Racial disparities in length-of-stay persist even with no postoperative complications

Racial Disparities in Bowel Preparation and Post-Operative Outcomes in Colorectal Cancer Patients

BACKGROUND

Combined pre-operative bowel preparation with oral antibiotics (OAB) and mechanical bowel preparation (MBP) is the current recommendation for elective colorectal surgery. Few have studied racial disparities in bowel preparation and subsequent post-operative complications.

METHODS

This retrospective cohort study used 2015-2021 ACS-NSQIP-targeted data for elective colectomy for colon cancer. Multivariate regression evaluated predictors of post-operative outcomes: post-operative ileus, anastomotic leak, surgical site infection (SSI), operative time, and hospital length of stay (LOS).

RESULTS

72,886 patients were evaluated with 82.1% White, 11.1% Black, and 6.8% Asian or Asian Pacific Islander (AAPI); 4.2% were Hispanic and 51.4% male. Regression accounting for age, sex, ASA classification, comorbidities, and operative approach showed Black, AAPI, and Hispanic patients were more likely to have had no bowel preparation compared to White patients receiving MBP+OAB. Compared to White patients, Black and AAPI patients had higher odds of prolonged LOS and pro-longed operative time. Black patients had higher odds of post-operative ileus.

CONCLUSIONS

Racial disparities exist in both bowel preparation administration and post-operative complications despite the method of bowel preparation. This warrants exploration into discriminatory bowel preparation practices and potential differences in the efficacy of bowel preparation in specific populations due to biological or social differences, which may affect outcomes. Our study is limited by its use of a large database that lacks socioeconomic variables and patient data beyond 30 days.

Evaluation of racial/ethnic disparities in surgical outcomes after rectal cancer resection: An ACS-NSQIP analysis

Background

Disparities exist the management of rectal cancer. We sought to evaluate short-term surgical outcomes among different racial/ethnic groups following rectal cancer resection.

Materials and Methods

National Surgical Quality Improvement Program (NSQIP) database (2016-2019) was queried. Patients undergoing rectal cancer resection were categorized by race/ethnicity. Circumferential resection margin positivity rate and postoperative outcomes were evaluated. 1:1 Propensity score matching (PSM) was used.

Results

Of 1,753 patients, 80.2 % were White, 7.6 % Black, 8.5 % Asian and 3.7 % Hispanic. On unadjusted analysis, Hispanic patients presented longer operative time(p = 0.029), and Black patients higher postoperative ileus(p = 0.003) and readmission(p = 0.023) rates. After PSM, Hispanics had a significantly higher circumferential resection margin positivity rate(p = 0.032), Black patients higher postoperative ileus rate(p = 0.014) and longer LOS(p = 0.0118) when compared to White counterparts.

Conclusion

Racial disparities were found in short-term postoperative outcomes. Hispanic patients presented higher margin positivity rate and Black patients worst 30-day postoperative outcomes. Comparative studies evaluating trends and a higher number of minority patients included in databases are warranted.

Understanding the Impact of Enhanced Recovery Programs on Social Vulnerability, Race, and Colorectal Surgery Outcomes

BACKGROUND

Increasing social vulnerability, measured by the Social Vulnerability Index, has been associated with worse surgical outcomes. However, less is known about the impact of social vulnerability on patients who underwent colorectal surgery under enhanced recovery programs.

OBJECTIVE

We hypothesized that increasing social vulnerability is associated with worse outcomes before enhanced recovery implementation, but that after implementation, disparities in outcomes would be reduced.

DESIGN

Retrospective cohort study using multivariable logistic regression to identify associations of social vulnerability and enhanced recovery with outcomes.

SETTINGS

Institutional American College of Surgeons National Surgical Quality Improvement Program database.

PATIENTS

Patients undergoing elective colorectal surgery (2010-2020). Enhanced recovery programs were implemented in 2015. Those adhering to 70% or more of enhanced recovery program components were defined as enhanced recovery and all others as nonenhanced recovery.

OUTCOMES

Length of stay, complications, and readmissions.

RESULTS

Of 1523 patients, 589 (38.7%) were in the enhanced recovery group, with 625 patients (41%) in the lowest third of the Social Vulnerability Index, 411 (27%) in the highest third. There were no differences in Social Vulnerability Index distribution by the enhanced recovery group. On multivariable modeling, social vulnerability was not associated with increased length of stay, complications, or readmissions in the enhanced recovery group. Black race was associated with increased length of stay in both the nonenhanced recovery (OR 1.2; 95% CI, 1.1-1.3) and enhanced recovery groups (OR 1.2; 95% CI, 1.1-1.4). Enhanced recovery adherence was associated with reductions in racial disparities in complications as the Black race was associated with increased odds of complications in the nonenhanced recovery group (OR 1.9; 95% CI, 1.2-3.0) but not in the enhanced recovery group (OR 0.8; 95% CI, 0.4-1.6).

LIMITATIONS

Details of potential factors affecting enhanced recovery program adherence were not assessed and are the subject of current work by this team.

CONCLUSION

High social vulnerability was not associated with worse outcomes among both enhanced recovery and nonenhanced recovery colorectal patients. Enhanced recovery program adherence was associated with reductions in racial disparities in complication rates. However, disparities in length of stay remain, and work is needed to understand the underlying mechanisms driving these disparities. See Video Abstract .

COMPRENDIENDO EL IMPACTO DE LOS PROGRAMAS DE RECUPERACIN MEJORADA EN LA VULNERABILIDAD SOCIAL, LA RAZA Y LOS RESULTADOS DE LA CIRUGA COLORRECTAL

ANTECEDENTES:El aumento de la vulnerabilidad social medida por el índice de vulnerabilidad social se ha asociado con peores resultados quirúrgicos. Sin embargo, se sabe menos sobre el impacto de la vulnerabilidad social en los pacientes de cirugía colorrectal bajo programas de recuperación mejorados.OBJETIVO:Planteamos la hipótesis de que el aumento de la vulnerabilidad social se asocia con peores resultados antes de la implementación de la recuperación mejorada, pero después de la implementación, las disparidades en los resultados se reducirían.DISEÑO:Estudio de cohorte retrospectivo que utilizó regresión logística multivariable para identificar asociaciones de vulnerabilidad social y recuperación mejorada con los resultados.ESCENARIO:Base de datos institucional del Programa de Mejora Nacional de la Calidad de la Cirugía del American College of Surgeons.PACIENTES:Pacientes sometidos a cirugía colorrectal electiva (2010-2020). Programas de recuperación mejorada implementados en 2015. Aquellos que se adhieren a ≥70% de los componentes del programa de recuperación mejorada definidos como recuperación mejorada y todos los demás como recuperación no mejorada.MEDIDAS DE RESULTADO:Duración de la estancia hospitalaria, complicaciones y reingresos.RESULTADOS:De 1.523 pacientes, 589 (38,7%) estaban en el grupo de recuperación mejorada, con 732 (40,3%) pacientes en el tercio más bajo del índice de vulnerabilidad social, 498 (27,4%) en el tercio más alto, y no hubo diferencias en la distribución del índice vulnerabilidad social por grupo de recuperación mejorada. En el modelo multivariable, la vulnerabilidad social no se asoció con una mayor duración de la estancia hospitalaria, complicaciones o reingresos en ninguno de los grupos de recuperación mejorada. La raza negra se asoció con una mayor duración de la estadía tanto en el grupo de recuperación no mejorada (OR1,2, IC95% 1,1-1,3) como en el grupo de recuperación mejorada (OR1,2, IC95% 1,1-1,4). La adherencia a la recuperación mejorada se asoció con reducciones en las disparidades raciales en las complicaciones, ya que la raza negra se asoció con mayores probabilidades de complicaciones en el grupo de recuperación no mejorada (OR1,9, IC95% 1,2-3,0), pero no en el grupo de recuperación mejorada (OR0,8, IC95% 0,4-1,6).LIMITACIONES:No se evaluaron los detalles de los factores potenciales que afectan la adherencia al programa de recuperación mejorada y son el tema del trabajo actual de este equipo.CONCLUSIÓN:La alta vulnerabilidad social no se asoció con peores resultados entre los pacientes colorrectales con recuperación mejorada y sin recuperación mejorada. Una mayor adherencia al programa de recuperación se asoció con reducciones en las disparidades raciales en las tasas de complicaciones. Sin embargo, persisten disparidades en la duración de la estadía y es necesario trabajar para comprender los mecanismos subyacentes que impulsan estas disparidades. (Traducción-Dr. Felipe Bellolio ).

