Disparities In Surgical Outcomes Research Articles

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

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. 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. 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. 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.].

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

BackgroundDisparities 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 MethodsNational 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. ResultsOf 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. ConclusionRacial 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.

Racial disparities in surgical outcomes after mastectomy in 223000 female breast cancer patients: a retrospective cohort study.

Breast cancer mortality and treatment differ across racial groups. It remains unclear whether such disparities are also reflected in perioperative outcomes of breast cancer patients undergoing mastectomy. The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2021) to identify female patients who underwent mastectomy for oncological purposes. The outcomes were stratified by five racial groups (white, Black/African American, Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and included 30-day mortality, reoperation, readmission, surgical and medical complications, and non-home discharge. The study population included 222947 patients, 68% ( n =151522) of whom were white, 11% ( n =23987) Black/African American, 5% ( n =11217) Asian, 0.5% ( n =1198) American Indian/Alaska Native, and 0.5% ( n =1018) Native Hawaiian/Pacific Islander. While 136690 (61%) patients underwent partial mastectomy, 54490 (24%) and 31767 (14%) women received simple and radical mastectomy, respectively. Overall, adverse events occurred in 17222 (7.7%) patients, the largest portion of which were surgical complications ( n =7246; 3.3%). Multivariable analysis revealed that being of Asian race was protective against perioperative complications [odds ratio (OR)=0.71; P <0.001], whereas American Indian/Alaska Native women were most vulnerable to the complication occurrence (OR=1.41; P <0.001). Black/African American patients had a significantly lower risk of medical (OR=0.59; P <0.001) and surgical complications (OR=0.60; P <0.001) after partial and radical mastectomy, respectively, their likelihood of readmission (OR=1.14; P =0.045) following partial mastectomy was significantly increased. The authors identified American Indian/Alaska Native women as particularly vulnerable to complications following mastectomy. Asian patients experienced the lowest rate of complications in the perioperative period. The authors' analyses revealed comparable confounder-adjusted outcomes following partial and complete mastectomy between Black and white races. Their findings call for care equalization in the field of breast cancer surgery.

Disparities in surgical outcomes and survival based on insurance status among patients with fibrolamellar hepatocellular carcinoma: A national perspective.

440 Background: Fibrolamellar hepatocellular carcinoma (FL-HCC), encompassing 1%-5% of all liver cancers, is a rare, malignant cancer that typically affects patients less than 40 years old. FL-HCC usually affects individuals with healthy livers and initially presents asymptomatically. Prior studies describe the importance of surgery on survival, with a 5-year survival of about 44%-68% with surgery versus 2%-17% without surgery. Disparities in outcomes regarding surgical factors and survival between private insurance, Medicare, Medicaid, and no insurance remain unknown. This study aims to determine differential surgical factors and survival of patients with FL-HCC based on insurance status. Methods: The National Cancer Database was used to identify patients diagnosed with FL-HCC from 2004-2019 using the histology code 8171 as assigned by the Commission on Cancer Accreditation program. Kaplan-Meier, Chi-Square, ANOVA, and Cox Proportional Hazards tests were performed. Data was analyzed using SPSS version 29 and statistical significance was set at α=0.05. Results: Of the 436 patients included, 241 (55%) had private insurance and 96 (22%) had Medicare. Patients with private insurance had a longer median survival (49 months) than patients with Medicare (18 months; p&lt;.001) and Medicaid (26 months; p&lt;.004);no significant survival difference existed between Medicare, Medicaid, and no insurance (39 months) ( p’s≥.063). After controlling for age, income, tumor size, adjuvant therapy, receiving surgery, and surgical margins of primary site, private insurance was associated with an independent decrease in hazard (HR=.899; p=.004).Patients with private insurance received more surgery (68%) than those with Medicaid (50%), no insurance (48%), and Medicare (32%) ( p’s&lt;.001); grade did not differ amongst insurance types ( p=.069).Furthermore, patients with private insurance had more surgical margins of the primary tumor site without residual tumor (57%) compared to those with Medicaid (40%), no insurance (38%), and Medicare (23%) ( p’s&lt;.001).While patients with Medicare presented with greater co-morbidities, age at diagnosis (67), tumor size (476 mm), positive regional lymph nodes (90), and days between diagnosis and treatment (45), patients with private insurance presented at a younger age (31) with fewer co-morbidities, smaller sized tumors (366 mm), and fewer days between diagnosis and treatment (26) ( p’s&lt;.018). Conclusions: Since patients with private insurance received the most surgery, best surgical margins, and displayed the highest overall survival, while patients with Medicare were diagnosed at the highest age with the largest tumor size and most positive regional lymph nodes, future research should explore ways to alleviate the disparity in factors affecting surgical resections and early diagnoses among insurance statuses.

