social modifiers of SDOH and had lower odds of being non-White. Patients who underwent surgery also had higher odds of being younger, White, female, and having a type III open fracture.

Conclusions

In the Medicare population, non-White race and adverse economic and social modifiers of SDOH were independent predictors of undergoing nonoperative treatment of DRF after controlling for age and fracture type. Future studies are needed to further elucidate the nuanced effects of race and SDOH on the management of DRFs.

Outcomes of Trabeculectomy and Predictors of Success in Patients of African Ancestry With Primary Open Angle Glaucoma

PRCIS

Trabeculectomy in African ancestry individuals with primary open angle glaucoma (POAG) shows a 46% success rate and frequent complications, indicating that younger age and family history are significant predictors of surgical failure in this high-risk population.

OBJECTIVE

To investigate outcomes of trabeculectomy ab externo in African ancestry POAG patients and to analyze the impact of demographic and phenotypic factors on surgical success and complication rates.

PATIENTS AND METHODS

A retrospective case-control study enrolled 63 eyes of 55 POAG cases who underwent trabeculectomy ab externo. Data on demographics, family glaucoma history, surgical specifics, and pre/postoperative measures (intraocular pressure, visual acuity, visual field, medication usage, complications within 1 year) were collected. The analysis included linear/logistic regression models adjusting for inter-eye correlation.

RESULTS

Trabeculectomy yielded success without additional medication in 46%, qualified success with medication in 22%, and surgical failure necessitating further intervention in 32% within 1 year. Subjects experienced a reduction in intraocular pressure (IOP) (46%), daily glaucoma medication (73%), and eye drop usage (67%) 1-year post-trabeculectomy (all P <0.001). However, there was a postoperative decline of 56% in visual acuity (VA) ( P <0.001) and a significant worsening of visual field parameters, including a 14% decrease in mean deviation ( P =0.02) and a 19% decrease in visual field index ( P =0.004). Fifty-nine percent of patient eyes experienced complications within 1 year of surgery. Univariate analysis of predictive factors for surgical outcomes revealed that younger age at surgery ( P =0.01) and family history of glaucoma ( P =0.046) were predictive of lower rates of surgical success. Multivariable analysis revealed worse preoperative VA (OR: 0.79 per 0.1 LogMAR increases, P =0.02) was associated with a lower likelihood of surgical success.

CONCLUSION

This study underscores the low rates of trabeculectomy success and high rates of complications in an African ancestry population with POAG. While the procedure exhibited positive effects on IOP control and medication reduction, our analysis found that multiple factors, particularly age, family history, and worse preoperative VA play crucial roles in influencing surgical success.

Lower Extremity Penetrating Trauma Care Associated With Race and Income in the United States of America

INTRODUCTION

For lower extremity penetrating traumas (LEPT), the impact of race and insurance status, as a surrogate of socioeconomic status, is still not fully elucidated. This study aims to explore the relationship between these variables and the likelihood of receiving an amputation for LEPT to further identify disparities in trauma care.

METHODS

We analyzed the 2017-2019 Trauma Quality Improvement Program databases to identify patients with LEPT. Univariate analysis of various patient factors was performed for mortality. Linear and logistic multivariate regressions were then conducted for the primary and secondary outcomes using significant variables from the univariate analysis. Finally, multivariate logistic regression identified associations between race, ethnicity, primary payor, and amputation rates.

RESULTS

The independent factors significantly linked to amputation included Black race (odds ratio (OR) 0.745, P < 0.001), Medicare (OR 0.557, P < 0.001), Medicaid (OR 0.697, P < 0.001), and uninsured status (OR 0.661, P < 0.001). We additionally evaluated the incidence of death among the penetrating trauma victims and determined that male (OR 2.008, P < 0.001), Black (OR 1.801, P = 0.001), and uninsured patients (OR 1.910, P = 0.003) were more likely to die during admission than the privately insured.

CONCLUSIONS

Compared to privately insured victims, uninsured patients and those on Medicaid and Medicare experience lower amputation rates post-LEPT. Black patients were found to have not only a decreased likelihood of receiving an amputation following LEPT but also an increased rate of mortality during admission compared to Caucasian victims. These findings underscore the urgency to address institutional barriers hindering vulnerable populations from accessing appropriate care after trauma.

Voting Trends Among Otolaryngology-Head and Neck Surgery Trainees

Objective

Health policies affect clinical practice and outcomes, serving as an impetus for civic engagement. Voting participation among Otolaryngology-Head and Neck Surgery (OHNS) trainees is poorly characterized and may be afflicted by distinct barriers specific to training. This is the first study to evaluate voter participation among OHNS trainees.

Methods

We analyzed survey data from the 2020 American Academy of Otolaryngology Section for Residents and Fellows (AAO SRF), capturing voting practices among trainees as well as attitudes to promoting electoral participation among programs. Wilcoxon rank-sum test was used to assess statistical differences by voting practices.

Results

20.9% of 277 respondents experienced decreased electoral participation since starting residency. These rates did not vary significantly by trainees' subjective views on the importance of voting (p = 0.69, 95% CI = [-184, 23]). While 84.6% (226 out of 267) of eligible trainees voted in the 2016 election, eligible nonvoters most frequently cited reasons such as lack of time and perceived lack of impact. Additionally, the greatest proportion of trainees voted on election day (42.6%), followed by mail-in/absentee ballot (24.2%), and finally by early voting (14.8%). Trainees reported a wide range of attendings (71.5% responded ≤ 2 attendings) who explicitly advocated for trainee voting participation. Greater attending support was concordant with trainees' overall voting (p = 0.057, 95% CI = [-6, 84]) and voting in the 2016 election (p = 0.042, 95%. CI = [-95, 0]). Even if excused from clinical duties, 10.5% of respondents stated they would not leave work to vote due to guilt of being away from clinical duties, and 27.8% of respondents would do so reluctantly. These different practices among trainees did not significantly vary with overall voting participation (p = 0.20, 95% CI = [-8, 124]) or 2016 electoral participation (p = 0.20, 95% CI = [-136, 1]).

Conclusion

Voting participation among OHNS trainees is higher than the national average of adults but slightly lower than other medical specialties. Training program culture can mitigate barriers to electoral participation.

Level of Evidence

NA.

Understanding the impact of racism on surgical outcomes in settler nation-states USA and Canada: a protocol for a systematic review and meta-analysis

INTRODUCTION

To improve surgical quality and safety, health systems must prioritise equitable care for surgical patients. Racialised patients experience worse postoperative outcomes when compared with non-racialised surgical patients in settler colonial nation-states. Identifying preventable adverse outcomes for equity-deserving patient populations is an important starting point to begin to address these gaps in care. To derive literature-based estimates of the outcome gap for racialised surgical patients, we will systematically review and meta-analyse rates of adverse postoperative events associated with common and/or high-risk operations performed in Canada and the USA.

