Surgical Disparities Research Articles

Diversity presentations at cardiothoracic surgery meetings: Opportunity to align our actions with our values

ObjectiveSubstantial efforts have been directed toward identifying and addressing cardiothoracic surgical disparities in both patient care and our workforce. We aimed to characterize the presence over time of diversity and disparities-related content at cardiothoracic surgical society meetings. MethodsAnnual meeting program books from the American Association for Thoracic Surgery and the Society of Thoracic Surgeons from 2013 to 2023 were manually reviewed to identify abstract presentations, invited talks, and dedicated sessions related to diversity, equity, or social determinants of health. Relevant presentations were further categorized as issues in the surgical workforce versus patient care. Applicable presentations and sessions were quantified in each domain and proportions compared with the χ2 test. ResultsOf 7812 presentations over 11 years, 167 (2.1%) were related to issues of diversity. These included 118 abstracts, among which 19 (16.1%) covered workforce diversity issues whereas 99 (83.9%) addressed patient care inequities. Among 48 invited disparities talks, 28 (58.3%) related to workforce challenges and 20 (41.7%) explored variabilities in patient care. Seventeen complete sessions were dedicated to diversity and disparities, with 9 (52.9%) addressing those in the workforce and 8 (47.1%) related to patient care. Comparing the first 5 years with the final 5 years of study, the proportion of talks (abstracts and invited) related to diversity and inclusion increased 3-fold. ConclusionsRecent years have shown an explosion in cardiothoracic surgery meeting content focused on diversity but still account for a diminutive proportion of overall content. These data highlight an opportunity to further align scholarly activity with our values.

Augmented Reality (AR) in Surgery in Low- and Middle-Income Countries (LMICs): A Scoping Review.

Surgical disparities persist in low- and middle-income countries (LMICs). Insufficient access to surgical care places a large burden on these regions, with high mortality rates for otherwise standard procedures performed in high-income countries (HICs). Augmented Reality (AR) and Virtual Reality (VR) now provide us with a platform to improve the delivery of surgical access and training to LMICs. The use of AR technologies to provide additional training to surgeons and residents globally can help bridge the gap and reduce health disparities in LMICs. The goal of this scoping review is to evaluate whether surgical trainees and surgeons from LMICs have access to or use AR software in their training or practice. A systematic search was conducted on seven databases. Inclusion criteria included populations in LMICs with access to AR-based training. Articles using VR software, or those conducted in HICs were excluded from the review. From the 428 records screened, 58 reports were assessed for eligibility, and of these, a total of six studies were included in the review. Five of the six studies used mentors from an HIC, including the United States (US) and the United Kingdom (UK), whereas one study had mentorship from another LMIC. Three surgical specialties were explored: neurosurgery, plastic surgery, and urology. Although the integration of AR in surgical training is promising, the six studies evaluated in this review emphasize that costs and connection issues are major challenges that can set back these technologies in the operating room. Despite these revelations, with certain improvements, AR training programs are promising as they can help to reduce the global disparity in surgical proficiency.

Understanding family-level decision-making when seeking access to acute surgical care for children: Protocol for a cross-sectional mixed methods study.

There is limited understanding of how social determinants of health (SDOH) impact family decision-making when seeking surgical care for children. Our objectives of this study are to identify key family experiences that contribute to decision-making when accessing surgical care for children, to confirm if family experiences impact delays in care, and to describe differences in family experiences across populations (race, ethnicity, socioeconomic status, rurality). We will use a prospective, cross-sectional, mixed methods design to examine family experiences during access to care for children with appendicitis. Participants will include 242 parents of consecutive children (0-17 years) with acute appendicitis over a 15-month period at two academic health systems in North Carolina and Virginia. We will collect demographic and clinical data. Parents will be administered the Adult Responses to Children's Symptoms survey (ARCS), the child and parental forms of the Adverse Childhood Experiences (ACE) survey, the Accountable Health Communities Health-Related Social Needs Screening Tool, and Single Item Literacy Screener. Parallel ARCS data will be collected from child participants (8-17 years). We will use nested concurrent, purposive sampling to select a subset of families for semi-structured interviews. Qualitative data will be analyzed using thematic analysis and integrated with quantitative data to identify emerging themes that inform a conceptual model of family-level decision-making during access to surgical care. Multivariate linear regression will be used to determine association between the appendicitis perforation rate and ARCS responses (primary outcome). Secondary outcomes include comparison of health literacy, ACEs, and SDOH, clinical outcomes, and family experiences across populations. We expect to identify key family experiences when accessing care for appendicitis which may impact outcomes and differ across populations. Increased understanding of how SDOH and family experiences influence family decision-making may inform novel strategies to mitigate surgical disparities in children.

