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How Can Surgical Outcomes be Improved for Black Patients?

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Black patients having surgery were over 40% more likely than White patients to be sent from the hospital to a nursing home, a disparity that appeared to be mitigated by preoperative treatment of severe diabetes and hypertension, a retrospective analysis of hospital data reports.

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



Matthias Eikermann, MD, PhD

“Importantly, preexisting severe diabetes mellitus and hypertension, which occur more frequently in Black patients than in White patients, explain the effect of self-identified Black patients having a higher rate of adverse postoperative discharge to a nursing home,” added Eikermann, professor of anesthesiology at the Albert Einstein College of Medicine and chair of the Department of Anesthesiology at Montefiore Medical Center in Bronx, New York.

As reported in Annals of Surgery, Eikermann and his colleagues analyzed electronic medical record and hospital admission data from all adult patients who underwent surgery between January 2007 and February 2020 at two academic healthcare networks in Massachusetts. They compared patients who self-identified as non-Hispanic Black with those who self-identified as non-Hispanic White.

The researchers determined the proportion of patients in each group who were transferred after surgery to a long-term nursing facility and lost their capacity to live independently. They included those who died after surgery while still hospitalized. The authors also investigated inpatient readmission within 30 days after hospital discharge and death within 30 days after surgery.

Overall, 38,010 (10.3%) patients identified their race as Black, and 330,350 (89.7%) identified their race as White. The Black group tended to be younger than the White group, have proportionally more women, and have lower household income. The Black patients also had higher rates of kidney disease, heart failure, diabetes, and hypertension but lower rates of cancer and tumor diagnosed before surgery. The Black patients were more likely to undergo procedures that were ambulatory, shorter, and less complicated, with lower rates of general anesthesia.

  • In adjusted analysis, Black patients were at higher risk of being unable to live independently after surgery than were 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 analyses, Black patients were at significantly higher risk for preexisting severe diabetes (ARDadj, 4.7%; 95% CI, 4.5%-5.0%) and hypertension (ARDadj, 14.1%; 95% CI, 13.6%-14.6%), which were linked with increased risk for loss of independent living.

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

  • Black patients were at higher risk for high preoperative A1c levels (ARDadj, 8.4%; 95% CI, 7.0%-9.9%). High preoperative A1c was linked with higher risk for postoperative discharge to a nursing home (ARDadj, 3.7%; 95% CI, 3.0%-4.5%).

  • The link between race and postoperative loss of independent living was stronger for patients who received no guideline-adherent pharmacotherapy during the year before surgery (ARDadj, 4.3%; 95% CI, 3.2%-5.4%). The link was weaker in patients who received a low proportion of guideline-adherent pharmacotherapy (ARDadj, 1.6%; 95% CI, 0.8%-2.4%), and it was nonsignificant in those who received a high-proportion of guideline-adherent pharmacotherapy.

  • Among patients with severe diabetes or hypertension who did not receive guideline-adherent pharmacotherapy, the 30-day readmission risk was higher for the Black patients (ARDadj, 1.8%; 95% CI, 0.8%-2.8%). By contrast, among patients who received a high proportion of guideline-adherent pharmacotherapy, the link between race and 30-day readmission was nonsignificant.

  • Black patients were less likely to be treated by the institutions’ longer-term surgical providers (ARDadj, -0.6%; 95% CI, -0.7%-0.5%).

The authors acknowledge limitations of the study, including its retrospective design and reliance on electronic medical records and administrative databases.

“Strengths of our study are the large patient cohort and sophisticated statistical analyses that were adjusted for many important factors that could have influenced our findings,” Eikermann said.

Screen and Treat Patients for Diabetes and Hypertension

“Racial and ethnic minorities, mainly Black and Hispanic individuals, are disproportionately impacted by diabetes and its complications,” Maya Fayfman, MD, assistant professor of medicine in the Division of Endocrinology at the Emory University School of Medicine in Atlanta, Georgia, said in an email.



Maya Fayfman, MD

“It is important that the research and health communities continue to study and implement interventions in these affected populations to reduce the burden of disease,” added Fayfman, who was not involved in the study. “As the diabetes epidemic grows, interventions focused on those at highest risk will have the greatest impact on improving outcomes overall.”

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



Chinenye Usoh, MD

“Many of the worse outcomes seen in African Americans are due to delayed access to healthcare and medications for common conditions that have relatively low-cost treatments,” she explained in an email. “I was encouraged by how simple the solution is: Treat diabetes and hypertension based on standard recommended guidelines.”

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

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

 

Eickermann agrees. “Patients who end up in a nursing home after surgery have higher risk for cognitive decline, have lower quality of life, and utilize healthcare more frequently,” he noted.

“Our results emphasize the value of guideline-adherent treatment of diabetes mellitus and hypertension and optimized preoperative assessment to improve surgical outcomes and help eliminate healthcare disparities. We should start now, but many hospitals do not have the resources to be successful without public support,” he said.

“Our next step is to show that the development and implementation of a rigorous program to improve treatment of severe diabetes mellitus and hypertension will also improve surgical outcomes,” Eikermann said. “If our society would be able to provide equitable treatment of diabetes and hypertension, then surgical outcomes would be improved and healthcare disparities effectively addressed.”

Eikermann and one co-author report financial relationships with pharmaceutical companies. Usoh and Fayfman report no relevant financial relationships. The study was funded by Jeffrey and Judith Buzen.

Annals of Surgery. Published online June 28, 2022. Abstract

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