Surgery News- July 2008

10 PRACTICE TRENDS SURGERY NEWS • J U LY 2 0 0 8 Race Alone Does Not Predict Surgical Outcomes BY BRUCE JANCIN Else vier Global Medical Ne ws N E W YO R K — African American race is not an independent predictor of worse perioperative outcomes following major general surgery, according to results of a large study that is at odds with earlier reports. Those prior studies didn’t adequately control for the greater comorbidities and other potential confounders present in African American, compared with white, general surgery patients, Dr. Nestor F. Esnaola said at the annual meeting of the American Surgical Association. Although race is not a modifiable characteristic, many of the comorbidities that were identified in the new study as being more common in African American surgery patients certainly are. The implication is that greater access to prehospital primary care and more inpatient comanagement by hospitalists might neutralize the racial disparity in perioperative outcomes, he said. Dr. Esnaola reported on 34,141 white and 5,068 African American patients who underwent major general surgery at one of 14 academic medical centers during 2001-2004 while enrolled in the National Surgery Quality Improvement Program’s Patient Safety in Surgery Study. The prospective study, sponsored by the American College of Surgeons with funding from the Agency for Healthcare Research and Quality, featured data collection on 97 patient variables. Unadjusted 30-day morbidity was 14.3% in African Americans, significantly higher than the 12.4% rate in whites; 30-day mor- American College of Surgeons 94th annual Clinical Congress October 12–16, 2008: San Francisco, CA Moscone Convention Center Save the Date! Join us in San Francisco for the 94th annual Clinical Congress. As always, it will be an educational opportunity you won’t want to miss! Please be sure to visit www.facs.org in the coming months for more details regarding the educational program, registration, housing, and transportation. tality was also higher, at 2.1% in African Americans versus 1.7% in whites, although this difference was not significant. But this study highlighted the need for comprehensive risk adjustment, said Dr. Esnaola, an ACS Fellow with the Medical University of South Carolina, Charleston. African American patients were younger but significantly more likely to present with hypertension, diabetes, renal failure, dyspnea, anemia, a history of heart failure, and open wounds or active infection. For example, the 6.1% prevalence of end-stage renal disease in African Americans was fivefold greater than in whites. The prevalence of diabetes was 17% in African Americans and 10% in whites. A history of hypertension was present in 49% of African Americans, compared with 34% of whites. African American patients were nearly twice as likely as whites to present for surgery with open wounds or active infection. Race had no Particularly strikindependent effect ing were the differon 30-day ent rates of emermorbidity when comorbidities were gency surgery (16% in African Americontrolled for. cans patients versus DR. ESNAOLA 10.5% in whites). African Americans and whites underwent similar types of general surgery, but African Americans had less complex operations based on relative-value units. In a multivariate logistic regression analysis controlling for comorbidities and numerous other potentially confounding pre- and intraoperative factors, race had no independent effect on 30-day morbidity or mortality. These findings suggest that efforts to improve perioperative outcomes in African American patients should focus on optimizing perioperative management of comorbidities and reducing the need for emergency surgery, Dr. Esnaola said. One way to do this might be to enhance reimbursement for surgeons who provide outpatient surgical consultation to minority patients. “Additional funding to improve infrastructure of hospitals caring for a disproportionate share of minority patients may be warranted,” he added. Audience members expressed a desire to see an analysis of the data based on socioeconomic status. Dr. Esnaola said such data weren’t collected in the national surgery study, although he agreed that socioeconomic status probably drives access to care, preoperative management of comorbidities, and the likelihood of emergency surgery. “There’s no biological reason to assume that African Americans would be more likely to have greater comorbidity across the board, other than the fact that they have less access to care, less access to primary care, and less opportunity to have these issues addressed preoperatively before they present for emergency surgery,” he noted. ■ http://www.facs.org http://www.facs.org

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Surgery News- July 2008 Contents The 20/20 Vision: Health Reform Trauma: Airway Anchor News From the College: Jacobson Winner General Surgery: Worth the Trouble

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