As a practicing surgeon for 30 years in the super-specialized field of otology, neurotology and skull base surgery, I have been privy to some of the most disturbing realities of surgical care. Often, these realities are bleaker than most people expect. One thing physicians, and the general population, need to be more aware of is the very real racial disparity in surgical care.
Are the outcomes for Black and Hispanic patients truly different than white patients when it comes to surgery? The answer is an astounding yes. Are the differences related to other factors such as socioeconomic class, insurance status, gender, income, extent of disease at presentation or other comorbidities? Even when controlling for many of these factors, racial disparities in the delivery of surgical care persist.
In 2013, Dr. Adil Haider and their team conducted an extensive meta-analysis reviewing the literature on the subject as it relates to surgical care. In their nationwide study of appendectomy, gastric fundoplication, and gastric bypass surgeries, Ricciardi et al. found that Black patients were significantly more likely to die in-hospital than white patients. In an analysis of the effect of gender on outcomes of lower extremity arterial disease, Vouyouka et al. showed that the female gender increased the odds of mortality among Black patients especially.
Larger disparities were noted in high-risk surgeries as well. An analysis showed that mortality in high-risk surgeries was 1.57 times higher for Black patients than for white patients, despite adjusting for age, insurance status, and geographic region. Additionally, Black men over 65 years of age less frequently received surgical treatment for aneurysms compared to white men despite higher disease prevalence.
Even when controlling for insurance status, racial outcome inequities continue to be observed. For instance, in one study of patients undergoing major surgery, Black patients had 2.15 times higher odds than white patients of death after surgery.
What are the solutions to this problem?
Awareness
Clearly, awareness amongst primary care physicians, surgeons, and nurses is an important first step. Publishing findings from Haidler’s group and others regarding racial disparities in surgery within professional journals would go a long way. Presentation of these topics at professional society meetings would increase awareness, foster discussion, and hopefully, lead to specialty-specific recommendations to combat these problems.
Behavioral modification
The next logical step is behavioral modification, especially as it relates to provider communication. Physicians and surgeons need to better ascertain the education level of their patients and tailor their discussions accordingly, using understandable language to break down complex aspects of their condition with use of analogies.
A plumber, for example, can easily understand features of the circulatory system if it is described in language he can understand, such as pipes leading to and away from the pump. Insisting on the presence of family members (even by phone) at office visits would also go a long way to ensure comprehension. Asking patients to repeat what was stated about their condition and treatment options would reinforce patient understanding.
Concierge service and technology
Consider the surgical process today. Patients are referred by their primary care physician to a surgeon without much thought about the cost of care or about the surgeon’s experience related to the patient’s condition. The result is that patients are pigeonholed to one surgeon. They have a whole provider book of surgeons in their network to choose from but no way to know how to pick the best surgeon for the complexity of their condition.
Here is where a concierge and technology service can help. Once patients are told they need surgery, a personalized concierge helps gather and upload their medical records and imaging studies to the HIPAA-compliant cloud. From here, the records are sent to multiple board-certified surgeons.
Herein lies a powerful solution because the records are blinded with regard to race and ethnicity. After review, surgeons validate medical necessity and enter their past experience with that case, such as the number of cases performed the previous year and success and complication rates. The experience data is verified and compared with the group of reporting surgeons and assigned a star grade of one to five stars. Surgeons can also report all-inclusive pricing.
Through peer review of their case, patients avoid unnecessary surgery and learn of alternatives to surgery. When their surgery is necessary, patients can choose their surgeon from their in-network provider book, based on the surgeon’s past experience with their procedure, including success rates and complication rates. The concierge is there every step of the way to ensure patients understand the quality outcomes measures.
Can racial disparity in surgical care be fixed?
In summary, racial disparities in surgical care delivery do exist. But I don’t believe a solution is impossible.
Provider awareness is a key initial step to increase awareness, followed by enhanced communication with the patient with family involvement whenever possible. Concierge service and technology helps handhold patients as their records are sent to multiple surgeons within their network. These cases are presented without race and ethnicity demographic information. Using the system, surgeons can make decisions more objectively, and patients are empowered with tools to make well-informed decisions.
Despite what seems like a long, uphill climb — there is hope on the horizon.
Sanjay Prasad is a neurotologist and founder, SurgiQuality. He can be reached on Facebook, Instagram, and Twitter @surgiquality. He is also the author of the book, Resetting Healthcare Post-COVID-19 Pandemic.
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