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How Can Surgical Outcomes be Improved for Black Patients?

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Black patients undergoing surgery were more than 40% more likely than white patients to be referred from the hospital to a nursing home, and this disparity appeared to be mitigated by preoperative management of severe diabetes and hypertension, a retrospective analysis of hospital data reports.

“Black race is a predictor of nursing home discharge after surgery,” study senior author Matthias Eikermann, MD, told Medscape Medical News in an email.

Matthias Eikermann, MD, PhD

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“Importantly, pre-existing severe diabetes mellitus and hypertension, which are more common in black patients than in white patients, explains the impact of self-identifying black patients having higher adverse postoperative discharge rates in nursing homes,” added Eikermann, professor of anesthesiology at the Albert Einstein College of Medicine and head of the department of anesthesiology at Montefiore Medical Center in the Bronx, New York.

As reported in Annals of Surgery, Eikermann and colleagues analyzed electronic medical records and hospitalization data for all adult patients who underwent surgery between January 2007 and February 2020 across two academic health networks in Massachusetts. They compared patients who identified as non-Hispanic blacks with those who identified as non-Hispanic whites.

The researchers determined the proportion of patients in each group who were transferred to a long-term facility after surgery and lost the ability to live independently. Among them were those who died after the operation while still in the hospital. The authors also examined readmission within 30 days of hospital discharge and death within 30 days of surgery.

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Overall, 38,010 (10.3%) patients identified their race as black and 330,350 (89.7%) identified their race as white. The black group tends to be younger than the white group, proportionately more female, and lower household income. Black patients also had higher rates of kidney disease, heart failure, diabetes and hypertension, but lower rates of cancers and tumors diagnosed before surgery. Black patients were more likely to have outpatient procedures that were shorter and less complex, with lower rates of general anesthesia.

  • In adjusted analysis, black patients were at higher risk of not being able to live independently after surgery than white patients (adjusted odds ratio 1.42; 95% CI 1.35–1.50; adjusted absolute risk difference). [ARDadj,] 1.9%; 95% CI, 1.6-2.2%).

  • In adjusted analyzes, Black patients had a significantly higher risk of pre-existing severe diabetes (ARDadj, 4.7%; 95% CI, 4.5–5.0%) and hypertension (ARDadj, 14.1%; 95% CI, 13.6–14.6%). which were associated with an increased risk of loss of independent living.

  • Although black patients were not at higher risk of 30-day mortality, they were more likely to be readmitted within 30 days of hospital discharge (ARDadj, 1.9%; 95% CI, 1.5%-2.2%) .

  • Black patients had a higher risk of high preoperative A1c levels (ARDadj, 8.4%; 95% CI, 7.0%-9.9%). A high preoperative A1c was associated with a higher risk of postoperative nursing home discharge (ARDadj, 3.7%; 95% CI, 3.0%-4.5%).

  • The association between race and postoperative loss of independent life was stronger in patients who did not receive pharmacotherapy as recommended during the year prior to surgery (ARDadj, 4.3%; 95% CI, 3.2%-5.4%). The association was weaker in patients who received a low proportion of recommended pharmacotherapy (ARDadj, 1.6%; 95% CI, 0.8–2.4%) and was not significant in those who received a high proportion of pharmacotherapy consistent with the recommendations. recommendations. .

  • Among patients with severe diabetes or hypertension who did not receive pharmacotherapy as recommended, the 30-day risk of rehospitalization was higher in black patients (ARDadj, 1.8%; 95% CI, 0.8%–2.8% ). In contrast, among patients who received a high proportion of pharmacotherapy as recommended, the association between race and 30-day readmission was not significant.

  • Black patients were less likely to be treated by the facility’s regular surgeons (ARDadj, -0.6%; 95% CI, -0.7%-0.5%).

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The authors acknowledge the study’s limitations, including its retrospective design and reliance on electronic health records and administrative databases.

“The strengths of our study are the large patient cohort and complex statistical analysis, which was adjusted for many important factors that may have influenced our results,” said Eikermann.

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Screening and management of patients with diabetes and hypertension

“Racial and ethnic minorities, primarily blacks and Hispanics, are disproportionately affected by diabetes and its complications,” said Maya Faifman, MD, assistant professor of endocrinology at Emory University School of Medicine in Atlanta, Georgia. email.

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Maya Faifman, MD

“It is important that the research and medical communities continue to explore and implement interventions in these affected populations to reduce the disease burden,” added Faifman, who was not involved in the study. “As the diabetes epidemic grows, interventions targeting those most at risk will have the greatest impact on overall improved outcomes.”

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Chinenye Uso, MD, assistant professor of endocrinology and metabolism at Wake Forest School of Medicine in Winston-Salem, North Carolina, urges healthcare professionals to understand that differences in care exist and lead to worse outcomes for certain groups of people.

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Repaired Usokhi, MD

“Many of the worst outcomes seen in African Americans are due to delayed access to medical care and medications for common diseases that have relatively inexpensive treatments,” she explained in an email. “I was encouraged by the simplicity of the solution: treat diabetes and hypertension based on standard guidelines.”

Usos, who was also not involved in the study, urges clinicians to screen for diabetes and hypertension in their African American and other high-risk patients and treat them early.

“Physicians need to be aware of the significant difference they can make by treating conditions early and appropriately,” she advises.

Ackerman agrees. “Patients who enter a nursing home after surgery have a higher risk of cognitive decline, have a lower quality of life, and seek medical care more often,” he noted.

“Our findings highlight the value of managing diabetes and hypertension as recommended and an optimized preoperative evaluation to improve surgical outcomes and address health disparities. We have to start now, but many hospitals don’t have the resources to succeed without public support,” he said.

“Our next step is to show that developing and implementing a rigorous program to improve the management of severe diabetes and hypertension will also improve surgical outcomes,” said Eikermann. “If our society could provide fair treatment for diabetes and hypertension, then surgical outcomes would be improved and healthcare disparities would be effectively eliminated.”

Eikermann and one co-author report financial relationships with pharmaceutical companies. Usokh and Faifman do not report any related financial relationship. The study was funded by Geoffrey and Judith Buzan.

Annals of Surgery. Posted online June 28, 2022 Abstract

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