International Hackathon as a Tool to Augment Education, Collaboration, and Innovation in Global Neurosurgery.

Health care providers' exposure to global surgical disparities is limited in current nursing and/or medical school curricula. For instance, global health is often associated with infectious diseases or maternal health without acknowledging the growing need for surgical care in low- and middle-income countries (LMICs). We propose an international virtual hackathon based on neurosurgical patient cases in under-resourced settings as an educational tool to bring awareness to global surgical disparities and develop relationships among trainees in different countries. Participants were recruited through email listservs, a social media campaign, and prize offerings. A 3-day virtual hackathon event was administered, which included workshops, mentorship, keynote panels, and pitch presentations to judges. Participants were presented with real patient cases and directed to solve a barrier to their care. Surveys assessed participants' backgrounds and event experience. The hackathon was executed through Zoom at Harvard Innovation Lab in Boston, MA, on March 25 to 27, 2022. Participants included medical students, with additional participants from business, engineering, or current health care workers. Three hundred seven applications were submitted for 100 spots. Participants included medical students, physicians, nurses, engineers, entrepreneurs, and undergraduates representing 25 countries and 82 cities. Fifty-one participants previously met a neurosurgeon, while 39 previously met a global health expert, with no difference between LMIC and high-income countries' respondents. Teams spent an average of 2.75 hours working with mentors, and 88% of postevent respondents said the event was "very" or "extremely conducive" to networking. Projects fell into 4 categories: access, language barriers, education and training, and resources. The winning team, which was interdisciplinary and international, developed an application that analyzes patient anatomy while performing physical therapy to facilitate remote care and clinical decision-making. An international virtual hackathon can be an educational tool to increase innovative ideas to address surgical disparities in LMICs and establish early collaborative relationships with medical trainees from different countries.

Providers’ and survivors’ perspectives on the availability and accessibility of surgery in gastrointestinal cancer care

BackgroundSurgery is essential for gastrointestinal (GI) cancer treatment. Many patients lack access to surgical care that optimizes outcomes. Scarce availability and/or low accessibility of appropriate resources may be the reason for this, especially in economically disadvantaged areas. This study aimed to investigate providers’ and survivors’ perspectives on barriers and facilitators to the availability and accessibility of surgical care. MethodsSemistructured interviews informed by surgical disparities and access-to-care conceptual frameworks with purposively selected GI cancer providers and survivors in Alabama and Mississippi were conducted. Survivors were within 3 years of diagnosis of stage I to III esophageal, pancreatic, or colorectal cancer. Transcripts were analyzed using inductive thematic and content analysis techniques. Intercoder agreement was reached at 90 %. ResultsThe 27 providers included surgeons (n = 11), medical oncologists (n = 2), radiation oncologists (n = 2), a primary care physician (n = 1), nurses (n = 8), and patient navigators (n = 3). This study included 36 survivors with ages ranging from 44 to 87 years. Of the 36 survivors, 21 (58.3 %) were male, and 11 (30.6 %) identified as Black. Responses were grouped into 3 broad categories: (i) transportation/geographic location, (ii) specialized care/testing, and (iii) patient-/provider-related factors. The barriers included lack and cost of transportation, reluctance to travel because of uneasiness with urban centers, low availability of specialized care, overburdened referral centers, provider-related referral biases, and low health literacy. Facilitators included availability of charitable aid, centralizing multidisciplinary care, and efficient appointment scheduling. ConclusionIn the Deep South, barriers and facilitators to the availability and accessibility of GI surgical cancer care were identified at the health system, provider, and patient levels, especially for rural residents. Our data suggest targets for improving the use of surgery in GI cancer care.

