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Journal ArticleDOI

Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors.

TL;DR: A comprehensive review of the currently published surgical disparity literature in the United States found that patient factors such as insurance status and socioeconomic status need to be further explored, as studies indicated only a premature understanding of the relationship between racial disparities and SES.
Abstract: It is well known that there are significant racial disparities in health care outcomes, including surgery. However, the mechanisms that lead to these disparities are still not fully understood. In this comprehensive review of the currently published surgical disparity literature in the United States, we assess racial disparities in outcomes after surgical procedures, focusing on patient, provider, and systemic factors. The PubMed, EMBASE, and Cochrane Library electronic databases were searched with the keywords: healthcare disparities AND surgery AND outcome AND US. Only primary research articles published between April 1990 and December 2011 were included in the study. Studies analyzing surgical patients of all ages and assessing the endpoints of mortality, morbidity, or the likelihood of receiving surgical therapy were included. A total of 88 articles met the inclusion criteria. This evidence-based review was compiled in a systematic manner, relying on retrospective, cross-sectional, case-control, and prospective studies in the absence of Class I studies. The review found that patient factors such as insurance status and socioeconomic status (SES) need to be further explored, as studies indicated only a premature understanding of the relationship between racial disparities and SES. Provider factors such as differences in surgery rates and treatment by low volume or low quality surgeons also appear to play a role in minority outcome disparities. Finally, systemic factors such as access to care, hospital volume, and hospital patient population have been shown to contribute to disparities, with research consistently demonstrating that equal access to care mitigates outcome disparities.
Citations
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Journal ArticleDOI
TL;DR: To eliminate racial and ethnic disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.
Abstract: The annual National Healthcare Quality and Disparities Reports document widespread and persistent racial and ethnic disparities. These disparities result from complex interactions between patient factors related to social disadvantage, clinicians, and organizational and health care system factors. Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias. Recent data suggest slow progress in many areas but have documented a few notable successes in eliminating these disparities. To eliminate these disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.

313 citations

Journal ArticleDOI
TL;DR: Gynecologic cancer disparities exist between Black and White women and much of the evidence suggests that equal care leads to equal outcomes for Black women diagnosed with gynecologic cancers.

163 citations

Journal ArticleDOI
TL;DR: Unconscious social class and race biases were not significantly associated with clinical decision making among acute care surgical clinicians and in univariate analyses, a association between race/social class bias and 3 of 27 possible patient-care decisions was found.
Abstract: Importance Significant health inequities persist among minority and socially disadvantaged patients. Better understanding of how unconscious biases affect clinical decision making may help to illuminate clinicians’ roles in propagating disparities. Objective To determine whether clinicians’ unconscious race and/or social class biases correlate with patient management decisions. Design, Setting, and Participants We conducted a web-based survey among 230 physicians from surgery and related specialties at an academic, level I trauma center from December 1, 2011, through January 31, 2012. Interventions We administered clinical vignettes, each with 3 management questions. Eight vignettes assessed the relationship between unconscious bias and clinical decision making. We performed ordered logistic regression analysis on the Implicit Association Test (IAT) scores and used multivariable analysis to determine whether implicit bias was associated with the vignette responses. Main Outcomes and Measures Differential response times (D scores) on the IAT as a surrogate for unconscious bias. Patient management vignettes varied by patient race or social class. Resulting D scores were calculated for each management decision. Results In total, 215 clinicians were included and consisted of 74 attending surgeons, 32 fellows, 86 residents, 19 interns, and 4 physicians with an undetermined level of education. Specialties included surgery (32.1%), anesthesia (18.1%), emergency medicine (18.1%), orthopedics (7.9%), otolaryngology (7.0%), neurosurgery (7.0%), critical care (6.0%), and urology (2.8%); 1.9% did not report a departmental affiliation. Implicit race and social class biases were present in most respondents. Among all clinicians, mean IAT D scores for race and social class were 0.42 (95% CI, 0.37-0.48) and 0.71 (95% CI, 0.65-0.78), respectively. Race and class scores were similar across departments (general surgery, orthopedics, urology, etc), race, or age. Women demonstrated less bias concerning race (mean IAT D score, 0.39 [95% CI, 0.29-0.49]) and social class (mean IAT D score, 0.66 [95% CI, 0.57-0.75]) relative to men (mean IAT D scores, 0.44 [95% CI, 0.37-0.52] and 0.82 [95% CI, 0.75-0.89], respectively). In univariate analyses, we found an association between race/social class bias and 3 of 27 possible patient-care decisions. Multivariable analyses revealed no association between the IAT D scores and vignette-based clinical assessments. Conclusions and Relevance Unconscious social class and race biases were not significantly associated with clinical decision making among acute care surgical clinicians. Further studies involving real physician-patient interactions may be warranted.

