Lisa Kodadek: Patient Factors Overview
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This document summarizes research on patient factors that contribute to surgical disparities. It finds that racial minorities, those of lower socioeconomic status, and other marginalized groups often receive lower quality surgical care. Specifically, black patients are less likely to receive appropriate cancer surgery or joint replacements compared to white patients. Low socioeconomic status also predicts worse access to transplants and bariatric surgery. The document calls for more research on how patient characteristics like race, ethnicity, and socioeconomics intersect and influence outcomes. It advocates for improving patient education, standardized treatment protocols, and equal access to care in order to eliminate disparities in surgical care.
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Lisa Kodadek: Patient Factors Overview
- 1. CENTER FOR SURGERY AND PUBLIC HEALTH N I H - A C S S Y M P O S I U M O N S U R G I C A L D I S PA R I T I E S R E S E A R C H Surgical Disparities: Patient Factors Lisa M. Kodadek, MD Johns Hopkins General Surgery Resident
- 2. CENTER FOR SURGERY AND PUBLIC HEALTH • Healthcare Disparities – Differences in the quality of care received by minorities and non-minorities who have equal access to care and no difference in preferences or needs for treatment1 – Disparities do not merely reflect pre-existing inequities (access to care, socioeconomic status) 2,3 – Health care quality = absence of disparities4 Background
- 3. CENTER FOR SURGERY AND PUBLIC HEALTH Language Behaviors Attitudes Beliefs Preferences Comorbidity Disease burden Immunity Obesity Presentation Income Resources Education Residence Community Age Sex Gender Race Ethnicity Demographics Physiology Socioeconomic Status (SES) Culture Patient Factors in Surgical Disparities
- 4. CENTER FOR SURGERY AND PUBLIC HEALTH • Race – Blacks less likely to receive appropriate surgical services • Reconstruction after mastectomy5 • Arthritis-related knee/hip surgery when age > 65 6 • Pulmonary resection for operable lung cancers7 – Blacks have higher operative mortality than Whites8-12 – Blacks have higher operative morbidity than Whites13-14 • Ethnicity – Hispanic patients compared to non-Hispanic patients experience similar or better operative mortality15-18 Patient Factors
- 5. CENTER FOR SURGERY AND PUBLIC HEALTH • Socioeconomic Status – Low SES patients less likely to receive surgical services • Bariatric surgery19 • Surgical resection for hepatocellular carcinoma20 • Kidney transplantation (Medicare beneficiaries)21 • Pediatric Heart Transplantation22 – Low SES predicts higher operative mortality21,22,23 – Higher income/education level more likely to receive surgical services and have better mortality outcomes5,21 Patient Factors
- 6. CENTER FOR SURGERY AND PUBLIC HEALTH • Patient Decisions & Preferences – Decision to forego lung cancer surgery associated with perception of provider communication & Black race24 – Decision-making, preferences and communication needs may differ among minority groups25 • Patient-Provider Communication/Education – Black patients may delay surgical treatment for breast cancer after diagnosis26 – Low SES patients less compliant with transplant medications22 Patient Factors
- 7. CENTER FOR SURGERY AND PUBLIC HEALTH • Eliminating disparities: What works? – Patient Education • Educational intervention “house call” increases live donor inquiries for Black patients on kidney transplant list27 – Systematic Changes • Systematic organ allocation by scoring system (MELD) eliminates racial disparities in liver transplantation28 – Equal Access to Care • Insurance expansion eliminates racial disparities in minimally invasive surgery access29 Patient Factors
- 8. CENTER FOR SURGERY AND PUBLIC HEALTH • What outcome disparities exist among racial and ethnic subgroups? – Broaden race/ethnicity studies2,3 • How does patient-level SES data predict outcomes? – Patient-level socioeconomic status data2,3 – Prospective studies2,3 Future Directions: Research Questions
- 9. CENTER FOR SURGERY AND PUBLIC HEALTH • How does intersectionality contribute to surgical outcomes? – Qualitative research24,30 – Hierarchical modeling3 • What patient-centered tools are effective? – Patient-provider communication31 – Patient decision-making32 Future Directions: Research Questions
- 10. CENTER FOR SURGERY AND PUBLIC HEALTH • “Statistics are human beings with the tears wiped off.”33 (Paul Brodeur) • Prioritize the Patient – Patient-level data – Patient-provider communication – Patient perspectives/qualitative methods Conclusions