Predicting Risk of Post-Operative Morbidity and Mortality following Gynaecological Oncology Surgery (PROMEGO): A Global Gynaecological Oncology Surgical Outcomes Collaborative Led Study.

The medical complexity of surgical patients is increasing, and surgical risk calculators are crucial in providing high-value, patient-centered surgical care. However, pre-existing models are not validated to accurately predict risk for major gynecological oncology surgeries, and many are not generalizable to low- and middle-income country settings (LMICs). The international GO SOAR database dataset was used to develop a novel predictive surgical risk calculator for post-operative morbidity and mortality following gynecological surgery. Fifteen candidate features readily available pre-operatively across both high-income countries (HICs) and LMICs were selected. Predictive modeling analyses using machine learning methods and linear regression were performed. The area-under-the-receiver-operating characteristic curve (AUROC) was calculated to assess overall discriminatory performance. Neural networks (AUROC 0.94) significantly outperformed other models (p < 0.001) for evaluating the accuracy of prediction across three groups, i.e., minor morbidity (Clavien-Dindo I-II), major morbidity (Clavien-Dindo III-V), and no morbidity. Logistic-regression modeling outperformed the clinically established SORT model in predicting mortality (AUROC 0.66 versus 0.61, p < 0.001). The GO SOAR surgical risk prediction model is the first that is validated for use in patients undergoing gynecological surgery. Accurate surgical risk predictions are vital within the context of major cytoreduction surgery, where surgery and its associated complications can diminish quality-of-life and affect long-term cancer survival. A model that requires readily available pre-operative data, irrespective of resource setting, is crucial to reducing global surgical disparities.

Exploring Social Support Dynamics After Bariatric Surgery: Insights From Patients and Providers

IntroductionWeight loss after bariatric surgery is impacted by several factors, and social support is one of them. Our objective was to characterize patient and provider perceptions about social support after bariatric surgery. MethodsWe reported a secondary analysis of qualitative data acquired from semi-structured interviews conducted from January-November 2020 with bariatric surgery patients and providers. Participants included primary care providers, health psychologists, registered dietitians, bariatric surgeons, and patients with at least 1 y of follow-up after their bariatric procedure. Interview guides were designed using a hybrid of Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Using directed content analysis, study team members generated codes, which were categorized into themes about social support pertaining to dietary habits, physical activity, and follow-up care. ResultsForty-five participants were interviewed, including 24 patients (83% female; 79% White; mean age 50.6 ± 10.7 y) and 21 providers (six primary care providers, four health psychologists, five registered dieticians, and six bariatric surgeons). We identified four themes relating to social support affecting weight loss after surgery: (1) family involvement in helping patients adjust to the bariatric diet, (2) engagement in activities with partners/friends, (3) help with transportation to appointments, and (4) life stressors experienced by patients within their social relationships. ConclusionsContinued assessment of interpersonal factors after bariatric surgery is essential for weight loss maintenance. Providers can contribute by reinforcing the facilitators of social support and making referrals that may help patients overcome barriers to social support for sustained weight loss after surgery.

Creating a more equitable future: development, implementation, and evaluation of a novel surgical disparities curriculum for medical students