Racial Disparities in 30-day Readmission After Orthopaedic Surgery: A 5-year National Surgical Quality Improvement Program Database Analysis

BACKGROUND

Readmission rate after surgery is an important outcome measure in revealing disparities. This study aimed to examine how 30-day readmission rates and causes of readmission differ by race and specific injury areas within orthopaedic surgery.

METHODS

The American College of Surgeon-National Surgical Quality Improvement Program database was queried for orthopaedic procedures from 2015 to 2019. Patients were stratified by self-reported race. Procedures were stratified using current procedural terminology codes corresponding to given injury areas. Multiple logistic regression was done to evaluate associations between race and all-cause readmission risk, and risk of readmission due to specific causes.

RESULTS

Of 780,043 orthopaedic patients, the overall 30-day readmission rate was 4.18%. Black and Asian patients were at greater (OR = 1.18, P < 0.01) and lesser (OR = 0.76, P < 0.01) risk for readmission than White patients, respectively. Black patients were more likely to be readmitted for deep surgical site infection (OR = 1.25, P = 0.03), PE (OR = 1.64, P < 0.01), or wound disruption (OR = 1.45, P < 0.01). For all races, all-cause readmission was highest after spine procedures and lowest after hand/wrist procedures.

CONCLUSIONS

Black patients were at greater risk for overall, spine, shoulder/elbow, hand/wrist, and hip/knee all-cause readmission. Asian patients were at lower risk for overall, spine, hand/wrist, and hip/knee surgery all-cause readmission. Our findings can identify complications that should be more carefully monitored in certain patient populations.

Racial disparities in postoperative outcomes persist for patients with inflammatory bowel disease under a colorectal enhanced recovery program

INTRODUCTION

Enhanced recovery programs (ERPs) reduce racial disparities in surgical outcomes for general colorectal surgery populations. It is unclear, however, if disparities in IBD populations are impacted by ERPs.

METHODS

Retrospective study comparing IBD patients undergoing major elective colorectal operations before (2006-2014) and after (2015-2021) ERP implementation using ACS-NSQIP data. The primary outcome of length of stay (LOS) was analyzed by negative binomial regression, and secondary outcomes (complications and readmissions) by logistic regression.

RESULTS

Of 466 IBD patients, 47% were pre-ERP and 53% were ERP patients. In multivariable analysis stratified by ERP period, Black race was associated with increased odds of complications in the pre-ERP (OR 3.6, 95%CI 1.4-9.3) and ERP groups (OR 3.1 95%CI 1.3-7.6). Race was not a predictor of LOS or readmission in either group. High social vulnerability was associated with increased odds of readmission pre-ERP (OR 15.1, 95%CI 2.1-136.3), but this disparity was mitigated under ERPs (OR 1.4, 95%CI 0.4-5.6).

CONCLUSION

While ERPs mitigated some disparities by social vulnerability, racial disparities persist in IBD populations even under ERPs. Further work is needed to achieve surgical equity for IBD patients.

A socioecological qualitative analysis of barriers to care in colorectal surgery

BACKGROUND

Although specific social determinants of health have been associated with disparities in surgical outcomes, there exists a gap in knowledge regarding the mechanisms of these associations. Gaining perspectives from multiple socioecological levels can help elucidate these mechanisms. Our study aims to identify social determinants of health that act as barriers or facilitators to surgical care among colorectal surgery stakeholders.

METHODS

We recruited participants representing 5 socioecological levels: patients (individual); caregivers/surgeons (interpersonal); and leaders in hospitals (organizational), communities (community), and government (policy). Patients participated in focus groups, and the remaining participants underwent individual interviews. Semistructured interview guides were used to explore barriers and facilitators to surgical care at each socioecological level. Transcripts were analyzed by 3 coders in an inductive thematic approach with content analyses. The intercoder agreement was 93%.

RESULTS

Six patient focus groups (total n = 18) and 12 key stakeholder interviews were conducted. The mean age of patients was 54.7 years, 66% were Black, and 61% were female. The most common diseases were colorectal cancer (28%), inflammatory bowel disease (28%), and diverticulitis (22%). Key social determinants of health impacting surgical care emerged at each level: individual (clear communication, mental stress), interpersonal (provider communication and trust, COVID-related visitation restrictions), organizational (multiple forms of contact, quality educational materials, scheduling systems, discrimination), community (community and family support and transportation), and policy (charity care, patient advocacy organizations, insurance coverage).

CONCLUSION

Key social determinants of health-impacting care among colorectal surgery patients emerged at each socioecological level and may provide targets for interventions to reduce surgical disparities.

Comparisons between White and Black Patients Hospitalized with Postliver Transplant Complications/Failure

OBJECTIVES

The impact of race on patients presenting to North American hospitals with postliver transplant complications/failure (PLTCF) has not been studied fully. We compared in-hospital mortality and resource utilization outcomes between White and Black patients hospitalized with PLTCF.

METHODS

This was a retrospective cohort study that evaluated the years 2016 and 2017 from the National Inpatient Sample. Regression analysis was used to determine in-hospital mortality and resource utilization.

RESULTS

There were 10,805 hospitalizations for adults with liver transplants who presented with PLTCF. White and Black patients with PLTCF made up 7925 (73.3%) hospitalizations from this population. Among this group, 6480 were White (81.7%) and 1445 were Black (18.2%). Blacks were younger than Whites (mean age ± standard error of the mean: 46.8 ± 1.1 vs 53.6 ± 0.39 years, P < 0.01). Blacks were more likely to be female (53.9% vs 37.4%, P < 0.01). Charlson Comorbidity Index scores were not significantly different (scores ≥3: 46.7% vs 44.2%, P = 0.83). Blacks had significantly higher odds for in-hospital mortality (adjusted odds ratio 2.9, confidence interval [CI] 1.4-6.1; P < 0.01). Hospital charges were higher for Blacks compared with Whites (adjusted mean difference $48,432; 95% CI $2708-$94,157, P = 0.03). Blacks had significantly longer lengths of hospital stays (adjusted mean difference 3.1 days, 95% CI 1.1-5.1, P < 0.01).

CONCLUSIONS

Compared with White patients hospitalized for PLTCF, Black patients had higher in-hospital mortality and resource use. Investigation into causes leading to this health disparity is needed to improve in-hospital outcomes.

Racial disparities in surgical treatment of type A acute aortic dissection

Objective

To determine whether there are racial disparities associated with mortality, cost, and length of hospital stay after surgical repair of type A acute aortic dissection (TAAAD).