METHODS AND ANALYSIS

An electronic search of Medline, Embase, Web of Science, Cochrane Central, CINAHL and Scopus will be conducted to identify studies reviewing complication rates of racialised compared with non-racialised patients from inception to December 2023. We will include publications from the USA and Canada comparing surgical outcomes of racialised and non-racialised patients. The procedures of interest will be the four most common (hip arthroplasty, knee arthroplasty, appendectomy and cholecystectomy), and the five highest risk (oesophagectomy, abdominal aortic aneurysm, aortic valve replacement, coronary artery bypass graft and pancreatectomy) surgical procedures performed in these countries. The outcomes will be mortality, length of stay in hospital, readmission, reoperation, wound dehiscence, surgical site infection, pulmonary embolism, sepsis or septic shock, pneumonia, blood transfusion, stroke, myocardial infarction and bile duct injury. Summary estimates of cumulative incidence, prevalence, incidence rate and occurrence rate of complications using DerSimonian and Laird random effects models will be calculated for the systematic review and meta-analysis. Heterogeneity in these estimates will be examined using subgroup analyses and meta-regression.

ETHICS AND DISSEMINATION

This study uses secondary data and, therefore, does not require ethics approval. This study will be communicated through presentations at international conferences and published in peer-reviewed literature. The results from this study will inform the development of future surgical equity tools and quality improvement programmes and provide benchmarks on the impact of racism on surgical outcomes.

PROSPERO REGISTRATION NUMBER

CRD42024491439.

Enhancing culturally responsive care in perioperative settings for older adult patients: A qualitative interview study

BACKGROUND

Older adults aged over 65 are increasingly admitted to hospital for acute care reasons, including surgical procedures. In multicultural societies, the diversity of an ageing population has significant implications for the planning and delivery of culturally responsive perioperative care for older adults from ethnically diverse backgrounds, who are admitted to hospital for surgical intervention.

OBJECTIVE

To explore the perspectives and experiences of perioperative staff when caring for older adult patients from ethnically diverse backgrounds.

DESIGN

Exploratory qualitative methodology.

SETTING(S)

Staff working in Australian perioperative care settings were recruited for semi-structured interviews.

PARTICIPANTS

Purposive sampling was used to recruit 15 perioperative staff members, who had experience with caring for older adult patients from ethnically diverse backgrounds during their surgical procedure.

METHODS

Individual, semi-structured interviews were conducted with perioperative staff. Reflexive thematic analysis was used to identify key themes.

RESULTS

Two themes were identified. These were 'Organisational barriers in delivering safe and culturally responsive care', and 'Staff experiences in navigating the challenges of providing culturally responsive care'. Staff reported that safety protocols often overshadowed patient-specific needs, especially for patients requiring additional linguistic or cultural support. The lack of formal interpreter services and the pressure to meet efficiency targets were cited as major barriers to delivering culturally responsive care.

CONCLUSIONS

Delivering culturally responsive care in the fast-paced, high-risk environment of the operating theatre presents complex challenges, as perioperative staff must navigate competing priorities of patient safety, organisational efficiency, and cultural nuances. This article highlights how the emphasis on efficiency can compromise culturally responsive care for older adults, with staff often frustrated by the lack of formalised organisational support, especially those for facilitating effective communication. Current approaches tend to treat cultural care as an "add-on" rather than integrating it into perioperative safety measures. A shift towards pre-emptive planning, with an organisational culture change that embeds culturally responsive care into the broader safety framework, is essential. This proactive approach would enhance both patient outcomes and staff readiness, fostering a perioperative environment where safety and cultural care are synonymous.

TWEETABLE ABSTRACT

Embedding culturally responsive care into safety protocols is essential for enhancing perioperative experiences among older migrant patients.

Demystifying delays: Factors associated with timely treatment of adrenocortical carcinoma

BACKGROUND

Delays in management of adrenocortical carcinoma (ACC) may lead to worse outcomes. We assessed for delays in ACC treatment according to sociodemographic factors.

METHODS

We performed a retrospective cohort study of patients treated for ACC (2010-2019) utilizing the National Cancer Database. Cox proportional hazards modeling was used to evaluate the associations between sociodemographic, geographic, and clinical factors and time to intervention from diagnosis.

RESULTS

Across 1399 subjects treated for ACC, the median time to treatment was 27 days (IQR 15-47). Non-Hispanic Black patients (HR 0.798, p ​= ​0.033) and patients aged 40-64 years (HR 0.800, p ​= ​0.008) were at greater risk of delays in care, whereas female patients (HR 1.169, p ​= ​0.011) and those with metastatic disease (HR 1.176, p ​= ​0.010) received more timely care.

CONCLUSIONS

Older age, male sex, and Black race were associated with delays in care for ACC though these delays did not translate to worsened overall survival.

Propensity analysis reveals survival disparities between T1a and T1b well-differentiated thyroid cancer based on surgery

Background

With rising well-differentiated thyroid cancer (WDTC) incidence, the appropriate treatment choice remains controversial for T1 tumors <2 cm. This study analyzed differences in surgery refusal and survival outcomes between T1a (<1 cm) and T1b (1-2 cm) WDTC, examining the demographic and clinical characteristics associated with patients who decide to either undergo or refuse recommended surgery.

Methods

We studied 81,664 T1N0M0 WDTC patients in the Surveillance, Epidemiology, and End Results (SEER) registry [2000-2019]. Treatment with surgery (n=81,565) or refusal (n=99) was compared. Propensity score matching balanced groups. Cox models assessed mortality predictors.

Results

Among 81,664 patients, the overall mortality rate was 5.7% (n=4,635 deaths). Refused surgery associated with higher mortality (11.1% vs. 5.7%, P=0.03) and shorter survival times (152.05±7.43 vs. 178.62±0.17 months, P<0.001). Thyroid cancer-specific mortality rates were 2.2% for refused surgery and 0.4% with surgery (P=0.01). Refusing surgery carried over twice the mortality risk [adjusted hazards ratio (aHR) =2.15, 95% confidence interval (CI): 1.01-4.57, P=0.046]. However, for T1b patients, refusing surgery escalated mortality risk over 3-fold (aHR =3.44, 95% CI: 1.43-8.28, P=0.006), yet for T1a patients it showed no increased risk (aHR =0.41, 95% CI: 0.049-3.46, P=0.42). Other independent risk factors for mortality included older age (aHR =6.24 for ≥55 years) and prior malignancy (aHR =2.78).

Conclusions

Our study reveals notable differences in survival and mortality between T1a and T1b WDTC, underscoring the need for subtype-specific, evidence-based treatment guidelines. For T1b patients, surgery remains the standard of care with significant improvements in outcomes. In contrast, select T1a patients may benefit from active surveillance, offering comparable survival rates while potentially enhancing quality of life.

Racial Disparities in the Use of Minimally Invasive Surgery for Gastrointestinal Cancer

INTRODUCTION

Racial disparities in minimally invasive surgery (MIS) utilization across gastrointestinal (GI) cancers are not well characterized. We evaluated racial/ethnic disparities in the use of MIS approaches and associated outcomes.

METHODS

We analyzed a cohort of patients with GI cancer in the National Cancer Database (2010-2020). Multinomial logistic regression was used to evaluate associations between race/ethnicity and approach. Logistic regression was used to assess 30-day readmission and 90-day mortality. Cox regression was used to analyze overall survival. Models were adjusted for demographics, clinical characteristics, cancer factors, and facility features.