PurposeThe AAMC has expanded its focus on healthcare disparities training during undergraduate medical education (UME). Currently, no standardized published curriculum dedicated to surgical disparity training exists. Therefore, our purpose was to develop, implement, and evaluate a novel Surgical Disparities Curriculum to equip medical students to recognize peri-operative disparities.MethodsThe Surgical Disparities Curriculum was developed based on the Surgical Disparity Framework created by the NIH-American College of Surgeons Summit on Health Disparity using Kern’s Model of Curriculum Development. The curriculum includes four components which are illustrated in Fig. 1: (1) a pre-session review of a journal article and multimedia adjunct highlighting one category within the framework, (2) a didactic session highlighting key elements of the state of surgical disparities and teaching the NIH-ACS framework, (3) a review of a clinical vignette and articles highlighting a framework factor, and (4) a discussion session applying all elements of the framework to disparities identified in pre-session materials, clinical vignette, and personal clinical experiences. The curriculum was administered at a single large academic institution to 223 third-year medical students. Curriculum evaluation was performed using Kirkpatrick’s Model of Training Evaluation and included post-participation surveys to evaluate participant reaction to the curriculum as well as pre- and post-course assessments to evaluate learning. Results were pooled and a Fisher’s exact test or independent samples t test was used for relevant analysis with p < 0.05 considered significant. Thematic analysis, using common word groupings, was also performed on post-survey comments.Fig. 1Outline of novel Surgical Disparities Curriculum for Medical Students. Pre-session preparation includes a survey and a guided reading with a relevant journal article and a multimedia adjunct. Next is a didactic session that introduces a Surgical Disparities Framework established by the ACS in 2016 and gives students a background in the language of discussing disparities. Next is a clinical vignette that highlights a framework factor and several disparities of interest. This is followed by a guided discussion on the pre-session materials, the didactic component, and the clinical vignette within the framework accompanied by a discussion on how to apply the framework and identify and prevent disparities. This was followed by a post-session surveyResultsParticipants stated they had prior dedicated training in recognizing health disparities integrated throughout the UME curriculum during pre-clinical (83%) and clinical (89%) experiences. Only 31% of students agreed surgical disparities had been discussed during their rotation prior to curriculum implementation. After curriculum participation, 90% of students endorsed an improved understanding of surgical disparities in healthcare and there was a 20% improvement in self-reported identification of peri-operative disparities from 68 to 88% (20% [CI 12–28%], p < 0.0001). Participation in the curriculum also resulted in knowledge acquisition with students scoring better (78% v 59% at baseline; p < 0.0001) on post-participation assessment.ConclusionThe Surgical Disparities Curriculum provides a novel solution for bridging the gap in training medical students to recognize disparities in the care of surgical patients. Future work will be done to assess long-term retention and behavioral changes because of our intervention. In addition, we will be working on the translatability of our curriculum to other institutions with the goal of training clerkship students across the country to better recognize surgical disparities.

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

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). 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. 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). 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.

Changing Surgical Culture Through Surgical Education: Introduction to the PACTS Trial

The Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum was developed to improve surgical resident cultural dexterity, with the goal of promoting health equity by developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care through structured educational interventions for surgical residents. Funded by the National Institute of Health (NIH)'s National Institute on Minority Health and Health Disparities, PACTS addresses surgical disparities in patient care by incorporating varied educational interventions, with investigation of both traditional and nontraditional educational outcomes such as patient-reported and clinical outcomes, across multiple hospitals and regions. The unique attributes of this multicenter, multiphased research trial will not only impact future surgical education research, but hopefully improve how surgeons learn nontechnical skills that modernize surgical culture and surgical care. The present perspective piece serves as an introduction to this multifaceted surgical education trial, highlighting the rationale for the study and critical curricular components such as key stakeholders from multiple institutions, multimodal learning and feedback, and diverse educational outcomes.

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.

Health Disparities in Hand and Upper Extremity Surgery: A Scoping Review

Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery. A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities. The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods. Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation. Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions.

One World Surgery: The Evolution of a Locally Run Surgical Mission in Honduras.

One World Surgery (OWS) is a medical mission organization that treats a variety of orthopaedic conditions and focuses on local partnerships, education, capacity-building, and high-quality care. OWS runs a Honduran ambulatory surgery center (ASC) with >50 full-time local staff; it operates year-round and accommodates visiting surgical teams bimonthly. Across its 12-year history, 8,703 surgical procedures have been performed and 54,940 total consults have been completed, with increasing autonomy of the local medical staff. From 2009 through 2021, OWS has provided 74 million U.S. dollars in surgical and consult patient care. By addressing global surgical disparities via life-enhancing surgical care in low- and middle-income country (LMIC) settings, the OWS ASC mission model may be a useful blueprint for other medical missions.

