Topic: J. Social and Ethical Issues in Surgery
Race and Surgical Outcomes: It’s Not All Black and White
Nestor F Esnaola1, Bruce L. Hall2, John Z. Ayanian3, William G. Henderson4, Shukri F. Khuri5, Michael J. Zinner3, Selwyn O. Rogers3
1Medical University of South Carolina, Charleston, SC;2Washington University, St. Louis, MO;3Brigham and Women's Hospital, Boston, MA;4Colorado Health Outcomes Program, Aurora, CO;5Veterans Administration Medical Center, West Roxbury, MA
Background: Studies using Medicare data have suggested that African American (AA) race is an independent predictor of death following major surgery. We hypothesized that the apparent adverse effect of race on surgical outcomes is due to confounding by comorbidity, not race itself.
Methods: We identified all non-Hispanic white (W) and AA general surgery patients (pts) included in the National Surgery Quality Improvement Program (NSQIP) Patient Safety in Surgery Study (2001-2004). Patient characteristics, comorbidity, and postoperative outcomes were collected and analyzed using NSQIP methodology. Characteristics between races were compared using Student's t and chi-square tests. Odds ratios (OR) for 30-day morbidity and mortality were calculated using multivariate logistic regression.
Results: We identified 34,141 W and 5068 AA pts. AA pts were younger, but more likely to undergo emergency surgery and present with hypertension, diabetes, dyspnea, renal failure, open wounds/infection, or advanced ASA class (all P<0.001). AA pts underwent less complex procedures (based on work relative value units, P<0.001), but had higher unadjusted 30-day morbidity (14.3% v. 12.4%, P<0.001) and mortality (2.1% v. 1.7%, P=0.02) compared to W pts. After controlling for comorbidity and other preoperative/intraoperative factors, however, AA race had no independent effect on morbidity (OR 0.98 [0.89-1.08]) or mortality (OR 0.87 [0.67-1.12]).
Conclusion: AA race is associated with greater comorbidity, but is not an independent predictor of worse perioperative outcomes after general surgery. Efforts to improve postoperative outcomes in AA pts should focus on reducing the need for emergency surgery and improving perioperative management of comorbid conditions.