Development of a comprehensive survey to assess key socioecological determinants of health

BackgroundAlthough disparities in surgical outcomes are well-documented, our understanding of how socioecological factors drive these disparities remains limited. Comprehensive and efficient assessment tools are needed. This study’s objective was to develop and assess the acceptability and feasibility of a comprehensive tool evaluating socioecological determinants of health in patients requiring colorectal surgery. MethodsIn the first phase, a comprehensive socioecological determinant of health assessment tool was developed. A review of validated socioecological health evaluation instruments was conducted, and a 2-step modified Delphi method addressed the length, clarity, appropriateness, and redundancy of each instrument. A comprehensive tool was then finalized. In the second phase, the tool was tested for acceptability and feasibility in adult patients requiring colorectal surgery using a theory-guided framework at 3 Alabama hospitals. Relationships between survey responses and measures of acceptability and feasibility were evaluated using results from initial pilot tests of the survey. ResultsIn Phase 1, a modified Delphi process led to the development of a comprehensive tool that included 31 socioecological determinants of health (88 questions). Results of acceptability and feasibility were globally positive (>65%) for all domains. Overall, 83% of participants agreed that others would have no trouble completing the survey, 90.4% of respondents reported the survey was not burdensome, 97.6% of patients reported having enough time to complete the survey, and 80.9% agreed the survey was well-integrated into their appointment. ConclusionAn 88-item assessment tool measuring 31 socioecological determinants of health was developed with high acceptability and feasibility for patients who required colorectal surgery. This work aids in the development of research needed to understand and address surgical disparities.

Current Trends in Mortality Attributable to Racial or Ethnic Disparities in Post-Surgical Population in The United States: A Population-Based Study.

No study has contextualized the excess mortality attributable to racial and ethnic disparities in surgical outcomes. Further, not much effort has been made to quantify the effort needed to eliminate these disparities. We examined the current trends in mortality attributable to racial or ethnic disparities in the US postsurgical population. We then identified the target for mortality reduction that would be necessary to eliminate these disparities by 2030. We performed a population-based study of 1,512,974 high-risk surgical procedures among adults (18-64 years) performed across US hospitals between 2000 and 2020. Between 2000 and 2020, the risk-adjusted mortality rates declined for all groups. Nonetheless, Black patients were more likely to die following surgery (adjusted relative risk 1.42; 95% CI, 1.39-1.46) driven by higher Black mortality in the northeast (1.60; 95% CI, 1.52-1.68), as well as the West (1.53; 95% CI, 1.43-1.62). Similarly, mortality risk remained consistently higher for Hispanics compared with White patients (1.21; 95% CI, 1.19-1.24), driven by higher mortality in the West (1.26; 95% CI, 1.21-1.31). Overall, 8364 fewer deaths are required for Black patients to experience mortality on the same scale as White patients. Similar figures for Hispanic patients are 4388. To eliminate the disparity between Black and White patients by 2030, we need a 2.7% annualized reduction in the projected mortality among Black patients. For Hispanics, the annualized reduction needed is 0.8%. Our data provides a framework for incorporating population and health systems measures for eliminating disparity in surgical mortality within the next decade.