Patient and Provider Perceptions About Communication After Bariatric Surgery: A Qualitative Analysis

IntroductionCommunication between patients and providers can strongly influence patient behavior after surgery. The objective of this study was to assess patient and provider perceptions of how communication affected weight-related behaviors after bariatric surgery. Materials and methodsSemistructured interviews with bariatric surgery patients and providers were conducted from April-November 2020. Patients who had Medicaid within 3 y of surgery were defined as socioeconomically disadvantaged. Interview guides were derived from Andersen's Behavioral Model of Health Services and Torain's Framework for Surgical Disparities. Participants described postoperative experiences regarding diet, physical activity, and follow-up care. A codebook was developed deductively based on the two theories. Directed content analysis identified themes pertaining to patient-provider communication. ResultsForty-five participants were interviewed, including 24 patients (83% female; 79% White), six primary care providers, four health psychologists, five registered dietitians, and six bariatric surgeons. Four themes regarding communication emerged: (1) Patients experiencing weight regain did not want to follow-up with providers to discuss their weight; (2) Patients from socioeconomically disadvantaged backgrounds had less trust and required more rapport-building from providers to enhance trust; (3) Patients felt that providers did not get to know them personally, which was perceived as a lack of personalized communication; and (4) Providers often changed their language to be simpler, so patients could understand them. ConclusionsPatient-provider communication after bariatric surgery is essential, but perceptions about the elements of communication differ between patients and providers. Reassuring patients who have attained less weight loss than expected and establishing trust with socioeconomically vulnerable patients could strengthen care after bariatric surgery.

Disparities in the recommendation, acceptance, and performance of surgery as treatment modality for patients with stage 0-III breast cancer.

e18509 Background: National data to identify disparities in breast cancer focus on the receipt of standard therapies, although receipt of those treatments is predicated upon three factors: provider recommendation, patient acceptance, and administration or performance of those therapies. We aim to determine whether surgical disparities exist for each of these three factors in patients diagnosed with stage 0-III breast cancer patients. Methods: The National Cancer Database (NCDB) was queried for females 40 to 70 years of age treated from 2010 to 2019 for stage 0-III breast cancer. Covariates of interest included race/ethnicity, socioeconomic status, and patient, facility, and tumor characteristics. Exclusion criteria were applied to mitigate biases in treatment variabilities. Outcomes of interest included whether surgery was recommended, whether the recommended surgery was accepted, and ultimately performed. Multivariable logistic regression models were fit to assess the outcomes of interest controlling for patient and tumor characteristics. Predictive margins were calculated, and chi-square tests were used to assess the differences between subgroups of interest. Results: Among 440,828 patients, unadjusted rates of recommendation, acceptance, and performance of surgery were 98.5%, 99.7%, and 99.6% respectively. After confounder adjustment, compared to White patients, the probabilities of having surgery recommended, accepted, and performed for Black patients were 0.6, 0.46, and 0.49 percentage points (ppt) lower respectively (all p &lt; 0.0001). The probabilities of accepting and having surgery performed were both 0.14 ppt lower (p = 0.0012 and p = 0.0041) for Asian patients compared to White patients. Insurance status was a predictor for all outcomes, with the probabilities being 1.19, 0.78, and 0.78 ppt lower respectively when uninsured patients were compared to patients with private insurance (all p &lt; 0.0001). Similarly, probabilities for all three factors were 0.92, 0.11, and 0.17 ppt lower respectively for patients treated at Academic/Research Programs compared to Comprehensive Community Cancer Programs (p &lt; 0.0001, p = 0.001, and p = 0.0002). Income and Hispanic ethnicity had no significant association with the studied outcomes. Conclusions: Concern is justified about recommendation and differences in the performance of surgery as cause of breast cancer disparities by race and socioeconomic status, but acceptance of recommendations is also lower. Differences in understanding and a sense of trust may contribute to the lower likelihood of accepting surgical recommendations seen here. Further exploration is needed to ensure that patients of all backgrounds are equally clear regarding the reasons for surgical recommendations, and to foster trust. Such a focus on acceptance may help narrow disparities that have proven resistant to change so far.

