Minority Patients May Less Often Receive Surgical Interventions

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Though we just celebrated the anniversary of Martin Luther King’s birthday, a man who was pivotal in the Civil Rights Movement, we are still seeing racial and ethnic disparities in healthcare. A new study published in the February issue of Archives of Surgery has found that minority patients in New York City appear less likely than white patients to receive surgeries at high-volume facilities.

According to the authors in the article’s background information, “One specific concern is whether minorities disproportionately receive treatment from lower-quality providers. While measuring quality accurately is difficult, research has shown mortality to be inversely related to hospital and surgeon volume for many surgical procedures.”

Andrew J. Epstein PhD of Yale University’s School of Public Health selected 10 procedures for which published evidence indicates surgical volume’s influence on a patient’s risk of death. Those included cancer (breast, colorectal, gastric, lung, and pancreatic), cardiovascular (coronary artery bypass graft, angioplasty, abdominal aortic aneurysm repair, and carotid endarterectomy) and orthopedic surgeries (total hip replacement). The team then researched medical records of over 130,000 patients in the New York City area who had one of these procedures between the years 2001 and 2004.

Each facility and surgeon was evaluated for their annual volume for each of the procedures performed, calculated using a statewide database which could include thresholds for high-volume versus low-volume providers.

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Even after adjusting for confounding factors such as income, education and insurance status, treatment at high-volume hospitals by high-volume surgeons was 11.8% lower for black patients, 8% lower for Asian patients, and 7% lower for Hispanic patients.

The authors offered two possible explanations for the disparities. One, of course, included geographical and financial incentives that keep minorities from the higher-quality providers. For example, Asian patients in the study were more likely to be uninsured or on Medicaid, limiting their choice of physician for certain procedures.

Another hypothesis given was differences and difficulties in the access of accurate information about provider quality. Medicare, for example, has an online quality tool called “Hospital Quality Compare.” The data lists hospital outcome measures based on procedures reimbursed by Medicare, but may not be reflective of patients with private insurance. The Joint Commission also reports on a set of quality measures, which may or may not be the same as those reported by CMS.

The study, unfortunately, is not the first to link racial and ethnic status with differences in surgical care. A recent study in the Journal of Vascular Surgery, for example, found that black and Hispanic patients are more likely to receive limb amputations for acute peripheral arterial disease, while white patients may undergo a surgical or endovascular repair in an attempt to save the limb.

1. Racial and Ethnic Differences in the Use of High-Volume Hospitals and Surgeons Andrew J. Epstein, PhD; Bradford H. Gray, PhD; Mark Schlesinger, PhD Arch Surg. 2010;145(2):179-186.
2. Racial and ethnic differences in patterns of treatment for acute peripheral arterial disease in the United States Rowe VL, Weaver FA, Lane JS, Etzioni DA., 1998-2006. J Vasc Surg. 2010;Epub ahead of print

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