- 11. CENTER FOR SURGERY AND PUBLIC HEALTH 1Smedley B, Stith A, Nelson A. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington,DC: Institute of Medicine; 2003. 2Haider AH, Scott VK, Rehman KA, Velopulos C, Bentley JM, Cornwell EE, Al-Refaie W. Racial Disparities in Surgical Care and Outcomes in the United States: A Comprehensive Review of Patient, Provider, and Systemic Factors. J Am Coll Surg 2013; 216 (3): 482-92. 3Morris AM, Rhoads KF, Stain SC, Birkmeyer JD. Understanding racial disparities in cancer treatment and outcomes. J Am Coll Surg 2010;211:105e113. 4Fiscella K, Franks P, Gold MR, et al. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA 2000;283:2579–2584. 5Rosson GD, Singh NK, Ahuja N, Jacobs LK, Chang DC. Multilevel analysis of the impact of community vs patient factors on access to immediate breast reconstruction following mastectomy in Maryland. Arch Surg. 2008;143(11):1076-81. 6Dunlop DD, Manheim LM, Song J, et al. Age and racial/ethnic disparities in arthritis-related hip and knee surgeries. Med Care. 2008;46(2):200-8. 6Birkmeyer NJ, Gu N, Baser O, Morris AM, Birkmeyer JD. Socioeconomic status and surgical mortality in the elderly. Med Care. 2008;46(9): 893-9. 7Shugarman LR, Mack K, Sorbero ME et al. Race and sex differences in the receipt of timely and appropriate lung cancer treatment. Med Care. 2009;47(7):774-81. 8Osborne NH, Upchurch GR Jr, Mathur AK, Dimick JB. Explaining racial disparities in mortality after abdominal aortic aneurysm repair. J Vasc Surg 2009;50:709e713. 9Sosa JA, Mehta PJ, Wang TS, et al. Racial disparities in clinical and economic outcomes from thyroidectomy. Ann Surg 2007;246:1083e1091. References
- 12. CENTER FOR SURGERY AND PUBLIC HEALTH 10Greenstein AJ, Litle VR, Swanson SJ, et al. Racial disparities in esophageal cancer treatment and outcomes. Ann Surg Oncol. 2008;15:881e888. 11Curry WT Jr, Carter BS, Barker FG 2nd. Racial, ethnic, and socioeconomic disparities in patient outcomes after craniotomy for tumor in adult patients in the United States, 1988e2004. Neurosurgury 2010;66:427e437. 12Breslin TM, Morris AM, Gu N, et al. Hospital factors and racial disparities in mortality after surgery for breast and colon cancer. J Clin Oncol 2009;27:3945e3950. 13 Kamath AF, Horneff JG, Gaffney V, et al. Ethnic and gender differences in the functional disparities after primary total knee arthroplasty. Clin Orthop Relat Res 2010;468:3355e3361. 14Singh TP, Almond C, Givertz MM, et al. Improved survival in heart transplant recipients in the United States: racial differences in era effect. Circ Heart Fail 2011;4:153e160. 15Du XL, Liu CC. Racial/ethnic disparities in socioeconomic status, diagnosis, treatment and survival among medicareinsured men and women with head and neck cancer. J Health Care Poor Underserved 2010;21:913e930. 16Mathur AK, Osborne NH, Lynch RJ, et al. Racial/ethnic disparities in access to care and survival for patients with early-stage hepatocellular carcinoma. Arch Surg 2010;145:1158e1163. 17Murphy EH, Davis CM, Modrall JG, et al. Effects of ethnicity and insurance status on outcomes after thoracic endoluminal aortic aneurysm repair (TEVAR). J Vasc Surg 2010;51: 14Se20S. 18Nathan H, Frederick W, Choti MA, et al. Racial disparity in surgical mortality after major hepatectomy. J Am Coll Surg 2008;207:312e319. 19Birkmeyer NJ, Gu N. Race, socioeconomic status, and the use of bariatric surgery in Michigan. Obes Surg.2012;22(2):259-65. 20Zak Y, Rhoads KF, Visser BC. Predictors of surgical intervention for hepatocellular carcinoma: race, socioeconomic status, and hospital type. Arch Surg 2011;146:778e784. 21Axelrod DA, Dzebisashvili N, Schnitzler MA, et al. The interplay of socioeconomic status, distance to center, and interdonor service area travel on kidney transplant access and outcomes. Clin J Am Soc Nephrol 2010;5:2276e2288. References
