Disparities and Risk Factors for Surgical Complication in American Indians and Native Hawaiians

Disparities in Postmastectomy Breast Reconstruction Among American Indian and Alaska Native Women: A Systematic Literature Review and Meta-analysis

Disparities in healthcare access and outcomes are well documented among racial and ethnic minority groups in the USA, with American Indian/Alaska Native (AI/AN) women experiencing significant barriers to postmastectomy breast reconstruction. This systematic review and meta-analysis of 11 studies highlights these disparities, revealing that AI/AN women are significantly less likely to undergo reconstruction compared with non-Hispanic white women (pooled OR 0.47, 95% CI 0.34-0.66). Contributing factors include geographic isolation, socioeconomic barriers, limited access to reconstructive surgeons, and cultural influences shaped by historical trauma and systemic inequities. Geographic and financial challenges are compounded by inadequate healthcare infrastructure and low rates of culturally sensitive outreach. Addressing these disparities requires targeted interventions such as enhanced healthcare access in rural areas, policy reforms to improve insurance coverage, and culturally tailored patient education initiatives.

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.

Taking action to achieve health equity and eliminate healthcare disparities within acute care surgery

Addressing disparities is crucial for enhancing population health, ensuring health security, and fostering resilient health systems. Disparities in acute care surgery (trauma, emergency general surgery, and surgical critical care) have been well documented and the magnitude of inequities demand an intentional, organized, and effective response. As part of its commitment to achieve high-quality, equitable care in all aspects of acute care surgery, the American Association for the Surgery of Trauma convened an expert panel at its eigty-second annual meeting in September 2023 to discuss how to take action to work towards health equity in acute care surgery practice. The panel discussion framed contemporary disparities in the context of historic and political injustices, then identified targets for interventions and potential action items in health system structure, health policy, the surgical workforce, institutional operations and quality efforts. We offer a four-pronged approach to address health inequities: identify, reduce, eliminate, and heal disparities, with the goal of building a healthcare system that achieves equity and justice for all.

An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes

BACKGROUND

Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics.

RESULTS

Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients.

CONCLUSION

Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].

Urgent versus elective surgical disparities among American Indian and Alaska Native patients

BACKGROUND

American Indian and Alaska Native (AIAN) health issues are understudied despite documentation of lower-than-average life expectancy. Urgent surgery is associated with higher rates of postsurgical complications and postoperative death. We assess whether American Indian and Alaska Native (AIAN) patients in Washington State are at greater risk of requiring urgent rather than elective surgery compared with non-Hispanic Whites (NHW).

METHODS

We accessed data for the period 2009-2014 from the Washington State Comprehensive Hospital Abstract Reporting System (CHARS) database, which captures all statewide hospital admissions, to examine three common surgeries that are performed both urgently and electively: hip replacements, aortic valve replacements, and spinal fusions. We extracted patient race, age, insurance status, comorbidity, admission type, and procedures performed. We then constructed multivariable logistic regression models to identify factors associated with use of urgent surgical care.

RESULTS

AIAN patients had lower mean age at surgery for all three surgeries compared with NHW patients. AIAN patients were at higher risk for urgent surgery for hip replacements (OR = 1.49, 95% CI 1.19-1.88), spinal fusions (OR = 1.39, 95% CI 1.04-1.87), and aortic valve replacements (OR = 2.06, 95% CI 1.12-3.80).

CONCLUSION

AIAN patients were more likely to undergo urgent hip replacement, spinal fusion, and aortic valve replacement than NHW patients. AIAN patients underwent urgent surgery at younger ages. Medicaid insurance conferred higher risks for urgent surgery across all surgeries studied. Further research is warranted to more clearly identify the factors contributing to disparities among AIAN patients undergoing urgent surgery.

The Relationship Between Public Interest and Surgical Demand During the COVID-19 Pandemic

INTRODUCTION

Surgical databases are useful for examining outcomes and case volume to improve care, while public interest data has the potential to track the supply and demand of medical services in specific communities. However, the relationship between public interest data and case volume from surgical databases, specifically during disruptive instances like the coronavirus pandemic, is unknown. Therefore, the purpose of this study is to determine how public interest data is related to the case volume of coronavirus and other surgical procedures performed during the coronavirus pandemic.

METHODS

This retrospective study included a review of appendectomy, total hip arthroplasty (THA), and total knee arthroplasty (TKA) cases from the National Surgery Quality Improvement Project and relative search volume (RSV) of hip replacement, knee replacement, appendicitis, and coronavirus from Google Trends from 2019 to 2020. T-tests were used to compare surgical caseload and RSV data before and after the COVID-19 surge in March 2020, while linear models were used to determine relationships between confirmed procedures and relative search volumes.

RESULTS

The RSV for knee replacement (p < 0.001, Cohen's D [d] = -5.01, 95% confidence interval [CI]: -7.64 to -2.34) and hip replacement (p < 0.001, d = -7.22, 95% CI: -10.85 to -3.57) had a large dip during the coronavirus pandemic, while the RSV for appendicitis had a smaller dip (p = 0.003, d = -2.37, 95% CI: -3.93 to -0.74). Linear models showed very strong linear relationships between surgical RSV and surgical volume for TKA (R² = 0.931) and THA (R² = 0.940).

CONCLUSIONS

There was a significant reduction in the number of elective surgeries, which correlated to drops in public interest during COVID-19. The strong correlations between RSV, surgical volume, and coronavirus cases indicate that public interest can be used to track and predict surgical case volume. Our findings allow for greater insight into the use of public interest data to gauge surgical demand.