RESULTS

Of the 839 398 patients included, 76.9% were White, 11.6% Black, 6.6% Hispanic/Latino, 4.0% Asian, and 0.3% Indigenous. Compared with patients of White race, the odds of robotic surgery were lower for Black (OR 0.89, 95% CI 0.86-0.93) and Indigenous patients (OR 0.72, 95% CI 0.59-0.89), but higher for Hispanic/Latino (OR 1.12, 95% CI 1.08-1.17) and Asian patients (OR 1.27, 95% CI 1.21-1.34). Indigenous patients had higher odds of readmission (OR 1.41, 95% CI 1.23-1.62), 90-day mortality (OR 1.31, 95% CI 1.11-1.54), and worse overall survival (HR 1.11, 95% CI 1.05-1.18).

CONCLUSION

Indigenous and Black patients have lower utilization of minimally invasive approaches and worse outcomes in GI cancer care.

Racial variations in maxillomandibular advancement for obstructive sleep apnea: a systematic review and meta-analysis

PURPOSE

We aimed to explore alterations in polysomnographic, cephalometric, and subjective outcomes amongst different ethnic/racial groups after MMA for OSA.

METHODS

A meta-analysis was performed according to PRISMA reporting guidelines. The COCHRANE Library, CINAHL, PubMed, and Scopus were searched from inception to August 8, 2023. Each measure was weighted according to the number of patients affected. Heterogeneity among studies was assessed using χ2 and I2 statistics with fixed effects (I2 < 50%) and random effects (I2 ≥ 50%).

RESULTS

Twenty studies with a total of 469 patients (n = 257 Caucasians, n = 204 Asians, n = 8 Latinos) with a mean patient age of 40.0 years (range: 18-67; 95% CI: 38.0, 42.1). The mean difference for Caucasians were AHI: -39.6 (95% CI: -55.0, -24.1; p <.001), LSAT: 7.5 (95% CI: 5.7, 9.3; p <.0001), and ESS: -4.5 (95% CI: -5.6, -3.4; p <.0001). The mean difference for Asians were AHI: -42.7 (95% CI -49.3, -36.0; p <.0001), LSAT: 13.8 (95% CI: 10.0, 17.4; p <.0001), and ESS: -6.7 (95% CI: -9.9, -3.5; p <.0001). The mean difference for Latinos were AHI: -21.2 (95 CI%: -37.7, -4.6; p =.01), and ESS: -2.0 (-7.9, 3.9; p =.50). Greater reduction of AHI was seen in Asians vs. Caucasians and Asians vs. Latinos. Lastly, the reduction of ESS was significantly better for Asians vs. Caucasians.

CONCLUSION

The study highlights significant variations in MMA outcomes among different ethnic/racial groups. Asians tend to have more severe OSA preoperatively and experience greater postoperative improvements in AHI, LSAT, and ESS compared to Caucasians.

Using a co-design methodological approach to optimize perioperative nursing care for older adult patients from ethnically diverse backgrounds: a study protocol

This article outlines the use of a co-design methodological approach aimed at optimizing perioperative care experiences for ethnically diverse older adults and their family carers. The research involved three phases. In Phase 1, the foundation was established with the formation of a Core Advisory Group comprising key informants, including health consumers. This initial phase focused on forming relationships and conducting a literature review to inform subsequent stages of the research. Phase 2 progressed to data collection, where a qualitative survey on perioperative experiences was conducted. Semi-structured interviews were held with patients, their family carers, and perioperative staff. Phase 3 advanced the co-design process through a workshop involving patients, family carers, perioperative staff, and key stakeholders. Workshop participants collaborated on potential practice changes, proposing strategies for future clinical implementation. While data analysis and reporting for Phases 2 and 3 are forthcoming, the continued involvement of the Core Advisory Group ensures ongoing consensus-building on health consumer needs. This methodology article adopts a prospective stance, with findings to be presented in subsequent scholarly works. Use of this methodology will help to determine how the use of a co-design approach may impact the development of culturally responsive perioperative nursing care for those from ethnically diverse communities.

Evaluating patient experience with a surgical navigation program for under-resourced patients

BACKGROUND

This study aimed to characterize patient satisfaction with navigators and surgical care accessed through a novel navigation program for under-resourced communities.

METHODS

PSN-I and PSQ-18 questionnaires assessed satisfaction with navigators and care, respectively. Primary outcomes were PSN-I and PSQ-18 scores. Secondary analyses tested associations between satisfaction and patient factors and between PSN-I and PSQ-18 scores.

RESULTS

Of 294 patients contacted, 88 (29.9 ​%) responded. Most were Hispanic/Latinx (76.1 ​%), Spanish-speaking (71.5 ​%), and uninsured (85.2 ​%). Participants were highly satisfied with navigators (mean 38.5, SD 7.6; max. 45) and most care domains except Financial Aspects (mean 3.2, SD 1.0; max. 5) and Accessibility/Convenience (mean 3.5, SD 0.6; max. 5). Higher navigator satisfaction was associated with post-consultation need for surgery (coeff. 5.6, 95 ​% CI[0.9, 10.3]) and increased the odds of care satisfaction (OR 1.1, 95 ​% CI[1.0, 1.2]).

CONCLUSIONS

Patients are satisfied with navigation services-a previously unstudied aspect of this unique surgical equity program.

Acute Care Surgery Model: High Quality Care for Higher Risk Populations

INTRODUCTION

Emergency General Surgery (EGS) represent a wide spectrum of diseases with high complication and mortality rates. Race, insurance, and socioeconomic status have been associated with mortality in EGS patients. Acute care surgery (ACS) models have previously shown improved outcomes for EGS patients. We hypothesized that transition to an ACS model would increase access to care for underserved and higher risk EGS patients in a community hospital, without a change in mortality.

METHODS

This retrospective cohort study included adult EGS patients from 2017 to 2021 with current procedural terminology (CPT) codes of colectomy, small-bowel resection, peptic-ulcer surgery, appendectomy, or cholecystectomy. In July 2020, the hospital transitioned from a traditional model to an ACS model. Patients were analyzed for 42-month before (pre-ACS) and 18-month after (post-ACS) transition. Primary outcome was mortality; secondary outcomes were 30-day postoperative emergency department visits and readmission.

RESULTS

We analyzed 467 pre-ACS and 238 post-ACS patients. After transition, patients were more likely to be Black, older, self-pay, and have higher Elixhauser Comorbidity Index (ECI) scores. Rates of cholecystectomies increased and appendectomies decreased after transition. Adjusting for age, race, and ECI, there were no changes in 30-day all-cause mortality (0.9% versus 2.1%, P = 0.63), length of stay (2.7-days versus 3-days, P = 0.91) and rate of postop emergency department visits (7.5% versus 11.3%, P = 0.16). There was a significant increase in hospital readmission after the ACS transition (5.1 versus 10.5%, P = 0.001, odds ratio 5.3).

CONCLUSIONS

After implementation of an ACS model, we found an increase in EGS patients who were older, Black, underinsured, with higher ECI without change in mortality. Implementation of ACS models at community hospitals may increase access to quality care for underserved and higher risk patient populations.

Hospital Quality and Racial Differences in Outcomes After Genitourinary Cancer Surgery

INTRODUCTION AND OBJECTIVES

Prior work has demonstrated racial disparities in surgical outcomes for solid organ cancers. We sought to assess the relationship between hospital quality and racial disparities in achievement of textbook outcomes among patients undergoing surgery for prostate, kidney, and bladder cancer.

