EXECUTIVE SUMMARY

Recent studies show that racial disparities affect access to surgery and outcomes across the United States.

  • Surgeons and other healthcare professionals carry biases they might not acknowledge, which can contribute to racial disparities.
  • A study of shoulder arthroplasty utilization revealed that black patients constituted slightly less than 4% of cases, about one-fourth of their overall proportion of the U.S. population.
  • Another study revealed black patients were 8% more likely than white patients to experience spine surgery-specific complications and 14% more likely to experience general postoperative complications.

Numerous studies in recent years highlighted differences between black and white surgery patients. Investigators have researched different surgeries as well as patients’ outcomes and access. They all came to the same conclusion: Black patients fare worse.

Surgery centers need to be aware that disparities exist, says Robert White, MD, assistant attending anesthesiologist, Weill Cornell Medicine. “Doctors aren’t aware of disparities or aware that they, their team, and hospital could be contributing to the disparities,” he observes. “People are blind to their biases that could impact treatment.”

Surgeons, like everyone, carry biases, which can influence patient care, says Charles G. Rickert, MD, PhD, a surgical resident at Massachusetts General Hospital in Boston. “A lot of these biases are not the result of deliberate negative attitudes toward a certain group or certain set of people. They’re influenced by the media around us and the population we grew up around,” Rickert says.

Rickert and colleagues at Massachusetts General Hospital founded a community health collaborative in 2016 to evaluate and improve patient care. Its goals included increasing awareness in the department about social determinants of health and healthcare disparities.1 They used implicit association testing to assess biases. It uses a set of tasks performed on a keyboard and records responses, Rickert explains.

“It’s not a perfect test, but the idea is that if you associate certain terms together faster than other terms, then that suggests an unappreciated association in your mind,” he says. This association could suggest positive or negative biases regarding a particular racial group.

Research also shows striking disparities in access to elective surgical procedures. The authors of a study of shoulder arthroplasty utilization examined more than 250,000 primary shoulder arthroplasties performed between 2005 and 2011. They found black patients constituted slightly less than 4% of cases.2

The findings revealed significant racial disparity at both national and institutional levels, which exists despite similar rates of osteoarthritis in both white and black patients. Over the study’s six-year period, the percentage of cases involving black patients increased slightly from 3.9% to 4.5%, says Joseph Abboud, MD, a study co-author and senior vice president of clinical affairs at the Rothman Orthopaedic Institute in Philadelphia. Black Americans represented about 15% of the total U.S. population during the study period. Even with the increase Abboud and colleagues observed, the disparity still was significant.

One hypothesis for the disparity is that people often choose elective surgeries based on word-of-mouth referrals. A friend, neighbor, or family member undergoes surgery. It goes well, and the person tells others about it, making it more likely they might seek the same procedure, Abboud explains.

If someone does not know anyone who has been exposed to shoulder replacement, then he or she might prefer to live with shoulder pain rather than expose themselves to an operation for which he or she has no personal knowledge, Abboud continues. Another factor could be that people are more comfortable seeing doctors of similar ethnicity, race, and gender, but there are no data to support that, Abboud adds.

Other research showed black patients experience worse outcomes after surgery vs. white patients. For example, in a study of 267,976 patient discharge records for inpatient lumbar spine surgery, White and colleagues found black race was a social determinant of health and outcomes.3 The study revealed black patients were 8% more likely than white patients to experience spine surgery-specific complications and 14% more likely to experience general postoperative complications. Black patients also stayed in facilities longer after surgery, paid more money, and were at higher risk for 30-day and 90-day readmissions.

Initially, these investigators were going to examine insurance policies and the differences between Medicare and Medicaid and the safety net among different populations, says Dima El Halawani Aladdin, MD, a study co-author and a resident in anesthesiology at Washington University in St. Louis. “When we had all the data in front of us, we said, ‘No, we need to change our major questions and talk about this,’” she says.

One factor concerned presurgery health. According to the data observed, black patients were more likely to be obese, diabetic, and suffer from heart disease prior to surgery, El Halawani Aladdin notes. Researchers took these factors, including demographics, comorbidities, hospital characteristics, surgical approaches, and state and year of surgery, into account. Nevertheless, they still found disparities when comparing patients with similar presurgery health.

The authors of a study published in 2018 found that African American children are more likely to die within 30 days after surgery compared with white children.4 “Risk of death was two times higher for African American children compared with white children,” says Oguz Akbilgic, PhD, MS, a study co-author and associate professor, department of health informatics and data science, Loyola University in Chicago. “Our goal was to provide more evidence to surgeons about which children are at higher risk and which are at lower risk. We developed a model that provided high accuracy.”

Investigators also found that the prevalence of preoperative risk factors associated with death after surgery was significantly higher for African American children. “We looked at social determinants of health, and we basically looked at socioeconomic status of children. We tried to adjust them by demography,” Akbilgic says.

These factors were relevant to the results. For example, when investigators looked at a particular city (Memphis, TN), they found that most of the African American population lived in poor-quality neighborhoods. Further, African American children there carried more risk factors and were at a higher risk of death after surgery, Akbilgic says.

The authors used information from a national database of about 250,000 surgeries, but there was no in-depth information on the socioeconomic status of the children, Akbilgic says. “We can assess by surgical risk factors, but there is much more information we need, and we don’t have these data,” he laments. “Maybe there are certain risk factors in how people are raised, their food intake, and what they’re provided as growing children. This impacts how fit they are before surgery.”

The study’s findings show surgeons need to pay more attention to risks among minority patients, Akbilgic says. “If surgeons know that African American children may be at higher risk for the same risk conditions, then they would be more prepared,” he adds.

Race also plays a role in where people choose to undergo elective surgery, according to a recently published investigation.5 The authors found that white people who live in the Bronx were more likely than racial minorities to travel to Manhattan for elective surgical care. This was true regardless of insurance type.

“The purpose behind that study was to examine racial segregation within healthcare,” says Numa Pompilio Perez, MD, a study co-author and general surgery resident, Massachusetts General Hospital. “Our take was to not look at outcomes. We wanted to look at where people choose to have surgery.”

Research into racial disparities in surgery do not demonstrate explicit racism, which is low, Perez notes. Surgeons try to treat patients the same, but there are subconscious processes, flawed science, and structural barriers that ultimately cause harm, he adds.

REFERENCES

  1. Rickert CG, Perez NP, Westfal ML, et al. Understanding our own biases as surgeons: A departmental effort. Ann Surg 2020;271:39-40.
  2. Tompson JD, Syed UA, Padegimas EM, Abboud JA. Shoulder arthroplasty utilization based on race – are black patients underrepresented? Arch Bone Jt Surg 2019;7:484-492.
  3. Aladdin DEH, Tangel V, Lui B, et al. Black race as a social determinant of health and outcomes after lumbar spinal fusion surgery: A multistate analysis, 2007-2014. Spine (Phila Pa 1976) 2019; Jan 15. doi: 10.1097/BRS.0000000000003367. [Epub ahead of print].
  4. Akbilgic O, Langham MR Jr, Davis RL. Race, preoperative risk factors, and death after surgery. Pediatrics 2018;141:e2017-e2221.
  5. Perez NP, Stapleton SM, Tabrizi MB, et al. The impact of race on choice of location for elective surgical care in New York City. Am J Surg 2020; Jan 24. pii: S0002-9610(20)30044-1. doi: 10.1016/j.amjsurg.2020.01.033. [Epub ahead of print].