161 citations


Additional excerpts

  • ...Non-Hispanic black 1 (5) 1 (1) 1 (3) 3 (4)...

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Journal ArticleDOI
TL;DR: Overall priorities, regardless of theme, included improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery.
Abstract: Health care disparities (differential access, care, and outcomes owing to factors such as race/ethnicity) are widely established. Compared with other groups, African American individuals have an increased mortality risk across multiple surgical procedures. Gender, sexual orientation, age, and geographic disparities are also well documented. Further research is needed to mitigate these inequities. To do so, the American College of Surgeons and the National Institutes of Health–National Institute of Minority Health and Disparities convened a research summit to develop a national surgical disparities research agenda and funding priorities. Sixty leading researchers and clinicians gathered in May 2015 for a 2-day summit. First, literature on surgical disparities was presented within 5 themes: (1) clinician, (2) patient, (3) systemic/access, (4) clinical quality, and (5) postoperative care and rehabilitation-related factors. These themes were identified via an exhaustive preconference literature review and guided the summit and its interactive consensus-building exercises. After individual thematic presentations, attendees contributed research priorities for each theme. Suggestions were collated, refined, and prioritized during the latter half of the summit. Breakout sessions yielded 3 to 5 top research priorities by theme. Overall priorities, regardless of theme, included improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery. The National Institutes of Health and American College of Surgeons Summit on Surgical Disparities Research succeeded in identifying a comprehensive research agenda. Future research and funding priorities should prioritize patients’ care perspectives, workforce diversification and training, and systematic evaluation of health technologies to reduce surgical disparities.

119 citations

Journal ArticleDOI
TL;DR: Unconscious preferences for white and upper-class persons are prevalent among trauma and acute care surgeons, but these biases were not statistically significantly associated with clinical decision making.
Abstract: BACKGROUNDRecent studies have found that unconscious biases may influence physicians’ clinical decision making. The objective of our study was to determine, using clinical vignettes, if unconscious race and class biases exist specifically among trauma/acute care surgeons and, if so, whether those bi

111 citations


Cites background from "Racial disparities in surgical care..."

  • ...Since then, racial disparities in the US health care system related to access, prevention, and patient outcomes have been reported in almost every field of medicine and surgery.(2,3) Initially, trauma surgery was thought to be immune to outcomes disparities because of the access of all patients to emergent treatment....

    [...]

References
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Book
02 Nov 2002
TL;DR: In this article, a panel of experts documents this evidence and explores how persons of color experience the health care environment, examining how disparities in treatment may arise in health care systems and looking at aspects of the clinical encounter that may contribute to such disparities.
Abstract: Racial and ethnic disparities in health care are known to reflect access to care and other issues that arise from differing socioeconomic conditions. There is, however, increasing evidence that even after such differences are accounted for, race and ethnicity remain significant predictors of the quality of health care received. In Unequal Treatment, a panel of experts documents this evidence and explores how persons of color experience the health care environment. The book examines how disparities in treatment may arise in health care systems and looks at aspects of the clinical encounter that may contribute to such disparities. Patients’ and providers’ attitudes, expectations, and behavior are analyzed. How to intervene? Unequal Treatment offers recommendations for improvements in medical care financing, allocation of care, availability of language translation, community-based care, and other arenas. The committee highlights the potential of cross-cultural education to improve provider–patient communication and offers a detailed look at how to integrate cross-cultural learning within the health professions. The book concludes with recommendations for data collection and research initiatives. Unequal Treatment will be vitally important to health care policymakers, administrators, providers, educators, and students as well as advocates for people of color.