Methods

Patient data from 2015 to 2018 were collected using the National Inpatient Sample. In-hospital mortality was the primary outcome. Multivariable logistical modeling was used to identify factors independently associated with mortality.

Results

Among 3952 admissions, 2520 (63%) were White, 848 (21%) were Black/African American, 310 (8%) were Hispanic, 146 (4%) were Asian and Pacific Islander (API), and 128 (3%) were classified as Other. Black/African American and Hispanic admissions presented with TAAAD at a median age of 54 years and 55 years, respectively, whereas White and API admissions presented at a median age of 64 years and 63 years, respectively (P < .0001). Additionally, there were higher percentages of Black/African American (54%; n = 450) and Hispanic (32%; n = 94) admissions living in ZIP codes with the lowest median household income quartile. Despite these differences on presentation, when adjusting for age and comorbidity, there was no independent association between race and in-hospital mortality and no significant interactions between race and income on in-hospital mortality.

Conclusions

Black and Hispanic admissions present with TAAAD a decade earlier than White and API admissions. Additionally, Black and Hispanic TAAAD admissions are more likely to come from lower-income households. After adjusting for relevant cofactors, there was no independent association between race and in-hospital mortality after surgical treatment of TAAAD.

The association of social vulnerability with colorectal enhanced recovery program failure

Background

Enhanced recovery programs (ERPs) improve outcomes, but over 20 % of patients fail ERP and the contribution of social vulnerability is unknown. This study aimed to characterize the association between social vulnerability and ERP adherence and failure.

Methods

This was a retrospective cohort study of colorectal surgery patients between 2015 and 2020 utilizing ACS-NSQIP data. Patients who failed ERP (LOS > 6 days) were compared to patients not failing ERP. The CDC's social vulnerability index (SVI) was used to assess social vulnerability.

Result

273 of 1191 patients (22.9 %) failed ERP. SVI was a significant predictor of ERP failure (OR 4.6, 95 % CI 1.3-16.8) among those with >70 % ERP component adherence. SVI scores were significantly higher among patients non-adherent with 3 key ERP components: preoperative block (0.58 vs. 0.51, p < 0.01), early diet (0.57 vs. 0.52, p = 0.04) and early foley removal (0.55 vs. 0.50, p < 0.01).

Conclusions

Higher social vulnerability was associated with non-adherence to 3 key ERP components as well as ERP failure among those who were adherent with >70 % of ERP components. Social vulnerability needs to be recognized, addressed, and included in efforts to further improve ERPs.

Key message

Social vulnerability is associated with non-adherence to enhanced recovery components and ERP failure among those with high ERP adherence. Social vulnerability needs to be addressed in efforts to improve ERPs.

Hysterectomy inequities between black and white patients in the US military health system: A retrospective cohort study

OBJECTIVE

To evaluate multicomponent aspects of hysterectomy-related care in the US Military Health System including the probability of open hysterectomy (versus vaginal or laparoscopic hysterectomy), probability of having a length of stay > 1 day, and discharge milligram morphine equivalent dose (MED). Analyses sought to identify the presence and strength of healthcare inequities between Black and white patients.

METHODS

In this retrospective cohort study, records of patients (N = 11,067) ages 18-65 years enrolled in TRICARE who underwent a hysterectomy between January 2017 to January 2021 in US military treatment facilities (direct care) or civilian facilities (purchased care) were included. Graphic representations illustrated provider and facility variation. Generalized additive mixed models (GAMMs) evaluated inequities across outcomes. Sensitivity analyses included only direct care receipt and added a random effect for the facility.

RESULTS

There was significant variation in provider use of open versus vaginal or laparoscopic hysterectomies, as well as provider and facility discharge MED. The GAMMs indicated Black patients were more likely to receive an open hysterectomy [log(OR) -0.54, (95 %CI -0.65, -0.43), p < 0.001] and have a length of stay > 1 day [log(OR) 0.18, (95 %CI 0.07, 0.30), p = 0.002], but had similar discharge MED [-2 mg (95% CI -7 mg, 3 mg), p = 0.51], relative to white patients. Patients receiving care in purchased care, relative to direct care, were more likely to receive a vaginal or laparoscopic hysterectomy [log(OR) 0.28, (95 %CI 0.17, 0.38), p = 0.002] and received approximately 21 mg lower discharge MED (95 %CI 16-26 mg less, p < 0.001), but were more likely to have a hospital stay > 1 day [log(OR) 0.95, (95 %CI 0.83, 0.1.10), p < 0.001]. Additional gynecological conditions (e.g., uterine fibroids) and prescription receipt were associated with some, but not all outcomes.

CONCLUSION

Improving timely care receipt, especially for uterine fibroids, increasing access to vaginal and laparoscopic hysterectomies, and reducing unwarranted variation in discharge MED could improve care quality and equity in the US Military Health System.

Race and prevalence of percutaneous endoscopic gastrostomy tubes in patients with advanced dementia

OBJECTIVE

Millions of Americans may face hard decisions when it comes to providing nutrition for their loved ones with advanced dementia. This study aimed to ascertain whether there is a difference in feeding tube placement between White and Black patients with advanced dementia and whether this potential difference varied by patient's other demographic and clinical characteristics.

METHOD

This is a retrospective, observational study conducted at Novant Health, a 15-hospital system in the southeastern United States. Data were obtained from Epic systems and included all hospital admissions with a diagnosis of advanced dementia, a total of 21,939, between July 1, 2015, and December 31, 2018. Descriptive statistics and logistics analyses were conducted to assess the relationship between receiving percutaneous endoscopic gastrostomy (PEG) and race, controlling for demographic and clinical characteristics.

RESULTS

Among patients admitted with advanced dementia, the multivariable logistic regression, controlled for age, gender, LOS, palliative care, and vascular etiology showed that Blacks had higher odds of having PEG tubes inserted than White patients (OR 1.97; CI 1.51-2.55; P < 0.001). Patients with longer stays had higher odds of PEG tube insertion. Females had lower odds of PEG tube insertion than males. There was no statistical significance in PEG insertion based on age, etiology, and palliative care consult.

SIGNIFICANCE OF RESULTS

The reasons for the observed higher odds of receiving PEG tubes among Black patients than White patients are likely multifactorial and embedded in a different approach to end-of-life care conversations by providers and caregivers of Black and White patients. Providers may need to be more aware of potential unconscious biases when talking to caregivers, especially in race-discordant relationships, have courageous conversations with caregivers, and be more aware of the importance of keeping in mind families' and caregivers' culture, including spirituality, when making end-of-life decisions.

Racial Disparities in Surgical Outcomes of Acute Diverticulitis: Have We Moved the Needle?

INTRODUCTION

There has been increasing national attention on reducing healthcare disparities. Prior studies cite worse surgical outcomes and less use of laparoscopy for Black patients with diverticulitis. Re-evaluation of these disparities is lacking despite national initiatives to improve health equity. This study aimed to evaluate the association of race with short-term outcomes and surgical approaches in patients with acute diverticulitis.

METHODS

The National Surgical Quality Improvement Program database was queried for patients who underwent nonelective surgery for acute diverticulitis from 2015 to 2019. Severity of presentation, morbidity, mortality, surgical approach, and ostomy creation were compared by race.