- 13. CENTER FOR SURGERY AND PUBLIC HEALTH 22Davies RR, Russo MJ, Reinhartz O et al. Lower socioeconomic status is associated with worse outcomes after both listing and transplanting children with heart failure. Pediatr Transplant 2013;17(6):573-81. 23Bennett KM, Scarborough JE, Pappas TN, Kepler TB. Patient socioeconomic status is an independent predictor of operative mortality. Ann Surg 2010;252:552e557; discussion 557558. 24Cykert S, Dilworth-Anderson P, Monroe M et al. Factors Associated With Decisions to Undergo Surgery Among Patients With Newly Diagnosed Early-Stage Lung Cancer. JAMA. 2010;303(23):2368-76. 25Torke AM, Corbie-Smith GM, Branch WT. African-American patients’ perspectives on medical decision making. Arch Intern Med. 2004;164(5):525-30. 26Bustami RT, Shulkin DB, O’Donnell N, Whitman ED. Variations in time to receiving first surgical treatment for breast cancer as a function of racial/ethnicity background: a cohort study. JRSM Open. 2014;5(7):epub. 27Rodrigue JR, Paek MR, Egbuna O et al. Making house calls increases living donor inquiries and evaluations for blacks on the kidney transplant waiting list. Transplantation. 2014;98(9):979-86. 28Moylan CA, Brady CW, Johnson JL, Smith AD, Tuttle-Newhall JE, Muir AJ. Disparities in Liver Transplantation Before and After Introduction of the MELD Score. JAMA. 2008;300(20): 2371-2378. 29Loehrer AP, Song Z, Auchincloss HG, Hutter MM. Massachusetts Health Care Reform and Reduced Racial Disparities in Minimally Invasive Surgery. JAMA Surg. 2013;148(12):1116-1122. 30Potter S, Mills N, Cawthorn S, Wilson S, Blazeby J. Exploring inequalities in access to care and the provision of choice to women seeking breast reconstruction surgery: a qualitative study. Br J Cancer. 2013;109(5):1181-91. 31Murphy MM, Tseng JF, Shah SA. Disparities in cancer care: an operative perspective. Surgery. 2010;147(5):733-7. 32Polacek GN, Ramos MC, Ferrer RL. Breast cancer disparities and decision-making among U.S. women. Patient Educ Couns. 2007;65(2):158-65. 33Brodeur P. Outrageous Misconduct. The Complete New Yorker Reports, 1985. References
Editor's Notes
- Good morning. My name is Lisa Kodadek and I am a general surgery resident at Johns Hopkins. Thank you for the opportunity to present our second theme for the NIH-ACS Surgical Disparities Conference: Patient Factors.
- The Institute of Medicine, in the seminal 2003 report Unequal Treatment, defined healthcare disparities as differences in the quality of care between minorities and non-minorities when both groups have equal access to care and no difference in their preferences or needs for treatment. While some have argued that perhaps surgical disparities are reflective of pre-existing inequities secondary to patient-level factors such as insurance status, access to care or SES, this has largely been disproven by a number of excellent review papers. Eliminating healthcare disparities has been a challenging and long elusive goal. A JAMA paper published nearly 15 years ago recognized that true health care quality must be absent of disparities among minority groups. However, we still face difficulty in reaching this goal, because the scope of the problem is immense, and there are a number of contributing factors and systems.
- Previous research has demonstrated different patient factors that may contribute to healthcare disparities. There is no one cause for healthcare disparities, but rather the intersection of multiple factors. Various theories have been applied to try and understand these complex interactions --Intersectionality and Syndemic Theory, for example, have been used to understand the multiplicity of patient factors that contribute to disparities among minority groups. We will briefly review a number of these factors which have been reported in the literature and patterns that have emerged. I will note that socioeconomic status and race have been extensively studied and much of the literature to date has focused on these patient factors. While these are crucially important, there are a number of other factors, as listed here, that may interact in complex and hierarchical ways that we have yet to fully understand.
- Overwhelmingly, Blacks are not receiving appropriate surgical care at the same rate that Whites are receiving care. For example, Blacks less commonly receive immediate reconstruction after mastectomy. Age and race may interact to cause disparities: Blacks are less likely to receive arthritis surgery than Whites when age > 65 years, but among younger patients, there is no difference between these races. Race and sex may also demonstrate parallel disparities: Women and Blacks are both more likely to not receive appropriate surgical resection for stage I and II operable lung cancers than their counterparts. When Black patients do undergo surgery, across various surgical disciplines, Black patients have higher surgical mortality and morbidity than White patients. Ethnicity has also been studied, and a large body of literature has demonstrated that Hispanic patients do not experience worse survival with surgery than their non-Hispanic counterparts. However, with the diverse number of ethnic groups and subgroups in the US, we have certainly not learned enough yet about what disparities exist among ethnic minorities.