Association of County-Level Food Deserts and Food Swamps with Hepatopancreatobiliary Cancer Outcomes

BackgroundMalnutrition has been linked to the development of hepatopancreatobiliary (HPB) cancer. We sought to examine the association between food swamps and food deserts on surgical outcomes of patients with HPB cancer. MethodsPatients who underwent surgery for HPB cancer between 2014 and 2020 were identified from the Medicare Standard Analytic Files. Patient-level data were linked to the United States Department of Agriculture data on food swamps and deserts. Multivariable regression was performed to examine the association between the food environment and outcomes. ResultsAmong 53,426 patients, patients from the worse food environment were more likely to be Black, have a higher Charlson Comorbidity Index, and reside in areas with high social vulnerability. Following surgery, the overall incidence of textbook outcome (TO) was 41.6% (n = 22,220). Patients residing in the worse food environments less often achieved a TO versus individuals residing in the healthiest food environments (food swamp: 39.4% vs. 43.9%; food desert: 38.5% vs 42.2%; p < 0.05). On multivariable analysis, individuals residing in the poorest food environments were associated with lower odds of achieving TO compared with individuals living in healthiest food environments (food swamp: OR 0.83, 95%CI 0.75–0.92, food desert: OR 0.86, 95%CI 0.76–0.97; both p < 0.05). ConclusionThe surrounding food environment of patients may serve as a modifiable socio-demographic risk factor that contributes to disparities in surgical outcomes of HPB cancer.

Quality surgery for gastrointestinal cancers in the Deep South: Disparities in elements of the Enhanced Recovery Program.

183 Background: Disparities in surgical outcomes exist for Black gastrointestinal cancer patients and may be due to the lower likelihood of undergoing quality surgery that minimizes adverse surgical outcomes. The Enhanced Recovery Program (ERP) has shown to improve perioperative outcomes through standardization of care and to reduce disparities in surgical outcomes in certain settings. The extent to which ERP is applied across patient groups is currently unclear, especially for patients in high poverty states of the Deep South. Methods: The ASCENDS study conducted a survey of colorectal, pancreatic, and esophageal cancer patients (stage 1-3, diagnosed within 5 years, had surgery) in Alabama and Mississippi. Survivors were recruited through the Alabama Statewide Cancer Registry and select hospitals in these states. Survey questions asked about selected ERP components including: 1) education and counseling about surgery, i.e., i) surgeon/other health care provider in surgery clinic gave instructions about getting ready for surgery, ii) instructions were definitely easy to understand; 2) carbohydrate drink before surgery (e.g., Sprite); 3) pain medication; 4) anti-thrombotic and antibiotic prophylaxis; 5) bladder catheter (removed day after surgery); 6) early mobilization (walking) and nutrition on day of surgery, and mobilization the day after surgery. Fisher Exact or Chi Square tests were performed to examine significant differences across White (W) and Black, Indigenous, or persons of color (BIPOC) respondents. Results: Of 272 survey respondents (mean age 63.17±11.57, range 23-92), 71.3% were W, 28.3% BIPOC, 55.5% women, 76.8% had colorectal,16.2% pancreatic, and 7% esophageal cancer, 58.8% were from rural areas, 33.8% had low health literacy, 46.7% had private insurance, 32.3% Medicaid or Medicare/Medicaid, and 21.7% Medicare. See Table 1. Conclusions: Overall, there were no disparities in ERP components as recalled by survey respondents. Low uptake of some of the ERP components is worrisome, although data from medical records is needed to confirm findings. Improvements may be needed to improve surgery outcomes for alI GI cancer patients in the Deep South.[Table: see text]

Demographic Disparities in Surgical Outcomes of Patients With Craniosynostosis

Demographic Disparities in Surgical Outcomes of Patients With Craniosynostosis

Perioperative care of vulnerable populations

Social determinants of health can affect outcomes after surgery. Access to care represents a target to minimize disparities in surgical outcomes. While the implementation of video virtual visits seems on the surface to be the natural solution for improving patient access to care in rural communities, successful implementation of video virtual visits depends on local access to broadband internet. Written communication can be an effective method to provide information to patients, as long as principles of health literacy are upheld.