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.

Socioeconomic status influences participation in cancer prehabilitation and preparation for surgical recovery: A pooled retrospective analysis using a validated area-level socioeconomic status metric.

Prehabilitation employs exercise, nutrition, and psychological interventions to optimize physiological status in preparation for surgery. First, we described the extent to which material deprivation index score (MDIS) influenced prehabilitation participation. Second, we evaluated the extent to which prehabilitation influenced recovery as compared to control. Pooled patient records from prospective multimodal prehabilitation studies in oncologic surgery were retrospectively examined. Patient postal codes were linked to their MDIS, a validated area-level socioeconomic status (SES) metric, as quintiles 1-5 (1=highest SES). Functional capacity was evaluated with the 6-min walking test (6MWT) at baseline, before, and 8 weeks post-surgery. Influence of prehabilitation on length of hospital stay (LOS) was explored using generalized linear models with a negative binomial distribution adjusted for age, sex, surgical population, and MDIS. Recruitment records were available from 2014 onwards, yielding 1013 eligible patients for prehabilitation participation with MDIS data. Fewer patients with a low SES enrolled (Q1:62% vs. Q5:47%; P = 0.01) and remained in prehabilitation studies (Q1: 59% vs. Q5: 45%; P = 0.07). Prehabilitation study records were available from 2008 onward, yielding 886 enrolled patients with MDIS data (n = 510 prehabilitation, n = 376 control). Preoperative 6MWT similarly improved by > 20 m in response to prehabilitation across SES strata (P < 0.05). Postoperative 6MWT could not be evaluated due to substantial missing data. Prehabilitation had a significant protective influence on LOS, as compared to control, in unadjusted and adjusted models [adjusted IRR:0.77 (95% CI:0.68 to 0.87; P < 0.001]. Findings suggest that prehabilitation is effective across all SES; however, participation across SES quintiles was not equal. Barriers to participation must be identified and addressed. Once these barriers are addressed, prehabilitation may reduce surgical disparities among SES.

Socioeconomic Disparity and Bariatric Surgery Outcomes: A Qualitative Analysis

INTRODUCTION: Disparity in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. Reasons for these disparities are unknown. Our objective was to identify socioeconomic barriers to weight loss after bariatric surgery. METHODS: We performed semi-structured interviews with bariatric surgery patients and providers from April to November 2020. Participants were asked to describe their postoperative experiences within 3 clinical areas: dietary habits, physical activity, and follow-up care. Purposeful sampling was used to recruit similar numbers of patients within low vs high SES and “optimal” vs “suboptimal” weight loss groups. Low SES patients were defined as having Medicaid within 3 years of operation. Patients with “optimal” weight loss had obtained ≥50% excess weight loss at their most recent clinic visit. Interview data were coded by team members using Directed Content Analysis based on the domains in Andersen’s Behavioral Model of Health Services Use and Torain’s Surgical Disparities Model. Codes pertaining to patient-level behaviors were included in the analysis. RESULTS: Twenty-four patients (median of 4.1 years postoperatively; mean age 50.6 ± 10.7 years; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss at the patient level related to 5 areas (Table 1): (1) limited health literacy; (2) challenging employment environments; (3) limited income; (4) unreliable transportation; and (5) unsafe/inconvenient neighborhoods. Table 1. - Socioeconomic Barriers to Weight Loss after Bariatric Surgery Barrier Description 1. Limited health literacy Patients with less formal education needed more training/teaching regarding recommendations for diet, physical activity, and postoperative care. 2. Challenging employment environments Patients who had physically demanding jobs or multiple jobs struggled to follow dietary, physical activity, and follow-up care recommendations. 3. Limited income Lower-income patients: (a) had a difficult time affording supplements and vitamins; (b) skipped meals or relied on cheaper convenience food options/unhealthy options at food pantry; (c) did not have access to affordable fitness centers; (d) did not have reliable internet access for virtual follow-up meetings; (e) struggled with gas money and co-pays, which prevented their attendance at follow-up meetings. 4. Unreliable transportation Patients who did not have reliable transportation were restricted by bus routes to obtain healthier foods. Public transportation or insurance-provided transportation (eg, scheduled service driver) was often unreliable. 5. Unsafe/inconvenient neighborhoods Grocery stores in disadvantaged neighborhoods carried fewer healthy options. Patients in these neighborhoods struggled to have groceries delivered to their homes because of fear of theft. These neighborhoods were often unsafe for exercising or did not have sidewalks. CONCLUSION: Numerous socioeconomic barriers to weight loss exist for bariatric surgery patients. Interventions targeting these factors are needed to support patients, particularly those who are socioeconomically disadvantaged.

