Postoperative Mortality Gap Narrows for Blacks

Pam Harrison

June 06, 2017

The mortality gap between black and white patients undergoing surgery is narrowing across much of the United States, with most of the improvement being seen within hospitals rather than between hospitals, a national study of fee-for-service Medicare beneficiaries 65 years of age and older indicates.

"[W]e found that modest gaps between blacks and whites in thirty-day, all cause, postoperative mortality declined over time across a range of procedures," Winta Tsegay Mehtsun, MD, research fellow, Harvard T.H. Chan School of Public Health, Boston, Massachusetts and colleagues report. "[T]he largest improvements in mortality rates for black patients occurred among small, public hospitals that were not minority-serving institutions," they add. "Taken together, these findings are good news for policy makers interested in seeing reductions in disparities in mortality after major surgery."

The study was published online June 5 in Health Affairs.

The researchers used claims data from January, 2005 through to November, 2014 for Medicare patients who had undergone one of 8 selected high or low- risk procedures. "The high-risk procedures were coronary artery bypass graft, abdominal aortic aneurysm repair (endovascular and open), pulmonary lobectomy, colectomy (laparoscopic and open), and hip replacement," they note. Appendectomy, cholecystectomy, and knee replacement surgery were all considered to be low risk.

The authors considered only mortality differences between black and white patients and excluded Hispanic patients from the analysis. During the study years, 6,596,550 patients underwent one of the eight selected procedures in a total of 3054 hospitals. Slightly less than half of the cohort required a high-risk procedure, 5.4% of whom were black.

A similar percentage (5.7%) of patients who underwent a low-risk procedure were also black. "Across all procedures, in the baseline year black patients had a composite mortality rate of 3.85 percent, compared to 3.27 percent for white patients," Dr. Mehtsun reports (P < .001). In 2005, composite mortality rates were 5.38% for black patients requiring high-risk surgery vs 4.9% for white patients undergoing a similar-risk surgery.

For low-risk procedures, composite mortality rates were predictably lower, at 2.16% in 2005 for black patients vs 1.49% for white patients.

Over the entire study interval, changes in composite mortality rates from all procedures were significant for both black and white patients at –0.10% and –0.07%, respectively. Composite mortality rates also changed significantly for high-risk procedures at –0.10% per year (P < .001) for black patients and –0.08% per year for white patients. For low-risk procedures, composite mortality rates changed by –0.09% per year for black patients and –0.05% per year for white patients.

"Over the study period, mortality rates for black patients improved more quickly than the rates for white patients for six of the eight procedures," the authors add.

Small and Medium-Sized Hospitals

The authors also analyzed where these reductions in mortality were most likely to occur and found that both small and medium-sized hospitals were more likely to post an improvement in mortality rates than large hospitals. "Similarly, hospitals located in the Northeast, Midwest, and West were more likely to be in that group, compared to hospitals in the South," they observe.

In contrast, fewer hospital that serve minorities were likely to be in the group that showed improvements in mortality rates, especially mortality linked to high-risk surgeries. "Much of the gains in mortality for black patients

came from within-hospital improvements — improvements in outcomes within institutions — instead of from patients' shifting from low- to high-quality hospitals," the authors note.

"Our findings suggest that broad-based quality improvement efforts such as those implemented in the past decade may have beneficial effects on disparities in surgical outcomes," they add.

That said, the authors emphasize that disparities in mortality rates between black and white patients still exist, especially for low-risk surgeries, and efforts to close the racial gap in postoperative mortality rates need to continue.

The authors have disclosed no relevant financial relationships.

Health Aff. 2017;36:1057-1064. Abstract

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