Disparities in Surgical Care Have Multilevel, Interconnected Causes

Surgeons and researchers, responding to the known prevalence of inequalities in U.S. surgical care, have taken the first steps toward eliminating surgical care disparities by grouping their causes into themes and identifying modifiable contributing factors — that according to a new article, including a comprehensive review of the medical literature on health care disparities, published online by the Journal of the American College of Surgeons.

Health care disparities encompass differential access, care, and outcomes due to factors such as minority group and socioeconomic status.

“Disparities are a huge problem at all stages of surgical care,” principal investigator, Adil Haider, MD, MPH, FACS, said. Haider serves as Kessler director of the Center for Surgery and Public Health, a joint initiative of Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston.

“As surgeons, we have a long way to go to make sure that all patients have equal access to high-quality surgical care and postoperative care,” Haider said. “However, we have raised awareness of the problem, which is step one to developing studies and interventions that will make a real difference for surgical patients.”

The authors’ work, in collaboration with leaders at the American College of Surgeons and the National Institutes of Health (NIH), led to the NIH’s National Institute on Minority Health and Health Disparities recently launching a research program to address disparities in surgical care.

For this investigation, the authors evaluated 328 U.S. studies of health care disparities published between January 2008 and February 2015. The researchers identified five common major themes from the causes of surgical disparities.

Previously, Dr. Haider and his colleagues identified three themes of factors that contribute to surgical disparities: Patient-, provider-, and health care systems-level factors. In this new article, the researchers added two additional themes.

The first new theme is clinical care and quality at the hospital level, which includes how variation in the quality of care across hospitals affects surgical results, complications, and hospital readmissions. The second new theme, postoperative care and rehabilitation, addresses how access to high-quality postoperative care and rehabilitative services can contribute to long-term recovery and outcomes. 

Haider called postoperative care “an important but largely unexplored area of health care disparities research.”

Together the five themes make up a conceptual framework that Haider said will allow researchers to more manageably evaluate factors contributing to surgical disparities by their related causes and/or impact. In turn, he noted, this process may speed development of effective interventions designed to improve access to optimal surgical care.

The themes reflect that surgical disparities are multilevel and often interconnected, the authors write. Hospital-level factors, for instance, sometimes explain why racial-ethnic minorities (a patient factor) fare worse than white patients do after operations.

Key hospital characteristics associated with improved surgical outcomes, according to the article, include use of quality improvement strategies, application of clinical guidelines and surgical protocols, use of supportive technology such as electronic health records, and a patient-centered culture that focuses on patient satisfaction and shared decision making.

Examples of disparities in clinical care and quality that affect racial-ethnic minorities and poor patients include the following:

• Hospitals that treat the most uninsured patients — so-called safety net hospitals — tend to have worse surgical outcomes than hospitals with a better insurance payer mix, partly because they usually cannot afford to invest in quality improvement programs, Haider said. Many minority patients use safety net hospitals.
   
• Patients who live in financially disadvantaged regions are likelier to use hospitals that perform a low volume of operations. Numerous studies show low volume is associated with worse outcomes for many surgical procedures, because the surgeons do not get enough practice.

Among the factors that can affect disparities in postoperative care and rehabilitation are the timing, duration, and quality of rehabilitation, as well as whether patients even receive rehabilitative care postoperatively.

• Race/ethnicity and insurance status affect whether trauma and joint replacement patients receive rehabilitation and how intensive it is, and rural residence makes getting rehabilitation more difficult for joint replacement patients.
   
• Women are less likely than men to be referred for cardiac rehab after angioplasty, as are nonwhites.

Inadequate follow-up with the surgeon may contribute to delays in patients receiving rehabilitation, according to Haider.

“Surgeons should go the extra mile to make sure their patients get the best possible postoperative rehabilitation when needed,” he suggested.