RESULTS

Of the 13,996 patients included in the study, 82.4% were White, 7.6% were Black, 1.1% Asian, 0.61% American Indian/Alaska Native, and 0.20% Native Hawaiian/Pacific Islander (NH/PI). Overall 30-day morbidity was 44.3% and 30-day mortality was 3.9%. In a multivariate logistic regression analysis, compared to Whites, Black race was independently associated with higher 30-day morbidity (Odds Ratio: 1.24, 95% confidence interval: 1.07-1.43, P = 0.003) and NH/PI race was independently associated with higher mortality (Odds Ratio: 5.35, 95% confidence interval: 1.32-21.6, P = 0.019). There was no difference in complicated disease (abscess or perforation), use of laparoscopy, or ostomy creation among races.

CONCLUSIONS

Despite national efforts to achieve equity in healthcare, disparities persist in surgical outcomes for those with diverticulitis. Black and NH/PI race are independently associated with increased morbidity and mortality, respectively. Use of laparoscopy, however, is no longer different by race suggesting some gaps may be closing.

Racial differences in time to blood pressure control of aneurysmal subarachnoid hemorrhage patients: A single-institution study

BACKGROUND AND PURPOSE

Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 patients annually in the United States. Uncontrolled blood pressure is a major risk factor for aneurysmal subarachnoid hemorrhage. Clinical guidelines recommend maintaining blood pressure control until definitive aneurysm securement occurs. It is unknown whether racial differences exist regarding blood pressure control and outcomes (HLOS, discharge disposition) in aneurysmal subarachnoid hemorrhage. Here, we aim to assess whether racial differences exist in 1) presentation, 2) clinical course, and 3) outcomes, including time to blood pressure stabilization, for aSAH patients at a large tertiary care medical center.

METHODS

We conducted a retrospective review of adult aneurysmal subarachnoid hemorrhage cases from 2013 to 2019 at a single large tertiary medical center. Data extracted from the medical record included sex, age, race, insurance status, aneurysm location, aneurysm treatment, initial systolic and diastolic blood pressure, Hunt Hess grade, modified Fisher score, time to blood pressure control (defined as time in minutes from first blood pressure measurement to the first of three consecutive systolic blood pressure measurements under 140mmHg), hospital length of stay, and final discharge disposition.

RESULTS

194 patients met inclusion criteria; 140 (72%) White and 54 (28%) Black. While White patients were more likely than Black patients to be privately insured (62.1% versus 33.3%, p < 0.001), Black patients were more likely than White patients to have Medicaid (55.6% versus 15.0%, p < 0.001). Compared to White patients, Black patients presented with a higher median systolic (165 mmHg versus 148 mmHg, p = 0.004) and diastolic (93 mmHg versus 84 mmHg, p = 0.02) blood pressure. Black patients had a longer median time to blood pressure control than White patients (200 minutes versus 90 minutes, p = 0.001). Black patients had a shorter median hospital length of stay than White patients (15 days versus 18 days, p < 0.031). There was a small but statistically significant difference in modified Fisher score between black and white patients (3.48 versus 3.17, p = 0.04).There were no significant racial differences present in sex, Hunt Hess grade, discharge disposition, complications, or need for further interventions.

CONCLUSION

Black race was associated with higher blood pressure at presentation, longer time to blood pressure control, but shorter hospital length of stay. No racial differences were present in aneurysmal subarachnoid hemorrhage associated complications or interventions.

Comparing Hospital Length of Stay Risk-Adjustment Models in US Value-Based Physician Payments

BACKGROUNG AND OBJECTIVES

Under the Affordable Care Act, the US Centers for Medicare & Medicaid Services created the Physician Value-Based Payment Modifier Program and its successor, the Merit-Based Incentive Payment System, to tie physician payments to quality and cost. The addition of hospital length of stay (LOS) to these value-based physician payment models reflects its increasing importance as a metric of health care cost and efficiency and its association with adverse health outcomes. This study compared the Centers for Medicare & Medicaid Services-endorsed LOS risk-adjustment methodology with a novel methodology that accounts for pre-hospitalization clinical, socioeconomic status (SES), and admission-related factors as influential factors of hospital LOS.

METHODS

Using the 2014 New York, Florida, and New Jersey State Inpatient Database, we compared the observed-to-expected LOS of 2373102 adult admissions for 742 medical and surgical diagnosis-related groups (DRGs) by 3 models: ( a ) current risk-adjustment model (CRM), which adjusted for age, sex, number of chronic conditions, Elixhauser comorbidity score, and DRG severity weight, ( b ) CRM but modeling LOS using a generalized linear model (C-GLM), and (c) novel risk-adjustment model (NRM), which added to the C-GLM covariates for race/ethnicity, SES, discharge destination, weekend admission, and individual intercepts for DRGs instead of severity weights.

RESULTS

The NRM disadvantaged physicians for fewer medical and surgical DRGs, compared with both the C-GLM and CRM models (medical DRGs: 0.49% vs 13.17% and 10.89%, respectively; surgical DRGs: 0.30% vs 13.17% and 10.98%, respectively). In subgroup analysis, the NRM reduced the proportion of physician-penalizing DRGs across all racial/ethnic and socioeconomic groups, with the highest reduction among Whites, followed by low SES patients, and the lowest reduction among Hispanic patients.

CONCLUSIONS

After accounting for pre-hospitalization socioeconomic and clinical factors, the adjusted LOS using the NRM was lower than estimates from the current Centers for Medicare & Medicaid Services-endorsed model. The current model may disadvantage physicians serving communities with higher socioeconomic risks.

Characterizing the Association of Race and Insurance Status with Resource Utilization in Brachial Plexopathy Surgery

BACKGROUND

Understanding the link between socioeconomic status and immediate postoperative brachial plexus injury (BPI) management outcomes is critical to mitigating disparities and optimizing postoperative recovery plans. The present study aimed to elucidate the association between socioeconomic status and resource utilization following surgery for BPI.

METHODS

We conducted a cross-sectional study of adult patients (18 years) with a BPI diagnosis from the 2002-2017 National Inpatient Sample. Primary outcomes included home discharge rates, length of stay (LOS), and cost. We used multivariable regressions to analyze outcome measures.

RESULTS

A total of 23,755 BPI admissions were identified, 14.67% of whom received surgical intervention. Patients receiving Medicare had lower odds of home discharge compared with privately insured patients (adjusted odds ratio 0.65, 95% confidence interval 0.58-0.74; P < 0.001). Medicaid, Medicare, and uninsured patients had 6%-32% longer LOS than privately insured patients (P < 0.001, P = 0.004, and P = 0.006, respectively). Patients in the top income quartile had a 12% increase in costs compared with those in the bottom quartile (P < 0.001). Latinx and Other race groups had 11%-14% increased costs compared with White patients (Latinx P < 0.001, Other P = 0.003).

CONCLUSIONS

Differences in BPI resource utilization and allocation exist, from increased LOS among non-privately insured and non-White patients to increased BPI treatment costs among patients in higher-income quartiles. Further research is necessary to elucidate how these disparities exist and impact functional outcomes.

Postoperative Outcomes in Pediatric Septoplasty

OBJECTIVE

Identify risk factors and perioperative morbidity for pediatric patients undergoing septoplasty.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was retrospectively queried to identify patients who underwent septoplasty (CPT 30520) for a diagnosis of deviated nasal septum (ICD J34.2) from 2018 to 2019. Outcomes analyzed include patient demographics, medical comorbidities, surgical setting, operative characteristics, length of stay, and postoperative outcomes.

RESULTS

A total of 729 children were identified. Median age at time of surgery was 15.8 years, with most patients (82.8%) >12 years of age; no significant association was identified between age at time of surgery and adverse surgical outcomes. Overall, postoperative complications were uncommon (0.6%), including readmission (0.4%), septic shock (0.1%), and surgical site infection (0.1%). A history of asthma was found to be a significant risk factor for postoperative complications (P = .035) as well as BMI (P = .028).