METHODS

We used 100% national Medicare Provider Analysis and Review files from 2017 to 2020 to assess textbook outcomes in Patients undergoing bladder (i.e., radical cystectomy), kidney (i.e., radical or partial nephrectomy), and prostate (i.e., radical prostatectomy) surgery for genitourinary malignancies. Our exposure was hospital-level quality, assessed by the predicted to expected ratio of achievement of textbook outcomes, agnostic to social and economic determinants of health. Our main outcome was achievement of textbook outcomes in White and Black patients. We defined the textbook outcome as the absence of in-hospital mortality, mortality within 30 days of surgery, readmission within 30 days of discharge, a postoperative complication, and prolonged length of stay. The secondary outcome was percentage of Black and White patients treated at the highest quality hospitals.

RESULTS

As hospital quality increased, disparities in the receipt of textbook outcome for White and Black patients narrowed. For every 0.1 increment increase in the predicted to expected ratio of hospital quality, Black-White disparities in the odds of achieving textbook outcomes decreased by 5.7% (interaction OR: 1.06; 95% CI 1.01-1.11 p = 0.026). Black patients were less likely to be treated at the highest quality hospitals compared to White patients (45.2% vs. 49.5% p = < 0.001%).

CONCLUSIONS

Compared to White patients, Black patients had lower odds of textbook outcomes after surgery for prostate, kidney, and bladder cancer. The racial differences in achieving textbook outcomes were narrowed as hospital quality increased. Black patients were less likely than White patients to be treated at the highest-quality hospitals. Our findings underscore the importance of improved access to high quality care among Black patients.

Same-day parathyroidectomy for primary hyperparathyroidism -an over 20-year practice

INTRODUCTION

There has been a shift in recent years toward same-day parathyroidectomies due to the decrease in mutual costs with few significant differences in postoperative morbidity or mortality. We sought to determine if demographics, preoperative patient risk factors, or comorbidities were associated with a patient's likelihood of having same-day or inpatient surgery.

MATERIALS AND METHODS

A prospective database of parathyroid operations from 2001 to 2022 (n = 2948 patients) was reviewed for surgeries completed for primary hyperparathyroidism. Patients were categorized as same-day or inpatient surgery; demographics, risk factors, and co-morbidities were examined and differences across practice patterns during the 21-year period were studied and also analyzed in a subset of patients from 2013 to 2022.

RESULTS

In a recent subset of patients from 2013 to 2022, patients having inpatient surgery were more likely to be Black and use anticoagulation or antiplatelet therapy. Multivariable regression confirmed increased odds of aging and black patients requiring inpatient parathyroidectomy. Compared to 2001-2003, there was a significantly increased proportion of patients undergoing same-day surgery; compared to 2010-2012, there was a similar proportion of patients undergoing outpatient surgery between 2013 and 2018, and there was an increased proportion from 2019 through 2022.

CONCLUSION

Same-day parathyroidectomies have been shown to be safe and has become the typical practice for high-volume parathyroid surgeons over the last decade. Complications such as postoperative hematoma or hypocalcemia were previously shown to be incompletely mitigated by increased LOS or inpatient surgery, although demographics are considered to increase the odds of inpatient parathyroidectomy.

Education, Language, and Cultural Concordance Influence Patient-Physician Communication in Orthopaedics

BACKGROUND

Orthopaedic surgery has a diversity gap, as it is not representative of the racial or sex proportions of the U.S. population. This gap can lead to communication barriers stemming from health literacy, language proficiency, or cultural discordance that may contribute to current health inequities. This study assesses the influence of educational attainment, language, and cultural concordance on patient-physician communication.

METHODS

In this cross-sectional study, 394 patients from an urban orthopaedic clinic were administered a Likert-type survey regarding race or ethnicity, educational level, communication, patient satisfaction, language proficiency, and culture. One-way analysis of variance, chi-square tests, and Welch t tests were used to evaluate responses.

RESULTS

The majority of subjects identified as African-American/Black (50%) or Hispanic/Latino (30%). Completing high school was associated with a better ability of the subjects to communicate with their orthopaedic surgeon (p < 0.001). Hispanic subjects reported lower English proficiency (p < 0.001) and decreased ability to communicate with their physician (p < 0.001) compared with other subjects, with educational attainment influencing their ability to understand their orthopaedic surgeon in English (p < 0.001). African-American and Hispanic patients placed greater importance on orthopaedic surgeons understanding their culture than White patients (p < 0.001). Hispanic patients who saw a language and culture-concordant surgeon valued having a Spanish-speaking surgeon more than Hispanic patients who did not see a concordant surgeon (p = 0.04).

CONCLUSIONS

These results suggest that patient-physician language concordance, particularly in patients with lower education, may be essential to delivering high-quality patient care. Hispanic and African-American patients placed significantly greater importance on their orthopaedic surgeons understanding their culture. Hispanic patients frequently sought care with language-concordant surgeons and placed higher value on physicians understanding their culture. To better serve minority communities, efforts should be made to increase orthopaedic surgeons' cultural humility and to recruit a diverse multilingual surgeon workforce.

CLINICAL RELEVANCE

This research demonstrates that cultural and language concordance, specifically between Hispanic patients and Hispanic, Spanish-speaking surgeons, can significantly enhance patient preference and potentially improve patient satisfaction and outcomes in orthopaedic care. Additionally, it underscores the importance of understanding and addressing the diversity within the field and the patient population to better meet the needs of a multicultural society.

Racial Disparities in Utilization and Outcomes of Cervical Disc Arthroplasty

STUDY DESIGN

Retrospective study.

OBJECTIVE

We examined racial disparities in (1) cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) utilization and (2) CDA in-hospital outcomes.

SUMMARY OF BACKGROUND DATA

ACDF and CDA are established treatments for cervical disc disease. While CDA may offer certain advantages over ACDF, its utilization patterns have not been comprehensively explored.

METHODS

This study of 2012 to 2019 discharges from the National Inpatient Sample included White, Black, and Hispanic patients aged 18 years and older who underwent elective ACDF or CDA. Patient demographics, comorbidities, cervical spine diagnoses, and hospital characteristics were extracted. Survey-weighted logistic regression modeled the adjusted association between race and CDA (vs. ACDF) utilization; an interaction between race and year examined temporal changes in disparities. For CDA outcomes, multivariable logistic regression was used for binary outcomes (nonhome discharge, combined complications, and dysphagia) and linear regression for length of stay.

RESULTS

The cohort included 712,355 weighted procedures (97.6% ACDF; 84.2% White, 9.7% Black, 6.1% Hispanic). CDA utilization increased from 1.0% of the procedures in 2012 to 3.8% in 2019. Black and Hispanic patients had significantly lower odds than White patients of receiving CDA versus ACDF (OR=0.77, 95% CI: 0.66-0.89, P=0.001; OR=0.80, 95% CI: 0.69-0.93, P=0.003) respectively. There was no statistically significant interaction between race and discharge year (P=0.50). For in-hospital CDA-specific outcomes, Black (vs. White) patients were more likely to experience dysphagia (OR=2.70, 95% CI: 1.53-4.78, P=0.001) and combined complications (OR=3.10, 95% CI: 1.91-5.05, P <0.001). There were no significant differences in any CDA outcome for Hispanic versus White patients.

CONCLUSIONS

This study revealed decreased utilization of CDA versus ACDF in minority patients, a pattern that persisted over time despite overall increasing CDA utilization. In addition, a higher burden of dysphagia and combined complications following CDA in Black patients warrants further examination.

LEVEL OF EVIDENCE

III.