6,185 citations

Journal ArticleDOI
TL;DR: Mortality decreased as volume increased for all 14 types of procedures, but the relative importance of volume varied markedly according to the type of procedure.
Abstract: Background Although numerous studies suggest that there is an inverse relation between hospital volume of surgical procedures and surgical mortality, the relative importance of hospital volume in various surgical procedures is disputed. Methods Using information from the national Medicare claims data base and the Nationwide Inpatient Sample, we examined the mortality associated with six different types of cardiovascular procedures and eight types of major cancer resections between 1994 and 1999 (total number of procedures, 2.5 million). Regression techniques were used to describe relations between hospital volume (total number of procedures performed per year) and mortality (in-hospital or within 30 days), with adjustment for characteristics of the patients. Results Mortality decreased as volume increased for all 14 types of procedures, but the relative importance of volume varied markedly according to the type of procedure. Absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals ranged from over 12 percent (for pancreatic resection, 16.3 percent vs. 3.8 percent) to only 0.2 percent (for carotid endarterectomy, 1.7 percent vs. 1.5 percent). The absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals were greater than 5 percent for esophagectomy and pneumonectomy, 2 to 5 percent for gastrectomy, cystectomy, repair of a nonruptured abdominal aneurysm, and replacement of an aortic or mitral valve, and less than 2 percent for coronary-artery bypass grafting, lower-extremity bypass, colectomy, lobectomy, and nephrectomy. Conclusions In the absence of other information about the quality of surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital.

4,363 citations

Journal ArticleDOI
TL;DR: Patients who undergo resection for lung cancer at hospitals that perform large numbers of such procedures are likely to survive longer than patients who have such surgery at hospitals with a low volume of lung-resection procedures.
Abstract: Background Among patients who have undergone high-risk operations for cancer, postoperative mortality rates are often lower at hospitals where more of these procedures are performed. We undertook a population-based study to estimate the extent to which the number of procedures performed at a hospital (hospital volume) is associated with survival after resection for lung cancer. Methods We studied patients 65 years old or older who received a diagnosis of stage I, II, or IIIA non–small-cell lung cancer between 1985 and 1996, resided in 1 of the 10 study areas covered by the Surveillance, Epidemiology, and End Results Program, and underwent surgery at a hospital that participates in the Nationwide Inpatient Sample (2118 patients and 76 hospitals). Results The volume of procedures at the hospital was positively associated with the survival of patients (P<0.001). Five years after surgery, 44 percent of patients who underwent operations at the hospitals with the highest volume were alive, as compared with 33 p...

672 citations

Journal ArticleDOI
TL;DR: Black patients have higher operative mortality risks across a wide range of surgical procedures, in large part because of higher mortality rates at the hospitals they attend.
Abstract: Objective: This study describes racial differences in postoperative mortality following 8 cardiovascular and cancer procedures and assesses possible explanations for these differences. Summary Background Data: Although racial disparities in the use of surgical procedures are well established, relationships between race and operative mortality have not been assessed systematically. Methods: We used national Medicare data to identify all patients undergoing one of 8 cardiovascular and cancer procedures between 1994 and 1999. We used multiple logistic regression to assess differences in operative mortality (death within 30 days or before discharge) between black patients and white patients, controlling for patient characteristics. Adding hospital indicators to these models, we then assessed the extent to which racial differences in operative mortality could be accounted for by the hospital in which patients were cared for. Results: Black patients had higher crude mortality rates than white patients for 7 of the 8 operations, including coronary artery bypass, aortic valve replacement, abdominal aortic aneurysm repair, carotid endarterectomy, radical cystectomy, pancreatic resection, and esophagectomy. Among these 7 procedures, odds ratios of mortality (black versus white) ranged from 1.23 (95% confidence interval, 1.18–1.29) for CABG to 1.61 (95% confidence interval, 1.28–2.03) for esophagectomy. Adjusting for patient characteristics had modest or no effect on odds ratios of mortality by race. However, there remained few clinically or statistically significant differences in mortality by race after we accounted for hospital. Hospitals that treated a large proportion of black patients had higher mortality rates for all 8 procedures, for white as well as black patients. Conclusions: Black patients have higher operative mortality risks across a wide range of surgical procedures, in large part because of higher mortality rates at the hospitals they attend.

310 citations

Journal ArticleDOI
16 Dec 2010-Blood
TL;DR: A younger age of onset among blacks; better survival in blacks 1973-2005; and significant survival improvement among whites over time, with smaller, nonsignificant change seen among blacks are found, possibly due to unequal access to and/or disparate responsiveness to novel therapies.

304 citations