CONCLUSION

The 30-day postoperative complications following pediatric septoplasty in children reported in the NSQIP-P database are infrequent. Special considerations regarding young age, complex sinonasal anatomy, and surgical technique remain important features in considering corrective surgery for the pediatric nose and certainly warrant further investigation in subsequent studies.

Hospital Length of Stay in Patients with and without Serious and Persistent Mental Illness: Evidence of Racial and Ethnic Differences

Background: Prior studies have documented racial and ethnic differences in mental healthcare utilization, and extensively in outpatient treatment and prescription medication usage for mental health disorders. However, limited studies have investigated racial and ethnic differences in length of inpatient stay (LOS) in patients with and without Serious and Persistent Mental Illness. Understanding racial and ethnic differences in LOS is necessary given that longer stays in hospital are associated with adverse health outcomes, which in turn contribute to health inequities. Objective: To examine racial and ethnic differences in length of stay among patients with and without serious and persistent mental illness (SPMI) and how these differences vary in two age cohorts: patients aged 18 to 64 and patients aged 65+. Methods: This study employed a retrospective cohort design to address the research objective, using the 2018 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample. After merging the 2018 National Inpatient Sample’s Core and Hospital files, Generalized Linear Model (GLM), adjusting for covariates, was applied to examine associations between race and ethnicity, and length of stay for patients with and without SPMI. Results: Overall, patients from racialized groups were likely to stay longer than White patients regardless of severe mental health status. Of all races and ethnicities examined, Asian patients had the most extended stays in both age cohorts: 8.69 days for patients with SPMI and 5.73 days for patients without SPMI in patients aged 18 to 64 years and 8.89 days for patients with SPMI and 6.05 days for patients without SPMI in the 65+ cohort. For individuals aged 18 to 64, differences in length of stay were significantly pronounced in Asian patients (1.6 days), Black patients (0.27 days), and Native American patients/patients from other races (0.76 days) if they had SPMI. For individuals aged 65 and older, Asian patients (1.09 days) and Native American patients/patients from other races (0.45 days) had longer inpatient stays if they had SPMI. Conclusion: Racial and ethnic differences in inpatient length of stay were most pronounced in Asian patients with and without SPMI. Further studies are needed to understand the mechanism(s) for these differences.

Association between implementation of a coordinated care pathway in idiopathic scoliosis patients and a reduction in perioperative outcome disparities

BACKGROUND

There are well-documented racial and ethnic disparities in treatment and perioperative outcomes for patients with adolescent idiopathic scoliosis.

AIMS

We hypothesize that the implementation of a coordinated care pathway for pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may be associated with a reduction in racial and ethnic disparities in perioperative outcomes.

METHODS

This is a retrospective pre- and post-test cohort study of patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution between July 1, 2013 and August 5, 2019. We implemented a coordinated care pathway in March 2015. Patient demographics included age, race, ethnicity, weight, gender, insurance status, ASA class, time between the date surgery was ordered and the date surgery occurred, degree of scoliosis, and the number of spinal levels fused. The primary outcome was length of stay. The secondary outcomes included transfusion rates, pain scores, and postoperative complications. Multivariable regression models compared outcome medians across race/ethnicity. Disparities were defined as the difference in adjusted outcomes by race/ethnicity.

RESULTS

Four hundred twenty-four patients underwent posterior spinal fusion for adolescent idiopathic scoliosis at our institution (116 prepathway and 308 postpathway). The median length of stay of Black patients was 1.0 day (95% CI: 0.4, 1.5; p = .006) longer than White patients prepathway. Prepathway patients who self-identified as Other had a 1.2 (95% CI: 0.5, 1.9; p = .004) higher median average pain score on postoperative day 1 compared with White patients. On postoperative day 2, patients who identified as Other had 2.0 (95% CI: 0.8, 3.2; p = .005) higher pain score compared with White patients prepathway. Postpathway, there were no significant differences in outcomes by race/ethnicity.

CONCLUSIONS

Our study supports the hypothesis that use of a coordinated care pathway is associated with a reduction in racial and ethnic disparities in length of stay and pain scores in pediatric patients undergoing posterior spinal fusion.

Association Between Patient Diversity in Hospitals and Racial/Ethnic Differences in Patient Length of Stay

BACKGROUND

Hospitals serving a disproportionate share of racial/ethnic minorities have been shown to have poorer quality outcomes. It is unknown whether efficiencies in inpatient care, measured by length of stay (LOS), differ based on the proportion patients served by a hospital who are minorities.

OBJECTIVE

To examine the association between the racial/ethnic diversity of a hospital's patients and disparities in LOS.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

One million five hundred forty-six thousand nine hundred fifty-five admissions using the 2017 New York State Inpatient Database from the Healthcare Cost and Utilization Project.

MAIN MEASURE

Differences in mean adjusted LOS (ALOS) between White and Black, Hispanic, and Other (Asian, Pacific Islander, Native American, and Other) admissions by Racial/Ethnic Diversity Index (proportion of non-White patients admitted to total patients admitted to that same hospital) in quintiles (Q1 to Q5), stratified by discharge destination. Mean LOS was adjusted for patient demographic, clinical, and admission characteristics and for individual intercepts for each hospital.

KEY RESULTS

In both unadjusted and adjusted analysis, Black-White and Other-White mean LOS differences were smallest in the most diverse hospitals (Black-White: unadjusted, -0.07 days [-0.1 to -0.04], and adjusted, 0.16 days [95% CI: 0.16 to 0.16]; Other-White: unadjusted, -0.74 days [95% CI: -0.77 to -0.71], and adjusted, 0.01 days [95% CI: 0.01 to 0.02]). For Hispanic patients, in unadjusted analysis, the mean LOS difference was greatest in the most diverse hospitals (-0.92 days, 95% CI: -0.95 to -0.89) but after adjustment, this was no longer the case. Similar patterns across all racial/ethnic groups were observed after analyses were stratified by discharge destination.

CONCLUSION

Mean adjusted LOS differences between White and Black patients, and White and patients of Other race was smallest in most diverse hospitals, but not differences between Hispanic and White patients. These findings may reflect specific structural factors which affect racial/ethnic differences in patient LOS.

Trends in Same-Day Discharge Rate After Minimally Invasive Sacrocolpopexy and Propensity Score-Matched Analysis of Postoperative Complication Rates Using the National Surgical Quality Improvement Program Database

OBJECTIVE

The primary aim of this study was to review trends in the same-day discharge (SDD) rate after minimally invasive sacrocolpopexy (MISCP). The secondary aim was to compare the composite 30-day postoperative complication rates between propensity score-matched SDD and admitted cohorts.

METHODS

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2019. Patients who underwent MISCP were identified by Current Procedural Terminology codes. Concurrent hysterectomy, anterior or posterior repairs, rectopexy, and midurethral sling were also identified. Multivariable logistic regression and propensity score matching were performed.