A Regional Analysis of Diversity, Equity, and Inclusion Initiatives in Plastic Surgery Residency Programs

Background

Residents seek inclusive training environments that prioritize diversity. To evaluate programs that focus on these elements, websites have become essential for applicants but often lack in diversity, equity, and inclusion (DEI) content. Thus, this study aimed to assess current efforts and attention to DEI within plastic surgery residency programs and compare them by region.

Methods

A retrospective review of Accreditation Council for Graduate Medical Education plastic surgery residency program websites was conducted. Various elements of DEI were identified on each program's page and were compared based on geographic region.

Results

Upon review, 82 residency programs were identified. Of these programs, 40 (48.7%) mentioned at least 1 element of DEI on their website, 38 (46.3%) promoted gender affirmation surgery as a part of their program, 29 (35.4%) mentioned advocacy, and 39 (47.6%) showcased at least 1 publication/presentation about DEI. Between the regions, there was no statistically significant difference in mention of DEI or perceptible representation in leadership. However, there was a significant difference in the mention of gender affirmation surgery, with the Northeast having the most mention (74.1%, P = 0.006). In addition, there was a significant difference in DEI research featured on websites, with the West having the highest rate of features (69.2%, P = 0.019).

Conclusions

This study demonstrates the variance of different aspects of DEI on plastic surgery websites. To foster diverse prospective applicants, plastic surgery residency programs must be aware of these paucities and address them accordingly.

Persistent Racial Disparities in Morbidity Following Major Elective Operations

Introduction: Despite considerable national attention, racial disparities in surgical outcomes persist. We sought to consider whether race-based inequities in outcomes following major elective surgery have improved in the contemporary era. Methods: All adult hospitalization records for elective coronary artery bypass grafting, abdominal aortic aneurysm repair, colectomy, and hip replacement were tabulated from the 2016-2020 National Inpatient Sample. Patients were stratified by Black or White race. To consider the evolution in outcomes, we included an interaction term between race and year. We designated centers in the top quartile of annual procedural volume as high-volume hospitals (HVH). Results: Of ∼2,838,485 patients, 245,405 (8.6%) were of Black race. Following risk-adjustment, Black race was linked with similar odds of in-hospital mortality, but increased likelihood of major complications (Adjusted Odds Ratio [AOR] 1.41, 95%Confidence Interval [CI] 1.36-1.47). From 2016-2020, overall risk-adjusted rates of major complications declined (patients of White race: 9.2% to 8.4%; patients of Black race 11.8% to 10.8%, both P < .001). Yet, the delta in risk of adverse outcomes between patients of White and Black race did not significantly change. Of the cohort, 158,060 (8.4%) were treated at HVH. Following adjustment, Black race remained associated with greater odds of morbidity (AOR 1.37, CI 1.23-1.52; Ref:White). The race-based difference in risk of complications at HVH did not significantly change from 2016 to 2020. Conclusion: While overall rates of complications following major elective procedures declined from 2016 to 2020, patients of Black race faced persistently greater risk of adverse outcomes. Novel interventions are needed to address persistent racial disparities and ensure acceptable outcomes for all patients.

Association of Race and Postoperative Outcomes in Ventral Hernia Repair With Component Separation

INTRODUCTION

Hernia repairs are the most common surgical procedures in the United States, with a significant financial burden primarily attributed to emergent presentations and postsurgery complications. This study aimed to examine race differences on postoperative outcomes.

METHODS

American College of Surgeons National Surgical Quality Improvement Program database was queried to identify ventral hernia repair (VHR) cases from 2016 to 2021, with a subgroup of patients undergoing component separation (CS). Statistical analysis utilized multinomial regression to compare outcomes across racial groups, generating weighted cohorts with balanced covariates to assess differences between groups.

RESULTS

288,515 patients were initially identified. Of these, 120,017 underwent VHR and 8732 VHR with CS. After weighting for the different groups, there were no differences in demographics or comorbidities between the racial groups for both cohorts. When evaluating postoperative complications after VHR, others (American Indian or Alaskan Native, Asian, Native Hawaiian, or Pacific Islander) had the highest rate of organ or space surgical site infection (SSI) (P < 0.001). Hospitalization >30 d was the lowest in Whites (0%), compared to Blacks (1%, P = 0.003) and others (1%, P < 0.001). For patients in the VHR with CS group, significant differences were noted in organ or space SSI (others 8%, P = 0.005), return to the operating room (others 13%, P = 0.015), hospitalizations >30 d (others 4% P = 0.002), and total LOS (others 5 [IQR 3,8], P = 0.004).

CONCLUSIONS

Despite advancements in surgical techniques, racial differences in VHR outcomes persist. These include higher rates of complications such as SSIs, higher rates of return to the operating room, and extended hospital stays among racial groups.

Measuring hospital inpatient Procedure Access Inequality in the United States

Geographic disparities in access to inpatient procedures are a significant issue within the US healthcare system. This study introduces the Procedure Access Inequality (PAI) index, a standardized metric to quantify these disparities while adjusting for disease prevalence. Using data from the Healthcare Cost and Utilization Project State Inpatient Databases, we analyzed inpatient procedure data from 18 states between 2016 and 2019. The PAI index reveals notable variability in access inequality across different procedures, with minimally invasive and newer procedures exhibiting higher inequality. Key findings indicate that procedures such as skin grafts and minimally invasive gastrectomy have the highest PAI scores, while cesarean sections and percutaneous coronary interventions have the lowest. The study highlights that higher inequality is associated with greater market concentration and in particular, fewer hospitals offering these procedures. These findings emphasize the need for targeted policy interventions to address procedural access disparities to promote more equitable healthcare delivery across the United States.

Racial and Ethnic Disparities in Sacrocolpopexy Approach

IMPORTANCE

Racial inequity elevates risk for certain diagnoses and health disparities. Current data show disparities for Black women when comparing open versus minimally invasive hysterectomy. It is unknown if a similar disparity exists in surgical management of pelvic organ prolapse.

OBJECTIVE

The objective of this study was to determine whether racial or ethnic disparities exist for open abdominal versus minimally invasive sacrocolpopexy.

STUDY DESIGN

Cross-sectional data of the Healthcare Cost and Utilization Project National Inpatient Sample and the Nationwide Ambulatory Surgery Sample for the year 2019 was used. Bivariate analysis identified demographic and perioperative differences between abdominal versus minimally invasive sacrocolpopexy, which were compared in a multivariable logistic regression.

RESULTS

Forty-one thousand eight hundred thirty-seven patients underwent sacrocolpopexy: 35,820 (85.6%), minimally invasive sacrocolpopexy, and 6,016, (14.4%) abdominal sacrocolpopexy. In an unadjusted analysis, Black patients were more likely to undergo an abdominal sacrocolpopexy compared to non-Hispanic White patients (OR 2.14, 95% CI 1.16-3.92, P <0.01). Hispanic patients were more likely to undergo abdominal sacrocolpopexy compared to non-Hispanic White patients (OR 1.69, 95% CI 1.26-2.26, P <0.001). Other factors associated with abdominal sacrocolpopexy are zip code quartile, payer status, composite comorbidity score, hospital control, and hospital bed size. In the regression model, Black patients remained more likely to undergo abdominal sacrocolpopexy compared to those who identified as White (aOR 2, 95% CI 1.26-3.16, P < 0.003). Hispanic patients were more likely to undergo abdominal sacrocolpopexy compared to those who identified as White (aOR 1.73, 95% CI 1.31-2.28, P < 0.001).

