Disparities due to Pre-existing Conditions

Despite attempts to improve access to care via the implementation of the Affordable Care Act, continue to persist. This study examines some of the causes of racial disparities between blacks and whites; it further attempts to understand and isolate the individual effects of pre-operative risk factors. Selected subjects were black Medicare patients who underwent general surgery procedures and were matched with white controls within 6 states and within 838 hospitals.

Source: Eric Schmuttenmaer (Flickr/CC)

By matching black patients with white patients across hospitals and within hospitals, based on age, sex, year, state, and procedure type this study was able to eliminate variances and further delineate possible explanations in outcome differences.  When matched on the before mentioned factors, there were several significant differences in outcomes; however, when pre-operative risk factors such as pre-existing co-morbidities were matched there were no longer any significant differences in mortality, failure to rescue, or readmissions.

Among patients undergoing similar procedures, blacks tended to have higher rates of risk factors prior to surgery. Risk factors such as congestive heart failure (p<0.0001), diabetes (p<0.0001), and hypertension (p<0.0001) tended to be more prevalent in black patients when compared to whites undergoing the same procedures. Addressing pre-existing co-morbidities will likely play a substantial role in eliminating existing health disparities.

There was little to no significant difference between black and white patients based on hospital quality, contrary to the conventional thought that those hospitals that provide care to larger minority and poorer populations tend to be “lower quality” hospitals. This study did not show any significant difference in facilities nor did it indicate such hospitals provided inferior care.

When it comes to health disparities, addressing poor health status in patients who are sicker pre-operatively and throughout an admission may improve surgical outcomes. It is not only important to identify these pre-operative risk factors that contribute to poor health outcome, but it is also necessary to identify their root cause in order to formulate effective solutions to combat pre-existing conditions which contribute to racial health disparities.

commentary by Ellana Stinson

Abstract

BACKGROUND: Racial disparities in general surgical outcomes are known to exist but not well understood.

OBJECTIVES: To determine if black-white disparities in general surgery mortality for Medicare patients are attributable to poorer health status among blacks on admission or differences in the quality of care provided by the admitting hospitals.

RESEARCH DESIGN: Matched cohort study using Tapered Multivariate Matching.

SUBJECTS: All black elderly Medicare general surgical patients (N=18,861) and white-matched controls within the same 6 states or within the same 838 hospitals.

MEASURES: Thirty-day mortality (primary); others include in-hospital mortality, failure-to-rescue, complications, length of stay, and readmissions.

RESULTS: Matching on age, sex, year, state, and the exact same procedure, blacks had higher 30-day mortality (4.0% vs. 3.5%, P<0.01), in-hospital mortality (3.9% vs. 2.9%, P<0.0001), in-hospital complications (64.3% vs. 56.8% P<0.0001), and failure-to-rescue rates (6.1% vs. 5.1%, P<0.001), longer length of stay (7.2 vs. 5.8 d, P<0.0001), and more 30-day readmissions (15.0% vs. 12.5%, P<0.0001). Adding preoperative risk factors to the above match, there was no significant difference in mortality or failure-to-rescue, and all other outcome differences were small. Blacks matched to whites in the same hospital displayed no significant differences in mortality, failure-to-rescue, or readmissions.

CONCLUSIONS: Black and white Medicare patients undergoing the same procedures with closely matched risk factors displayed similar mortality, suggesting that racial disparities in general surgical mortality are not because of differences in hospital quality. To reduce the observed disparities in surgical outcomes, the poorer health of blacks on presentation for surgery must be addressed.

Silber, JH, et al. Medical Care. 2015; 53 (7) : 619-29. PMID: 26057575