RESULTS

A total of 12,762 MISCP patients were captured: 3,968 underwent MISCP only, 4,065 underwent MISCP with total laparoscopic hysterectomy, 734 underwent MISCP with laparoscopically assisted vaginal hysterectomy, and 3,995 underwent MISCP with laparoscopic supracervical hysterectomy. Overall, the SDD rate was 16.3%, with an increase from 12.3% in 2015 to 23.1% in 2019. Multivariable logistic regression showed that admitted patients were more likely to be older, to be of Black race, have an American Society of Anesthesiologists classification of 3 or 4, have hypertension requiring medication, have longer operative time, and have undergone concurrent anterior or posterior repair, rectopexy, or sling. After propensity score matching, the composite postoperative complication rates were similar between the 2 cohorts (5.7% vs 6.4%, P = 0.818). However, superficial surgical site infection was more likely in the SDD cohort (adjusted odds ratio, 2.3; P < 0.001) and blood transfusion in the admitted cohort (adjusted odds ratio, 11.9; P = 0.0.34).

CONCLUSIONS

The rate of SDD after MISCP seems to be increasing. Composite postoperative complication rates are similar between SDD and admitted cohorts.

Racial Disparities in 30-Day Outcomes After Colorectal Surgery in an Integrated Healthcare System

BACKGROUND

Racial disparities in colorectal surgery outcomes have been studied extensively in the USA, and access to healthcare resources may contribute to these differences. The Veterans Health Administration (VHA) is the largest integrated healthcare network in the USA with the potential for equal access care to veterans. The objective of this study is to evaluate the VHA for the presence of racial disparities in 30-day outcomes of patients that underwent colorectal resection.

METHODS

Colon and rectal resections from 2008 to 2019 were reviewed retrospectively using the Veterans Affairs Surgical Quality Improvement Program database. Patients were categorized by race and ethnicity. Multivariable analysis was used to compare 30-day outcomes. Cases with "unknown/other/declined to answer" race/ethnicity were excluded.

RESULTS

Thirty-six-thousand-nine-hundred-sixty-nine cases met inclusion criteria: 27,907 (75.5%) Caucasian, 6718 (18.2%) African American, 2047 (5.5%) Hispanic, and 290 (0.8%) Native American patients. There were no statistically significant differences in overall complication incidence or mortality between all cohorts. Compared to Caucasian race, African American patients had longer mean length of stay (10.7 days vs. 9.7 days; p < 0.001). Compared to Caucasian race, Hispanic patients had higher odds of pulmonary-specific complications (adjusted odds ratio with 95% confidence interval = 1.39 [1.17-1.64]; p < 0.001).

CONCLUSIONS

The VHA provides the benefits of integrated healthcare and access, which may explain the improvements in racial disparities compared to existing literature. However, some racial disparities in clinical outcomes still persisted in this analysis. Further efforts beyond healthcare access are needed to mitigate disparities in colorectal surgery. CLASSIFICATIONS: [Outcomes]; [Database]; [Veterans]; [Colorectal Surgery]; [Morbidity]; [Mortality].

Inpatient Palliative Care Is Less Utilized in Rare, Fatal Extrahepatic Cholangiocarcinoma: A Ten-Year National Perspective

Background—Extrahepatic cholangiocarcinoma (ECC) is a rare, morbid, fatal cancer with distressing symptoms. Maintaining a high quality of life while reducing hospital charges and length of stay (LOS) for the end-of-life period remains a major challenge for the healthcare system. Palliative care utilization has been shown to address these challenges; moreover, its use has increased in recent years among cancer patients. However, the utilization of palliative care in rare cancers, such as ECC, has not yet been explored. Objectives—To investigate palliative care utilization among ECC patients admitted to US hospitals between 2007 and 2016 and its association with patient demographics, clinical characteristics, hospital charges, and LOS. Methods—De-identified patient data of each hospitalization were retrieved from the National Inpatient Sample (NIS) database. Codes V66.7 (ICD-9-CM) or Z51.5 (ICD-10-CM) were used to find palliative care utilization. Multivariate adjusted logistic regression analyses were conducted to assess factors associated with palliative care use, LOS, hospital charges, and in-hospital death. Results—Of 4426 hospitalizations, only 6.7% received palliative care services. Palliative care utilization did not significantly increase over time (p = 0.06); it reduced hospital charges by USD 25,937 (p < 0.0001) and LOS by 1.3 days (p = 0.0004) per hospitalization. Palliative care was positively associated with female gender, severe disease, and age group ≥80 (p ≤ 0.05). The average LOS was 8.5 days for each admission. Conclusions—Hospital admissions with palliative care utilization had lower hospital charges and LOS in ECC. However, ECC patients received less palliative care compared with more common cancers sharing similar symptoms (e.g., pancreatic cancer). ECC patients also had longer LOS compared with the national average. Further research is warranted to develop interventions to increase palliative care utilization among ECC hospital patients.

Predictors of Extended Hospitalization and Early Reoperation After Elective Lumbar Disc Arthroplasty

BACKGROUND

Lumbar disc arthroplasty (LDA) has emerged as a motion-sparing alternative to lumbar fusion. Although LDA may be amenable to the ambulatory surgical setting, to date no study has identified the factors predisposing patients to extended hospital stay.

METHODS

A national surgical quality improvement database was queried from 2011 to 2019 for patients undergoing elective, single-level, primary LDA. Univariate and multivariate logistic regression analyses were performed to elucidate predictors of length of stay (LOS) at or above the 90th percentile of the study population (3 days). Secondary study endpoints included rates of complications, as well as predictors and reasons for unplanned reoperation within 30 days.

RESULTS

A total of 630 patients met eligibility criteria for the study, of whom 517 (82.1%) had LOS <3 days and 113 (17.9%) had LOS ≥3 days. Multivariate logistic regression revealed associations between prolonged hospitalization and postoperative diagnosis of degenerative disk disease, obesity, Hispanic identity, and operation length >120 minutes. Before discharge, patients with LOS ≥3 days were more likely to have venous thromboembolisms, pneumonia, surgical site infections, and reoperations. Independent predictors of reoperation were wound infections, diabetes, and smoking.

CONCLUSIONS

Complications following elective single-level LDA are relatively rare, with few extended hospitalizations being attributable to any specific complication. Risk factors for prolonged LOS appear to be related to diagnosis and surgical time rather than to modifiable preoperative comorbidities. Conversely, unplanned reoperations within 30 days are associated with optimizable perioperative factors such as smoking, diabetes, and surgical site infection.

Racial disparities in complications and mortality after bariatric surgery: A systematic review

BACKGROUND

Studies have shown racial discrepancies in the rates of postoperative adverse events following bariatric surgery (BS). We aim to systematically review the literature examining racial disparities in postoperative adverse events.

METHODS

PubMed, Embase, and SCOPUS databases were searched for studies that reported race, postoperative adverse events and/or length of stay.

RESULTS

Thirty-five studies were included. Most compared Black and White patients using standardized databases. Racial/ethnic terminology varied. The majority found increased 30-day mortality and morbidity and length of stay in Black relative to White patients. Differences between White and Hipanic patients were mostly non-significant in these outcomes.

CONCLUSIONS

Black patients may experience higher rates of adverse events than White patients within 30 days following bariatric surgery. Given the limitations in the large multicenter databases, explanations for this disparity were limited. Future research would benefit from longer-term studies that include more races and ethnicities and consider socioeconomic factors.

Racial and Ethnic Disparities in Access to Local Anesthesia for Inguinal Hernia Repair

BACKGROUND

Many studies have identified racial disparities in healthcare, but few have described disparities in the use of anesthesia modalities. We examined racial disparities in the use of local versus general anesthesia for inguinal hernia repair. We hypothesized that African American and Hispanic patients would be less likely than Caucasians to receive local anesthesia for inguinal hernia repair.