CONCLUSION

Abdominal sacrocolpopexy was more likely to occur in patients who identified as Black or Hispanic.

The need for more inclusive measurement to advance equity in eating disorders prevention

Eating disorder (ED) research and practice have been shaped by prevailing stereotypes about who EDs are most likely to affect. Subsequently, the field has prioritized the needs and concerns of affluent, cisgender, heterosexual, white girls and women to the exclusion of others, especially people marginalized based on their race, ethnicity, sexual orientation, and/or gender identity. However, EDs exist across diverse groups and actually occur with elevated prevalence in several marginalized groups. Growing research points to differences in the drivers of EDs in such groups (e.g. desire to attain the curvy rather than thin ideal; dietary restraint due to food insecurity rather than weight/shape concerns), yet tools typically used for screening and intervention evaluation do not capture eating pathology driven by such factors. In this commentary, we describe gaps in existing ED assessment tools and argue these gaps likely underestimate EDs among marginalized groups, bias who is invited, participates in, and benefits from ED prevention programs, and obscure potential group differences in the efficacy of such programs. We also discuss the potential of these ramifications to exacerbate inequities in EDs. Finally, we outline recommendations to overcome existing gaps in measurement and, consequently, advance equity in the realm of ED prevention.

A comprehensive analysis of health care Inequities in randomized clinical trials following bariatric surgeries

BACKGROUND

Obesity is a global epidemic, leading to an increasing focus on interventions like bariatric surgeries. Despite this, there's a noticeable gap in understanding the demographic distribution of patients in clinical trials for bariatric surgery.

METHODS

We conducted a comprehensive analysis of 117 registered randomized clinical trials related to bariatric surgery on ClinicalTrials.gov. We extracted demographic information, including age, sex, race, and ethnicity, and performed descriptive statistical analyses.

RESULTS

The analysis covered 8,418 participants. The mean age was 43.8 years, with a substantial majority (93.8 ​%) falling within the 18-65 age group. Females comprised 74.9 ​% of participants, surpassing real-world estimates. Racially, 65.3 ​% of participants were White, while African Americans represented 18.5 ​%, Asians 1.2 ​%, Native Hawaiians 0.2 ​%, and American Indians 0.1 ​%, indicating an underrepresentation of diverse racial groups, notably lower compared to real-world demographic data. In terms of ethnicity, only 17.6 ​% were Hispanic.

CONCLUSIONS

This study reveals significant demographic disparities in patients undergoing bariatric surgeries in clinical trials. This suggests a lack of generalizability, emphasizing the need for inclusive recruitment strategies to enhance health equity.

Analyzing the Social Vulnerability Index With Metabolic Surgery

INTRODUCTION

The social vulnerability index (SVI) is a census tract-level population-based measure generated from 16 socioeconomic and demographic variables on a scale from 1 (least) to 100 (most) vulnerable. This study has three objectives as follows: 1) to analyze multiple ways of utilizing SVI, 2) compare SVI as a group measure of marginalization to individual markers, and 3) to understand how SVI is associated with choice of surgery in metabolic surgery.

METHODS

We retrospectively identified adults undergoing Roux-en-Y gastric bypass and gastric sleeve in 2013-2018 National Surgical Quality Improvement Program data from a single academic center. High SVI was defined as >75th percentile. Low SVI was coded as <75th percentile in measure 1 and < 25th percentile in measure 2. Chi-square and Mann-Whitney U tests were utilized for categorical and continuous variables, respectively. Multivariable regression models were performed comparing SVI to marginalized status as a predictor for type of metabolic surgery.

RESULTS

We identified 436 patients undergoing metabolic surgery, with a low overall morbidity (6.1%). Complication and readmission rates were similar across comparator groups. The logistic regression models had similar area under the curve, supporting SVI as a proxy for individual measures of marginalization.

CONCLUSIONS

SVI performed as well as marginalized status in predicting preoperative risk. This suggests the validity of using SVI to identify high risk patients. By providing a single, quantitative score encompassing many social determinants of health, SVI is a useful tool in identifying patients facing the greatest health disparities.

Unveiling Equitable Surgical Prioritization: Insights From a Comprehensive Analysis Using the Medically Necessary and Time-Sensitive (MeNTS) Scoring System

BACKGROUND

This study addresses the intricate landscape of racial disparities in healthcare delivery, with a specific focus on surgical procedures. The concern was accentuated by the challenges posed during the COVID-19 pandemic when resources became scarce. Recognizing the potential impact of provider bias in medical decision-making, the American College of Surgeons introduced the Medically Necessary and Time-Sensitive (MeNTS) scoring system. This methodology aims to address procedures that, while not emergent, are deemed medically necessary and time-sensitive. This study analyzed whether using this scoring system decreased racial disparities between patients receiving surgery during the pandemic.

METHODOLOGY

A retrospective cross-sectional study was conducted using Electronic Medical Records from June 1, 2020, to December 31, 2021. We analyzed variations in MeNTS scores and time to surgery based on racial and ethnic backgrounds using bivariate and multivariate analyses.

RESULTS

The analysis included 2,997 patients. Of these, 1,442 (42.84%) were Hispanic participants, 1,282 (38.09%) were non-Hispanic participants, and 642 (19.07%) were participants of other specified ethnic backgrounds. The racial composition comprised 2,955 (87.79%) White participants, 98 (2.91%) Asian participants, 50 (1.49%) African American participants, and 72 (2.14%) Alaska Native or American Indian participants. No significant differences in mean days to surgery or MeNTS scores were observed across racial and ethnic groups (Hispanic participants = 76.62 vs. non-Hispanic participants = 78.82, P = 0.8). A multivariate survival model showed that MeNTS scores below 30 were associated with higher surgery likelihood, with no significant disparities in race, ethnicity, or gender.

CONCLUSIONS

This comprehensive study utilizing the MeNTS scoring system reveals an absence of statistically significant racial disparities in surgical prioritization. These findings contribute valuable insights to the ongoing discourse surrounding equitable healthcare practices and emphasize the potential efficacy of standardized scoring systems in mitigating biases in medical decision-making.

Impact of Atrioventricular Valve Intervention at Each Stage of Single Ventricle Palliation

Background: Significant atrioventricular valve dysfunction can be associated with mortality or need for transplant in functionally univentricular heart patients undergoing staged palliation. The purposes of this study are to characterize the impact of concomitant atrioventricular valve intervention on outcomes at each stage of single ventricle palliation and to identify risk factors associated with poor outcomes in these patients. Methods: The Society of Thoracic Surgeons Congenital Heart Surgery Database was queried for functionally univentricular heart patients undergoing single ventricle palliation from 2013 through 2022. Separate analyses were performed on cohorts corresponding to each stage of palliation (1: initial palliation; 2: superior cavopulmonary anastomosis; 3: Fontan procedure). Bivariate analysis of demographics, diagnoses, comorbidities, preoperative risk factors, operative characteristics, and outcomes with and without concomitant atrioventricular valve intervention was performed. Multiple logistic regression was used to identify predictors associated with operative mortality or major morbidity. Results: Concomitant atrioventricular valve intervention was associated with an increased risk of operative mortality or major morbidity for each cohort (cohort 1: 62% vs 46%, P < .001; cohort 2: 37% vs 19%, P < .001; cohort 3: 22% vs 14%, P < .001). Black race in cohort 1 (odds ratio [OR] 3.151, 95% CI 1.181-9.649, P = .03) and preterm birth in cohort 2 (OR 1.776, 95% CI 1.049-3.005, P = .032) were notable predictors of worse morbidity or mortality. Conclusions: Concomitant atrioventricular valve intervention is a risk factor for operative mortality or major morbidity at each stage of single ventricle palliation. Several risk factors are associated with these outcomes and may be useful in guiding decision-making.