- Socioeconomic status is a complex marker of affluence, resources, education, income and occupation. Of note, much of our study of SES to date has relied on a proxy—patient level zip code—to understand and compare outcomes, since this is most commonly available in administration datasets. While these database studies have been important and have furthered our knowledge, we must not forget that we are using a marker of the whole location or community to represent a potentially wide spectrum of individual people living within that zipcode. This may be a particularly inaccurate representation of SES in large cities and urban areas. Patients with low SES are less likely to receive appropriate surgical services including bariatric surgery, hepatocellular carcinoma resection, kidney transplant. These findings are also unfortunately also noted among children with low SES who less commonly receive heart transplant. Patients with low SES, when they do get needed surgical care, have worse outcomes and higher mortality. Conversely, patients with higher income, higher education are more likely to receive services and have better outcomes.
- While these disparities exist, the causes underlying these findings highlight areas where we might focus to improve surgical outcomes for our patients. Patient decision-making, preferences, behaviors may explain some of the disparities, but commonly these are not so much explanations as they are markers for lack of clear provider communication and culturally competent patient-provider discussions. For example, a patient’s decision to forego curative resection for lung cancer is associated with perceptions of provider communication effectivenes. Furthermore, there is evidence that lack of appropriate patient education may be contributing to outcomes disparities. Black patients delay surgical treatment after diagnosis, which may reflect lack of understanding of the recommended treatment secondary to poor communication. Low SES patients are less compliant with medications, highligting a need for increased education and assistance with understanding sometimes complicated medication regimens.
- Why do these disparities persist and what have we done to eliminate these disparities? Many of the solutions rely on improved patient-provider communication, patient education, and systematic processes to encourage equity. Patient education house calls increased inquiries for live donors for Black patients in need of kidney transplants. A group from Duke published results in JAMA (2008) demonstrating how liver transplantation differed before and after introduction of the MELD score system for allocation. Before introduction of the MELD, liver transplantation rates differed by race: black patients were more likely than white patients to die on the waiting list or become too sick for transplant. After introduction of the MELD, the racial disparities no longer existed. Finally, equal access to care in universally insured populations has also eliminated known disparities.
- What can we do now to help understand and eliminate disparities in surgical healthcare? We need better data and more data. We need to standardize race and ethnicity reporting and broaden studies to include ethnic subgroups otherwise poorly represented in the surgical literature. SES is a complex patient factor and zip code as a proxy is not sufficient. Without a complete patient-level understanding of SES, further improvements to address this complex patient factor are hindered. We need patient-level SES data to truly make progress in this area. Most of the surgical disparities research to date have used retrospective data collected for other purposes such as billing. Prospective studies are critical.
- We need fresh and innovative methodology such as qualitative research and hierarchical modeling to truly understand the complex phenomena we week to study. We need to understand the lived experience of our patients. We need to explore the intersectionality of race, ethnicity, low SES—how does the multiplicity of all of these factors contribute to the overall outcome of a patient? Furthermore, we need patient-centered tools and data to truly understand the meeds of our patients and how beliefs, preferences and behaviors may contribute to surgical outcomes. We need new and innovative research methodologies. Qualitative research is an excellent method to understand complex phenomena such as the interplay between age, race, socicoeconomic status and healthcare preferences and outcomes (e.g. in-depth interviews, focus groups). We need to engage patients and engage communities to understand these disparities (patient co-investigator). We need to understand how clinicians make decisions and determine how implicit bias may affect outcomes. Furthermore, databases are not well suited to study patient and provider decision making, or aspects of the continuum of care. Many minorities may have difficulty navigating the healthcare system due to cultural or behavioral aspects or language barriers. We need to support research that will develop tools to allow patients ease of use of the healthcare system. We need to empower patients to make healthcare decisions and to communicate with providers.
- In conclusion, to address current surgical healthcare disparities attributed to patient factors, we need to delve deeper than current databases allow. Paul Brodeur, a lay science writer, once wrote that statistics are human beings with the tears wiped off. We know the statistics—they are dismal; disparities exist. Now—we need the stories! We need to engage and prioritize patients. We need quality patient-level data, prospective studies and we need fresh methodology that sees and values human beings as human beings. We are talking about complex and difficult phenomena—race, ethnicity, age, sex, socioeconomics, communication. We need to realize that these issues warrant an entirely new and innovative approach to surgical disparities research. We need to better understand patient perspectives and complex patient-provider interactions. Qualitative methodologies are well suited to explore these types of issues and should be prioritized to better understand surgical disparities. Only then can we assure all our patients equal treatment and equal opportunity for the best possible outcomes from their surgical care. Thank you.