MATERIALS AND METHODS

We included 78,766 patients aged ≥ 18 years in the Veterans Affairs Surgical Quality Improvement Program database who underwent elective, unilateral, open inguinal hernia repair under general or local anesthesia from 1998-2018. We used multiple logistic regression to compare use of local versus general anesthesia and 30-day postoperative complications by race/ethnicity.

RESULTS

In total, 17,892 (23%) patients received local anesthesia. Caucasian patients more frequently received local anesthesia (15,009; 24%), compared to African Americans (2353; 17%) and Hispanics (530; 19%), P < 0.05. After adjusting for covariates, we found that African Americans (OR 0.82, 95% CI 0.77-0.86) and Hispanics (OR 0.77, 95% CI 0.69-0.87) were significantly less likely to have hernia surgery under local anesthesia compared to Caucasians. Additionally, local anesthesia was associated with fewer postoperative complications for African American patients (OR 0.46, 95% CI 0.27-0.77).

CONCLUSIONS

Although local anesthesia was associated with enhanced recovery for African American patients, they were less likely to have inguinal hernias repaired under local than Caucasians. Addressing this disparity requires a better understanding of how surgeons, anesthesiologists, and patient-related factors may affect the choice of anesthesia modality for hernia repair.

Racial/ethnic and socioeconomic variations in hospital length of stay: A state-based analysis

Disparities by race/ethnicity and socioeconomic status (SES) exist in rehospitalization rates and inpatient mortality rates. Few studies have examined how length of stay (LOS, a measure of hospital efficiency/quality) differs by race/ethnicity and SES.This study's objective was to determine whether differences in risk-adjusted LOS exist by race/ethnicity and SESUsing a retrospective cohort of 1,432,683 medical and surgical discharges, we compared risk-adjusted LOS, in days, by race/ ethnicity and SES (median household income by patient ZIP code in quartiles), using generalized linear models controlling for demographic and clinical factors, and differences between hospitals and between diagnoses.White patients were on average older than both Black and Hispanic patients, had more chronic conditions, and had a higher inpatient mortality risk. In adjusted analyses, Black patients had a significantly longer LOS than White patients (0.25-day difference when discharged to home and 0.23-day difference when discharged to non-home destinations, both P<.001); there was no difference between Hispanic and White patients. Wealthier patients had a shorter LOS than poorer patients (0.16-day difference when discharged to home and 0.06-day difference when discharged to nonhome destinations, both P<.001). These differences by race/ethnicity reversed for Medicaid patients.Disparities in LOS exist based on a patient's race/ethnicity and SES. Black and poorer patients, but not Hispanic patients, have longer LOS compared to White and wealthier patients. In aggregate, these differences may be related to trust and implicit bias and have implications for use of LOS as a quality metric. Future research should examine the drivers of these disparities.

Insurance Type and Marital Status Impact Hospital Length of Stay After Pancreatoduodenectomy

BACKGROUND

Recognition of the impact of social determinants on health care and surgical outcomes is imperative to improve patient care. This study aims to examine the impact social determinants have on hospital length of stay (LOS) after pancreatoduodenectomy (PD).

METHODS

Retrospective review of a prospective American College of Surgeons-National Surgical Quality Improvement Program database identified patients who underwent PD from 2013 to 2018. Patients were categorized by insurance type (public/private/multiple), and electronic medical record review was performed to obtain distance from home, marital status, and race. Public insurance included Medicare and Medicaid; multiple types were defined as public insurance supplemented by a private insurance. Univariable analysis was used to identify potential confounders. Significant differences (P < 0.05) were controlled for using multivariable regression models to examine the effect of variables on LOS.

RESULTS

About 813 PDs were included (n = 341 public; n = 238 private; and n = 234 multiple). Patients with public insurance had significantly longer LOS than patients with private on univariate (P < 0.001) and multivariable analyses (P = 0.021) (8 versus 7 d). Patients with multiple insurance types showed significantly increased LOS compared with patients with private on univariable (P < 0.001) and multivariable analyses (P = 0.006) (8 versus 7 d). Single patients had significantly longer LOS compared with married patients on univariable (P = 0.012) and multivariable analyses (P = 0.005) (8 versus 7 d). Distance from home, race, gender, or age did not have a significant impact on LOS.

CONCLUSIONS

Single patients and patients with public or multiple insurance types are more likely to have longer hospital LOS after PD. These findings will enable physicians to identify patients at risk and target them for enhanced recovery programming.

Trends in Medical and Surgical Admission Length of Stay by Race/Ethnicity and Socioeconomic Status: A Time Series Analysis

BACKGROUND

Length of stay (LOS), a metric of hospital efficiency, differs by race/ethnicity and socioeconomic status (SES) and longer LOS is associated with adverse health outcomes. Historically, projects to improve LOS efficiency have yielded LOS reductions by 0.3 to 0.7 days per admission.

OBJECTIVE

To assess differences in average adjusted length of stay (aALOS) over time by race/ethnicity, and SES stratified by discharge destination (home or non-home).

METHOD

Data were obtained from 2009-2014 Healthcare Cost and Utilization Project State Inpatient Datasets for New York, New Jersey, and Florida. Multivariate generalized linear models were used to examine trends in aALOS differences by race/ethnicity, and by high vs low SES patients (defined first vs fourth quartile of median income by zip code) controlling for patient, disease and hospital characteristics.

RESULTS

For those discharged home, racial/ethnic and SES aALOS differences remained stable from 2009 to 2014. However, among those discharged to non-home destinations, Black vs White aALOS differences increased from 0.21 days in Q1 2009, (95% confidence interval (CI): 0.13 to 0.30) to 0.32 days in Q3 2013, (95% CI: 0.23 to 0.40), and for low vs high SES patients from 0.03 days in Q1 2009 (95% CI: -0.04 to 0.1) to 0.26 days, (95% CI: 0.19 to 0.34). Notably, for patients not discharged home, racial/ethnic and SES aALOS differences increased and persisted after Q3 2011, coinciding with the introduction of the Affordable Care Act (ACA).

CONCLUSION

Further research to understand the ACA's policy impact on hospital efficiencies, and relationship to racial/ethnic and SES differences in LOS is warranted.

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease

BACKGROUND

Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients.

METHODS

This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005-2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes.

RESULTS

Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1-1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1-2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4-1.9), and sepsis (OR: 1.7; 95% CI 1.4-2.02) compared to White patients.

CONCLUSIONS

Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.

Racial Disparities in Complications, Length of Stay, and Costs Among Patients Receiving Orthognathic Surgery in the United States

INTRODUCTION

Black and Hispanic/Latino patients in the United States often experience poorer health outcomes in comparison to White patients. We aimed to assess the impact of race on complications, length of stay, and costs after orthognathic surgery.

METHODS

Pediatric and young adult orthognathic surgeries (age <21) were isolated from the Kids Inpatient Database from 2000-2012. Procedures were grouped into cohorts based on the preoperative diagnosis: apnea, malocclusion, or congenital anomaly. T tests and χ² analyses were employed to compare complications, length of stay (LOS), and costs among Black, Hispanic, Asian/Pacific Islander, and other patients in comparison to White patients. Multivariable regression was performed to identify associations between sociodemographic variables and the primary outcomes. Post-hoc χ² analyses were performed to compare proportions of patients of a given race/ethnicity across the 3 surgical cohorts.