Characteristics and Outcomes of Infants in Texas by Facility Children's Surgery Verification Status

INTRODUCTION

The American College of Surgeons Children's Surgery Verification (CSV) status recognizes hospitals that deliver high-quality pediatric surgical care. Texas has 5 CSV centers in three cities, which may limit equitable access to care. We explored the characteristics and outcomes of infants admitted in Texas as a function of facility CSV status.

MATERIALS AND METHODS

We retrospectively reviewed a state-wide hospital discharge database (2013-2021). All patients <1 y of age were included. Patients transferred to an outside hospital were excluded to avoid double counting. Descriptive statistics and chi-square analysis were performed.

RESULTS

We analyzed 3,617,173 admissions, with 211,278 (6%) treated at CSV centers. CSV admissions were less likely to be inborn (46% versus 93%) and more likely to be transfers (16% versus 1%). CSV centers also had sicker patients (32% versus 13% extreme illness severity) with higher mortality rates (1% versus 0%), longer length of stay (9 ± 22 versus 4 ± 9), and higher operative rates (33% versus 20%). However, mortality was lower at CSV centers when matched for illness severity. Proportionately more patients from rural counties (9% versus 4%) and counties along the United States-Mexico border (13% versus 1%), as well as patients of Hispanic ethnicity (39% versus 33%), were treated at non-CSV centers. Meanwhile, proportionately more African Americans (21% versus 11%) were treated at CSV centers.

CONCLUSIONS

CSV centers are associated with improved outcomes among patients with high illness severity. Population differences among patients treated at CSV centers compared to non-CSV centers may represent disparities in access to care and warrant further evaluation.

Access to Laparoscopic Pediatric Surgery: Do Ethnic and Racial Disparities Exist?

INTRODUCTION

Disparate access to laparoscopic surgery may contribute to poorer health outcomes among racial and ethnic minorities, especially among children. We investigated whether racial and ethnic disparities in laparoscopic procedures existed among four common surgical operations in the pediatric population in the United States.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatrics, we conducted a retrospective review of pediatric patients, aged less than 18 y old, undergoing appendectomy, fundoplication, cholecystectomy, and colectomy from 2012 to 2021. To compare the surgical approach (laparoscopy or open), a propensity score matching algorithm was used to compare laparoscopic and open procedures between non-Hispanic Black with non-Hispanic White children and Hispanic with non-Hispanic White children.

RESULTS

143,205, 9,907, 4,581, and 26,064 children underwent appendectomy, fundoplication, colectomy, and cholecystectomy, respectively. After propensity score matching, non-Hispanic Black children undergoing appendectomy were found to be treated laparoscopically less than non-Hispanic White children (93.5% versus 94.4%, P = 0.007). With fundoplication, Hispanic children were more likely to be treated laparoscopically than White ones (86.7% versus 80.9%, P < 0.0001). There were no statistically significant differences between Black or Hispanic children and White children in rates of laparoscopy for other procedures.

CONCLUSIONS

Though some racial and ethnic disparities exist with appendectomies and fundoplications, there is limited evidence to indicate that widespread inequities among common laparoscopic procedures exist in the pediatric population.

Exploring Prognostic Implications of Race and Ethnicity in Patients With Peripheral Arterial Disease

INTRODUCTION

Significant health inequalities in major adverse limb events exist. Ethnically minoritized groups are more prone to have a major adverse event following peripheral vascular interventions. This systematic review and meta-analysis aimed to describe the postoperative implications of racial and ethnic status on clinical outcomes following vascular interventions for claudication and chronic limb-threatening ischemia.

METHODS

Searches were conducted across seven databases from inception to June 2021 and were updated in October 2022 to identify studies reporting claudication or chronic limb-threatening ischemia in patients who underwent open, endovascular, or hybrid procedures. Studies with documented racial and ethnic status and associated clinical outcomes were selected. Extracted data included demographic and clinical characteristics, vascular interventions, and measured outcomes associated with race or ethnicity. Meta-analyses were performed using random-effect models to report pooled odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Seventeen studies evaluating the impact of Black versus White patients undergoing amputation as a primary intervention were combined in a meta-analysis, revealing that Black patients had a higher incidence of amputations as a primary intervention than White patients (OR: 1.91, 95% CI: 1.61-2.27). Another meta-analysis demonstrated that Black patients had significantly higher rates of amputation after revascularization (OR: 1.56, 95% CI: 1.28-1.89). Furthermore, multiple trends were demonstrated in the secondary outcomes evaluated.

CONCLUSIONS

Our findings suggest that Black patients undergo primary major amputation at a significantly higher rate than White patients, with similar trends seen among Hispanic and First Nations patients. Black patients are also significantly more likely to be subjected to amputation following attempts at revascularization when compared to White patients.

Insurance-Related Disparities in Withdrawal of Life Support and Mortality After Spinal Cord Injury

Importance

Identifying disparities in health outcomes related to modifiable patient factors can improve patient care.

Objective

To compare likelihood of withdrawal of life-supporting treatment (WLST) and mortality in patients with complete cervical spinal cord injury (SCI) with different types of insurance.

Design, Setting, and Participants

This retrospective cohort study collected data between 2013 and 2020 from 498 trauma centers participating in the Trauma Quality Improvement Program. Participants included adult patients (older than 16 years) with complete cervical SCI. Data were analyzed from November 1, 2023, through May 18, 2024.

Exposure

Uninsured or public insurance compared with private insurance.

Main Outcomes and Measures

Coprimary outcomes were WLST and mortality. The adjusted odds ratio (aOR) of each outcome was estimated using hierarchical logistic regression. Propensity score matching was used as an alternative analysis to compare public and privately insured patients. Process of care outcomes, including the occurrence of a hospital complication and length of stay, were compared between matched patients.

Results

The study included 8421 patients with complete cervical SCI treated across 498 trauma centers (mean [SD] age, 49.1 [20.2] years; 6742 male [80.1%]). Among the 3524 patients with private insurance, 503 had WLST (14.3%) and 756 died (21.5%). Among the 3957 patients with public insurance, 906 had WLST (22.2%) and 1209 died (30.6%). Among the 940 uninsured patients, 156 had WLST (16.6%) and 318 died (33.8%). A significant difference was found between uninsured and privately insured patients in the adjusted odds of WLST (aOR, 1.49; 95% CI, 1.11-2.01) and mortality (aOR, 1.98; 95% CI, 1.50-2.60). Similar results were found in subgroup analyses. Matched public compared with private insurance patients were found to have significantly greater odds of hospital complications (odds ratio, 1.27; 95% CI, 1.14-1.42) and longer hospital stay (mean difference 5.90 days; 95% CI, 4.64-7.20), which was redemonstrated on subgroup analyses.