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

IntroductionEnhanced 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. MethodsRetrospective 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. ResultsOf 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). ConclusionWhile 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

BackgroundAlthough 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. MethodsWe 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%. ResultsSix 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). ConclusionKey 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.

Invited commentary: Mediation analysis and cancer screening, identifying areas to target to improve cancer disparities.

Surgical health services research has traditionally focused on reporting “associations” between specific risk factors and healthcare outcomes. Fewer studies have sought to address the underlying “how” or “in what way” the risk factors/exposures affect the outcome in question. Mediation analysis is a statistical approach that attempts to define underlying mechanisms through which an exposure influences an outcome. Mediation analysis differs from classic multivariable regression analysis in that it aims to understand the factors involved in the pathways between the exposure and the outcome. In particular, mediation models seek to identify and explain the mechanism or process that underlies an observed relationship between an independent variable and a dependent variable via the inclusion of a third hypothetical variable, known as a mediator variable.1 In essence, the effect of the exposure (X) on the outcome (Y) is decomposed into the indirect effect (X → M → Y) of the exposure (X) through which other factors act as mediators (M) versus the direct effect (X → Y) that denotes the impact of the exposure not explained by these mediators (Figure 1).2 Mediation analysis can help deconstruct how various factors may be driving outcomes of interest and help identify both indirect and direct factors to target for intervention. In turn, this analytic tool may help delineate the various contributions of different mediators associated with social determinants and health outcome inequities. Determining which variables may function as mediators can be difficult to discern, however, as there are multiple ways that factors in the causal pathway may interact with each other. Unmeasured confounders may cause an opposite directional effect or, in certain cases, entirely nullify the total effect; even true opposite direct and indirect effects may coexist.3 In turn, variable selection for mediation analysis should be informed relative to the possible directionality of associations based on prior knowledge, experience, and existing data in the literature. In addition, sensitivity analyses may be helpful to examine the strength of unmeasured confounders and interaction effects, as well as estimate whether these factors might alter the conclusions drawn from the analysis.2 The current study examined the role of structural factors that underlie racial/ethnic and economic disparities related to cancer screening using mediation analysis.4 Specifically, we utilized mixed-effect beta distribution models to assess direct and indirect effects of race/ethnicity and economic disparities on county-level cancer screening rates. Mediation analysis was conducted using generalized structural equation models, which is a validated methodologic approach.5 Mediators were assessed as continuous variables and standardized (mean centered) before inclusion into the final model. A Gaussian distribution with an identity link for all mediators was used and the random intercept was assumed to have a normal distribution, which was appropriate for our dataset yet needs to be tailored based on the specific data being analyzed. In the current study, we noted an association between racial/ethnic and economic privilege on USPSTF-recommended cancer screening. Perhaps more importantly, mediation analysis revealed that the observed disparities between county-level privilege and cancer screening were explained by mediators such as poverty status, lack of health insurance or employment, urban-rural location and access to primary care physicians that accounted for 64% (95% confidence interval [CI]: 61%–67%), 85% (95% CI: 80%–89%), and 74% (95% CI: 71%–77%) of the effect on breast, colorectal and cervical cancer screening, respectively. The combination of more rigorous statistical approaches such as mediation analysis with the use of publicly available datasets such as the Center for Disease Control and Prevention (CDC)'s PLACES dataset and the American Community Survey can help better elucidate area-level social determinants of health that mediate disparities in cancer prevention strategies. In turn, rather than simply identifying and describing disparities, these analyses may hopefully inform which specific disparities need to be addressed to improve health equity. Over the last decades, disparities in surgical outcomes have been well described. A new era of surgical health services research should now focus on more “mechanistic” analyses that identify which specific direct and indirect factors should be targeted by healthcare institutions, payers, policymakers, and professional organizations to improve access to quality healthcare and enhance health equity through state and national policies. NA.