RESULTS

There were 8,809 patients identified in the KID database (mean age of 16.3 years). Compared to White patients, complication rates were increased among Hispanic patients (2.1 vs 1.3%, P = .037) and other patients treated for apnea (8.7 vs 0.83%, P = .002). Hospital LOS was increased in both Black (3.3 vs 2.1 days, P < .001) and Hispanic (2.9 days, P < .001) patients. Costs were higher than Whites ($35,633.47) among Hispanic ($48,029.15, P < .001), Black ($47,034.41, P < .001), and Asian/Pacific-Islander ($44,192.49, P < .001) patients. White patients comprised a larger proportion of the malocclusion group (77.8%) than apnea (66.9%, P < .001) or congenital anomaly (59.1%, P < .001), while the opposite was true for Black, Hispanic, and Asian/Pacific-Islander patients.

CONCLUSION

There are significant differences in complications, LOS, and costs after orthognathic surgery among patients of different race/ethnicity. Further studies are needed to better understand the causes of disparity and their clinical manifestations.

Low Health Literacy Exists in the Inflammatory Bowel Disease (IBD) Population and Is Disproportionately Prevalent in Older African Americans

BACKGROUND

Low health literacy is common in general populations, but its prevalence in the inflammatory bowel disease (IBD) population is unclear. The objective of this study was to assess the prevalence of low health literacy in a diverse IBD population and to identify risk factors for low health literacy.

METHODS

Adult patients with IBD at a single institution from November 2017 to May 2018 were assessed for health literacy using the Newest Vital Sign (NVS). Demographic and socioeconomic data were also collected. Primary outcome was the prevalence of low health literacy. Secondary outcomes were length-of-stay (LOS) and 30-day readmissions after surgical encounters. Bivariate comparisons and multivariable regression were used for analyses.

RESULTS

Of 175 IBD patients, 59% were women, 23% were African Americans, 91% had Crohn disease, and mean age was 46 years (SD = 16.7). The overall prevalence of low health literacy was 24%. Compared to white IBD patients, African Americans had significantly higher prevalence of low health literacy (47.5% vs 17.0%, P < 0.05). On multivariable analysis, low health literacy was associated with older age and African American race (P < 0.05). Of 83 IBD patients undergoing abdominal surgery, mean postoperative LOS was 5.5 days and readmission rate was 28.9%. There was no significant difference between LOS and readmissions rates by health literacy levels.

CONCLUSIONS

Low health literacy is present in IBD populations and more common among older African Americans. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities and to benefit those with low health literacy.

Hospital Disparities between Native Hawaiian and Other Pacific Islanders and Non-Hispanic Whites with Alzheimer's Disease and Related Dementias

Objective: To compare important indicators of quality of care between Native Hawaiians and other Pacific Islanders (NHOPIs) and non-Hispanic Whites (NHWs) with Alzheimer's disease and related dementias (ADRD). Methods: We used the Health Care Cost and Utilization Project, Hawaii State Inpatient Databases, 2010-2014. They included 10,645 inpatient encounters from 7,145 NHOPI or NHW patients age ≥ 50 years, residing in Hawaii, and with at least one ADRD diagnosis in the discharge record. Outcome variables were inpatient mortality, length of hospital stay, and hospital readmission. Results: NHOPIs with ADRD had, on average, a hospital stay of .94 days less than NHWs with ADRD but were 1.16 times more likely than NHWs to be readmitted. Discussion: These patterns have important clinical care implications for NHOPIs and NHWs with ADRD as they are important indicators of quality of care. Future studies should consider specific contributors to these differences in order to develop appropriate interventions.

Progress in research of enhanced recovery after surgery and surgery related differences

Enhanced recovery after surgery (ERAS) refers to the use of standardized, multimodal perioperative strategies to reduce physiological stress and organ dysfunction caused by surgery. Since the ERAS concept was put forward, it has been widely respected in the surgical field. Its benefits in the surgical field for the vast majority of patients, medical staff and healthcare systems are obvious. However, for some specific people undergoing surgery, the benefits are not certain, which is the so-called surgery-related differences. This article analyzes recent studies of different surgical fields related to surgical-related differences in different ethnic groups, reviews a large number of positive effects of the implementation of ERAS on surgical-related differences, and elaborates its possible mechanism. It is finally concluded that ERAS, a standardized model for resolving surgical-related differences, should become the gold standard for surgical perioperative management.

Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013–2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88–6.69) (OR: 11.24; 95% CI: 8.53–13.95), more time spent in ICU (2.73; 1.70–3.76) (7.98; 6.10–9.87), and increased risk for surgical site infection (1.32; 1.03–1.68) (2.54; 1.71–3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.

Quality Improvement in Minimally Invasive Esophagectomy: Outcome Improvement Through Data Review

BACKGROUND

Esophagectomy is a complex operation in which outcomes are profoundly influenced by operative experience and volume. We report the effects of experience and innovation on outcomes in minimally invasive esophagectomy.

METHODS

Esophageal resections for cancer from 2007 to 2016 at Levine Cancer Institute at Carolinas Medical Center (Charlotte, NC) were reviewed. During this time, three changes in technique were made to improve outcomes: vascular evaluation of the gastric conduit to improve anastomotic healing (beginning at case #63), one-stage approach to permit access to abdomen and chest through one draped surgical field (case #82), and adoption of a lung-protective anesthetic protocol (case #101). Mortality, operative time, complications, and length of stay were analyzed relative to these interventions using GLM regression.

RESULTS

200 patients underwent minimally invasive esophagectomy. There were no mortalities at 30 days, and no change in mortality rate at 60 and 90 days. Anastomotic leak decreased significantly after the introduction of intraoperative vascular evaluation of the gastric conduit (3.6 vs 19.4%). Operative time decreased with adoption of a one-stage approach (416 vs 536 min). Pulmonary complications decreased coincident with a change in anesthetic technique (pneumonia 6 vs 28%). Lymph node harvest increased over time. Length of stay was driven primarily by complications and decreased with operative experience.

CONCLUSIONS

Postoperative complications, operative time, and length of stay decreased with case experience and alterations in surgical and anesthetic technique. We believe that adoption of the techniques and technology described herein can reduce complications, reduce hospital stay, and improve patient outcomes.

South Carolina Surgical Quality Collaborative Colon Surgery Outcomes Vary by Age and Race

Identifying disparities in surgical outcomes among patient populations may help hospitals target patients at highest risk for complications. The South Carolina Surgical Quality Collaborative (SCSQC) is a regional collaborative made up of eight facilities whose goal is to improve the quality and value of general surgical care in South Carolina. Using SCSQC data, we reviewed colon surgery outcomes to determine whether disparities exist between specific patient populations. SCSQC colon surgery data were reviewed from August 2015 to August 2017. SSI, length of stay, return to the ED, and reoperation rates were used as outcome measures. They were evaluated in patient populations stratified by gender, race (white, black, and other), and age (<50, 50–70, and >70 years). A total of 2611 patients were included in this study. Statistically significant differences in outcomes were identified between white and black patients in length of stay (6.0 vs 7.5 days, P < 0.0001) and return to the ED (8.1% vs 14.7%, P < 0.0001), but not in SSI (6.4% vs 6.8%, P = 0.8839) or reoperation rates (6.4% vs 8.4%, P = 0.1886). Length of stay increased with increasing age (4.1 vs 7.1 vs 8.8, P < 0.0001). SSI varied by age (4.0% vs 8.2% vs 6.4%, P = 0.0005), as did return to the ED (11.2% vs 9.7% vs 769%, P = 0.0987) and reoperation rates (4.5% vs 8.1% vs 8.2%, P = 0.0034). SCSQC data indicate that race and age may place patients at risk for negative outcomes after colorectal surgery.

Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients.

METHODS

A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes.

RESULTS

Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64).

CONCLUSIONS

Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.