R. Udyavar1, A. Salim2, E. Cornwell3, Z. Hashmi1, J. Havens1,2, A. Haider1,2 1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 3Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA
Introduction: Understanding the mechanisms that lead to health care disparities is necessary to create robust solutions and ensure that all patients receive the best possible care. Many factors, including patients’ clinical/demographic characteristics and socioeconomic issues have been examined, but the extent to which surgeon-level factors contribute to disparities has not been established. Our objective was to quantify the influence of the individual surgeon on disparate outcomes for minority patients undergoing Emergency General Surgery (EGS).
Methods: We analyzed the Florida State Inpatient Database (SID) and extracted all patients who underwent 1 or more of 7 EGS procedures from 2010-2014. These procedures (laparotomy, cholecystectomy, small bowel resection, colectomy, peptic ulcer disease repair, lysis of adhesions, and appendectomy) represent 80% of all EGS cases performed in the U.S. Our outcome of interest was postoperative complications, including pulmonary embolism, infection, and anastomotic leak. To determine the individual surgeon effect, we performed multi-level random effects modeling, adjusting for clinical and hospital factors, such as comorbidities, illness severity, and hospital volume. This allowed us to determine if there was an increased adjusted odds of developing complications for black patients attributable to the individual provider.
Results: The study sample consisted of 291,497 cases performed by 1,736 surgeons at 205 hospitals. Black patients comprised 21.5% of the sample. On unadjusted analysis, the overall complication rate was 12.7%. For white patients, this was 10.7%, but for black patients, the complication rate increased to 31.2%. Black patients had a higher adjusted risk of having a complication than white patients (OR 1.32, 95% confidence interval [CI] 1.02-1.85). Between surgeons, the complication rate ranged from 3.02% and 21.7%. The proportion of the overall surgeon-level variation explained by measured clinical and hospital-level factors was 23.8%, and the proportion attributable to the individual surgeon effect was only 2.3%. However, when comparing patients according to race, the proportion of the between-surgeon variation due to the individual surgeon increased to 11.7%. This multifold increase suggests that the individual surgeon influences the degree to which black patients are more susceptible to experiencing a complication than their white counterparts.
Conclusion: This multi-institution analysis within a single large state demonstrates that not only do black patients have a higher risk than white patients of developing a complication after undergoing EGS, surgeon-level effects account for a larger proportion of the between-surgeon variation when comparing the two demographics. This suggests that there are factors both measurable and unmeasurable at the individual surgeon level that contribute to racial disparities in EGS.