Using the Social Vulnerability Index to Examine Disparities in Surgical Pediatric Trauma Patients

IntroductionThe Social Vulnerability Index (SVI) is a composite measure geocoded at the census tract level that has the potential to identify target populations at risk for postoperative surgical morbidity. We applied the SVI to examine demographics and disparities in surgical outcomes in pediatric trauma patients. MethodsSurgical pediatric trauma patients (≤18-year-old) at our institution from 2010 to 2020 were included. Patients were geocoded to identify their census tract of residence and estimated SVI and were stratified into high (≥70th percentile) and low (<70th percentile) SVI groups. Demographics, clinical data, and outcomes were compared using Kruskal–Wallis and Fisher's exact tests. ResultsOf 355 patients included, 21.4% had high SVI percentiles while 78.6% had low SVI percentiles. Patients with high SVI were more likely to have government insurance (73.7% versus 37.2%, P < 0.001), be of minority race (49.8% versus 19.1%, P < 0.001), present with penetrating injuries (32.9% versus 19.7%, P = 0.007), and develop surgical site infections (3.9% versus 0.4%, P = 0.03) compared to the low SVI group. ConclusionsThe SVI has the potential to examine health care disparities in pediatric trauma patients and identify discrete at-risk target populations for preventative resources allocation and intervention. Future studies are necessary to determine the utility of this tool in additional pediatric cohorts.

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

IntroductionThere 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. MethodsThe 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. ResultsOf 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. ConclusionsDespite 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.

Ethnic Disparities in Ileal Pouch Anal Anastomosis Outcomes: An ACS-NSQIP Study

IntroductionIleal pouch-anal anastomosis (IPAA) has become the gold standard operation performed for patients with ulcerative colitis (UC) who require colectomy for medically refractory disease or colitis-associated neoplasia. This study aims to evaluate whether differences in surgical outcomes following IPAA creation is associated with minority ethnicity using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical outcomes database. MethodsThe ACS-NSQIP proctectomy-targeted data files (2016-2019) were reviewed to identify patients who underwent an IPAA creation (Current Procedural Terminology codes: 44157, 44158, 44211, and 45113). Demographic, comorbidity, perioperative characteristics, and postoperative outcomes, particularly total-morbidity, surgical site infection, and anastomotic leak, were compared for White, African–American, Hispanic, and Asian patients. Separate multivariable logistic regressions were calculated for each outcome of interest. Certain postoperative outcomes required collation to be analyzed due to low numbers, such as combining all surgical site infections (SSIs), anastomotic leak, and septic complications as “infection complications”. For each regression, a P value of <0.05 was considered to be significant. ResultsA total of 1462 patients were identified who underwent an IPAA creation. There were 1290 (88.2%) Caucasian, 66 (4.5%) African–American, 49 (3.4%) Hispanic, and 57 (3.9%) Asian patients. Minority race or ethnicity was not associated with higher odds of total morbidity, readmission, reoperation, the development of any SSI, anastomotic leak, or other septic complications as compared to White patients. African–American ethnicity was associated with higher odds of developing postoperative bleeding complications (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.15-5.21; P = 0.020) and postoperative renal dysfunction (OR 4.32, CI 1.43-13.07; P = 0.010) as compared to White patients. Elevated body mass index (BMI) was associated with higher odds of developing an SSI (OR 1.03, CI 1.00-1.06; P = 0.045), or an “infection” complication (OR 1.04, CI 1.01-1.07; P = 0.012), but was protective against bleeding complications (OR 0.94, CI 0.9-0.98; P = 0.004). Smoking was associated with higher odds of developing an SSI, anastomotic leak, or septic complications in the combined “infection” regression analysis (OR 2.02, CI 1.25-3.26; P = 0.004). In the analysis of total-morbidity, both hypertension (OR 1.64, CI 1.11-2.42; P = 0.013) and an ASA Class score >3 (OR 1.36, CI 1.03-1.79; P = 0.029) were associated with increased odds of complications. ConclusionsThis analysis of the ACS-NSQIP national database data suggests that ethnicity is not associated with disparities in surgical outcomes following IPAA surgery. African–American ethnicity was however associated with higher odds of developing postoperative bleeding complications and renal dysfunction as compared to White patients. Elevated BMI and smoking history are associated with an increased risk of SSI, anastomotic leak and septic complications.