Conclusions and Relevance

Health insurance type was associated with significant differences in the odds of WLST, mortality, hospital complications, and days in hospital among patients with complete cervical SCI in this study. Future work is needed to incorporate patient perspectives and identify strategies to close the quality gap for the large number of patients without private insurance.

The Impact of Race and Ethnicity in Microvascular Head and Neck Reconstruction Postoperative Outcomes: A Nationwide Data Analysis

BACKGROUND

Racial and ethnic disparities have been extensively reported across surgical specialties, highlighting existing healthcare inequities. Nevertheless, evidence is lacking regarding their influence on postoperative outcomes after head and neck reconstruction. This study aimed to evaluate the impact of race and ethnicity on postoperative complications in head and neck microvascular reconstruction.

METHODS

The ACS-NSQIP database was used to identify patients who underwent head and neck microvascular reconstruction between 2012 and 2022. Baseline characteristics were compared based on race (White, non-White) and ethnicity (Hispanic, non-Hispanic). Group differences were assessed using t tests and Fisher Exact tests. Multivariable logistic regression models were constructed to evaluate postoperative complications between the groups. A Cochran-Armitage test was conducted to evaluate the significance of trends over time.

RESULTS

A total of 11,373 patients met inclusion criteria. Among them, 9,082 participants reported race, and 9,428 reported ethnicity. Multivariable analysis demonstrated that Hispanic patients were more likely to experience 30-day readmission (OR 6.7; 95% CI, 1.17-38.4; P=0.032) and had an average total length of stay of 5.25 days longer (95% CI, 0.84-9.65; P=0.020) compared with non-Hispanic patients. Additional subgroup analyses revealed higher rates of all readmissions among non-White patients, particularly those indicated by malignancy (OR 1.23; 95% CI, 1.1-1.4; P=0.002). No significant differences were found in mortality, reoperation rates, and operative times between racial and ethnic groups.

CONCLUSIONS

The findings of this study suggest that ethnicity may be a significant risk factor for readmission in head and neck microvascular reconstruction. However, future studies are needed to further clarify the impact of race and ethnicity on longer postoperative outcomes, particularly in head and neck cancer minorities.

Variation in Long-Term Postoperative Mortality Risk by Race/Ethnicity After Major Non-cardiac Surgeries in the Veterans Health Administration

BACKGROUND

Few large sample studies have examined whether disparities, as measured by the proxy of race/ethnicity, are observed in long-term mortality after high-risk operations performed in a United States national health system. We compared operation year-related mortality risk by race/ethnicity after high-risk operative interventions among patients receiving care within the VHA.

METHODS

From the Veterans Affairs Corporate Data Warehouse and Surgical Quality Improvement Program, data were retrieved for 426,695 patients undergoing high-risk surgical procedures in non-cardiac, general, vascular, thoracic, orthopedic, neurosurgery, and genitourinary specialties between 2000 and 2018. Operation year was used as a surrogate measure of advances in technology and perioperative management. Underrepresented race/ethnicity groups were compared in a binary form with Caucasian/White race, as the reference category. The primary outcome was time to mortality, defined as death occurring at any time, due to any cause, during follow up, and after the initial, eligible surgery.

RESULTS

The median follow-up after 537,448 operations among 426,695 patients was 4.8 years. After adjustment for preoperative risk factors and demographics, long-term mortality risk decreased significantly to a hazard ratio of 0.96 (95% confidence interval, 0.962 to 0.964) over calendar time. Long-term mortality was not significantly higher among African Americans/Blacks compared to Caucasians/Whites (p = 0.22). Among Hispanics, differences in mortality risk favored Caucasians/Whites in the early years under study-a difference that dissipated as time progressed. In the most recent years, no difference in mortality was observed among Asian/Native Americans and Caucasians/Whites.

CONCLUSIONS

Risk-adjusted long-term mortality after high-risk operations among Veterans Affairs hospitals did not significantly vary between African Americans/Blacks, Hispanics, and Asian/Native Americans groups.

Poverty and Its Impact on Surgical Care

In this article, the authors explore the intricate relationship between poverty and surgical care, underscoring its multifaceted nature and its profound impact on access and outcomes. Poverty extends beyond financial constraints to encompass barriers related to healthcare infrastructure, geographic isolation, education, mental health, and social determinants of health, resulting in persistent disparities in access to high-quality surgical care, especially for those in persistently impoverished areas and access-sensitive surgical conditions. Additionally, the authors delve into the complex intersection of poverty, race, and ethnicity, emphasizing the heightened risks faced by minority patients in surgical care.

A Randomized Crossover Trial Evaluating the Impact of Cultural Dexterity Training on Surgical Residents' Knowledge, Cross-Cultural Care, Skills, and Beliefs: The Provider Awareness and Cultural Dexterity Training for Surgeons (PACTS) Trial

OBJECTIVES

This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents' knowledge, cross-cultural care, skills, and beliefs.

BACKGROUND

Cross-cultural training of providers may reduce health care outcome disparities, but its effectiveness in surgical trainees is unknown.

METHODS

PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group ("Early") received PACTS between periods 1 and 2, while the Delayed group ("Delayed") received PACTS between periods 2 and 3. Residents were assessed preintervention and postintervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. χ 2 and Fisher exact tests were conducted to evaluate within-intervention and between-intervention group differences.

RESULTS

Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents' Cross-Cultural Care (79.6%-88.2%, P <0.0001), Self-Assessed Skills (74.5%--85.0%, P <0.0001), and Beliefs (89.6%-92.4%, P =0.0028) improved after PACTS; knowledge scores (71.3%-74.3%, P =0.0661) were unchanged. Delayed resident scores pre-PACTS to post-PACTS showed minimal improvements in all domains. When comparing the 2 groups in period 2, Early residents had modest improvement in all 4 assessment areas, with a statistically significant increase in Beliefs (92.4% vs 89.9%, P =0.0199).

CONCLUSIONS

The PACTS curriculum is a comprehensive tool that improved surgical residents' knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations.

The impact of the affordable care act on access to bariatric surgery in Maryland

INTRODUCTION

This study aims to investigate the influence of the Affordable Care Act (ACA) on the utilization of Roux-en-Y gastric bypass (RYGB) procedures in Maryland.

METHODS

Using the Maryland State Inpatient Database, this retrospective study compared all patients undergoing RYGB during the pre-ACA (2007-2009) and post-ACA (2018-2020) periods, including patient demographic factors, pre-existing conditions, and socioeconomic factors.

RESULTS

A total of 16,494 RYGB procedures were performed during the study period, of which 12,089 (73.3 ​%) were post-ACA. This was a 179.2 ​% increase in patients undergoing RYGB post-ACA; nearly triple that of the pre-ACA period. There was a significant decrease in uninsured patients (5.6 ​%-1.5 ​%, p ​< ​0.01) an increase in Black patients (32.1 ​%-46.8 ​%, p ​< ​0.01) and Medicaid beneficiaries (6.0 ​% pre-ACA to 17.8 ​% post-ACA, p ​< ​0.01). There were significant reductions in adverse outcomes (long hospital stays, hemorrhage, GIT leaks, and mortality) across all insurance types (all p ​< ​0.01).

CONCLUSION

The ACA increased access to RYGB procedures, especially in Black and Medicaid recipients in Maryland, enhancing healthcare across all insurance types.