Racial Disparities in Disease-Specific Survival and Surgical Management of Patients with Ductal Carcinoma In Situ with Microinvasion

INTRODUCTION: Despite persistent racial disparities in breast cancer outcomes, there are no studies examining the impact of race on treatment of the rare entity Ductal Carcinoma In-Situ with Microinvasion (DCIS-MI). The objective of this study is to examine racial differences in disease-specific survival (DSS) and surgical management among breast cancer patients presenting with DCIS-MI. METHODS: The Surveillance, Epidemiology, and End Results (SEER) Program was queried for patients with breast cancer age 18+ diagnosed with DCIS-MI between January 1, 2010, and December 31, 2018. The study cohort was divided into non-Hispanic Black (NHB) and non-Hispanic White (NHW). Sociodemographic, clinical, and treatment variables were compared using bivariable analysis. DSS was evaluated using a Cox proportional hazards model. RESULTS: A total of 3,476 patients were identified, of whom 608 (17.5%) identified as NHB and 2868 (82.5%) identified as NHW. The median age for NHB women was slightly younger (57 years, range [50 to 66]) than NHW women (59 years [50 to 67]; p = 0.01). Compared with NHW patients, NHB patients were more likely to undergo mastectomy (42.6% vs 38.4%, p = 0.04) and axillary lymph node dissection (ALND; 6.4% vs 3.7%, p = 0.01). Additionally, NHB patients had a worse DSS (hazard ratio 3.2, p < 0.01) compared with NHW patients. Of note, there were no racial differences in chemotherapy (p = 0.19) and radiation therapy (p = 0.34). CONCLUSION: A higher percentage of NHB women with DCIS-MI have a mastectomy and ALND than NHW women, yet NHB women have worse DSS. Future studies should examine patient, physician, and institutional factors driving surgical disparities and poor survival in NHB patients with DCIS-MI.

Socioeconomic disparities and bariatric surgery outcomes: A qualitative analysis

BackgroundDisparities in socioeconomic status (SES) have been associated with less weight loss after bariatric surgery. The objective of this study was to identify socioeconomic barriers to weight loss after bariatric surgery. MethodsWe performed semi-structured interviews with bariatric surgery patients and providers from April–November 2020. Participants were asked to describe their post-operative experiences regarding dietary habits, physical activity, and follow-up care. Interview data were coded using Directed Content Analysis based on domains in Andersen's Behavioral Model of Health Services Use and Torain's Surgical Disparities Model. Results24 patients (median of 4.1 years post-operatively; mean age 50.6 ± 10.7 years; 12 bypass and 12 sleeve; 83% female) and 21 providers (6 bariatric surgeons, 5 registered dietitians, 4 health psychologists, and 6 primary care providers) were interviewed. Barriers to weight loss included: 1) challenging employment situations; 2) limited income; 3) unreliable transportation; 4) unsafe/inconvenient neighborhoods; and 5) limited health literacy. ConclusionsInterventions targeting socioeconomic barriers to weight loss are needed to support patients, particularly those who are socioeconomically disadvantaged.