ASO Visual Abstract: Racial Disparities in Surgical Outcomes Among Women with Endometrial Cancer.

ASO Visual Abstract: Racial Disparities in Surgical Outcomes Among Women with Endometrial Cancer.

Racial Disparities in Surgical Outcomes Among Women with Endometrial Cancer.

Endometrial cancer (EC) is the most common gynecological cancer among women in the United States. Despite well-documented racial/ethnic disparities in EC incidence and mortality rates, limited data exist regarding disparities in hysterectomy surgical outcomes. We evaluated associations of race/ethnicity with postoperative complications, serious adverse events (SAEs), and length of hospital stay among women undergoing EC-related hysterectomy. Using National Surgical Quality Improvement Program (NSQIP) data, we identified women (≥18 years) undergoing hysterectomy to treat EC between 2014 and 2020. We used multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations of race/ethnicity (white, black, and Latina) with postoperative complications and SAEs. We used Poisson regression with robust standard errors to calculate incidence rate ratios (IRRs) and 95% CIs for the association of race/ethnicity with length of hospital stay. Of 22,778 women undergoing EC-related hysterectomy, 3.1% developed postoperative complications. Black (adjusted OR: 1.62; 95% CI 1.05-2.48) and Latina women (adjusted OR: 1.79; 95% CI 1.04-3.09) had higher postoperative complication risks than white women. The overall SAE incidence was 5.0%. Black women (adjusted OR: 1.55, 95% CI 1.13-2.15) had higher SAE risks than white women. Length of hospital stay was significantly longer for black women than white women (IRR: 1.18; 95% CI 1.07-1.30). We observed racial/ethnic disparities in EC-related hysterectomy surgical outcomes in a large, diverse sample of U.S. women between 2014 and 2020. Studies to elucidate the underlying mechanisms of these racial disparities, with a focus on social context remain necessary.

Barriers to Quality Perioperative Care Delivery in Low- and Middle-Income Countries: A Qualitative Rapid Appraisal Study.

Provision of timely, safe, and affordable surgical care is an essential component of any high-quality health system. Increasingly, it is recognized that poor quality of care in the perioperative period (before, during, and after surgery) may contribute to significant excess mortality and morbidity. Therefore, improving access to surgical procedures alone will not address the disparities in surgical outcomes globally until the quality of perioperative care is addressed. We aimed to identify key barriers to quality perioperative care delivery for 3 "Bellwether" procedures (cesarean delivery, emergency laparotomy, and long-bone fracture fixation) in 5 low- and middle-income countries (LMICs). Ten hospitals representing secondary and tertiary facilities from 5 LMICs were purposefully selected: 2 upper-middle income (Colombia and South Africa); 2 lower-middle income (Sri Lanka and Tanzania); and 1 lower income (Uganda). We used a rapid appraisal design (pathway mapping, ethnography, and interviews) to map out and explore the complexities of the perioperative pathway and care delivery for the Bellwether procedures. The framework approach was used for data analysis, with triangulation across different data sources to identify barriers in the country and pattern matching to identify common barriers across the 5 LMICs. We developed 25 pathway maps, undertook >30 periods of observation, and held >40 interviews with patients and clinical staff. Although the extent and impact of the barriers varied across the LMIC settings, 4 key common barriers to safe and effective perioperative care were identified: (1) the fragmented nature of the care pathways, (2) the limited human and structural resources available for the provision of care, (3) the direct and indirect costs of care for patients (even in health systems for which care is ostensibly free of charge), and (4) patients' low expectations of care. We identified key barriers to effective perioperative care in LMICs. Addressing these barriers is important if LMIC health systems are to provide safe, timely, and affordable provision of the Bellwether procedures.

Conducting Health Policy Research.

Conducting Health Policy Research.