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Racial/Ethnic Disparities in Longer-term Outcomes Among Emergency General Surgery Patients

The Unique Experience of Universally Insured Older Adults

Zogg, Cheryl K., MSPH, MHS*,†; Jiang, Wei, MS; Ottesen, Taylor D., BS*; Shafi, Shahid, MD, MPH, FACS; Schuster, Kevin, MD, MPH, FACS, FCCM*,§; Becher, Robert, MD, MS*,§; Davis, Kimberly A., MD, MBA, FACS, FCCM*,§; Haider, Adil H., MD, MPH, FACS

doi: 10.1097/SLA.0000000000002449
ORIGINAL ARTICLES

Objectives: To determine whether racial/ethnic disparities in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among universally insured older adult (≥65 years) emergency general surgery patients; vary by diagnostic category; and can be explained by variations in geography, teaching status, age-cohort, and a hospital's percentage of minority patients.

Summary of Background Data: As the US population ages and discussions surrounding the optimal method of insurance provision increasingly enter into national debate, longer-term outcomes are of paramount concern. It remains unclear the extent to which insurance changes disparities throughout patients’ postacute recovery period among older adults.

Methods: Survival analysis of 2008 to 2014 Medicare data using risk-adjusted Cox proportional-hazards models.

Results: A total of 6,779,649 older adults were included, of whom 82.8% identified as non-Hispanic white (NHW), 9.2% non-Hispanic black (NHB), 5.6% Hispanic, and 1.5% non-Hispanic Asian (NHA). Relative to NHW patients, each group of minority patients was significantly less likely to die [30-day NHB vs NHW hazard ratio (95% confidence interval): 0.88 (0.86–0.89)]. Differences became less apparent as outcomes approached 180 days [180-day NHB vs NHW: 1.00 (0.98–1.02)]. For major morbidity and unplanned readmission, differences among NHW, Hispanic, and NHA patients were comparable. NHB patients did consistently worse. Efforts to explain the occurrence found similar trends across diagnostic categories, but significant differences in disparities attributable to geography and the other included factors that combined accounted for up to 50% of readmission differences between racial/ethnic groups.

Conclusion: The study found an inversion of racial/ethnic mortality differences and mitigation of non-NHB morbidity/readmission differences among universally insured older adults that decreased with time. Persistent disparities among nonagenarian patients and hospitals managing a regionally large share of minority patients warrant particular concern.

*Yale School of Medicine, New Haven, CT

Center for Surgery and Public Health: Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, MA

Department of Surgery, Baylor Scott & White Health, Dallas, TX

§Department of Surgery, Yale School of Medicine, New Haven, CT.

Reprints: Cheryl K. Zogg, MSPH, MHS, Yale School of Medicine, 367 Cedar Street, Room 316 ESH, New Haven, CT 06510. E-mail: czogg@jhmi.edu.

A portion of this work was previously presented as an oral (podium) presentation at the 11th Annual Academic Surgical Congress, February 2 to 4, 2016, in Jacksonville, FL.

CKZ, WJ, and AHH made substantial contributions to the conception or design of the work. CKZ and WJ participated in the acquisition and analysis of the data. CKZ, WJ, TDO, SS, KS, RB, KAD, and AHH contributed toward the interpretation of data for the work. CKZ and TDO drafted the manuscript, and WJ, SS, KS, RB, KAD, and AHH critically revised the manuscript for intellectual content. All authors provided final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

The authors declare that we have no sources of funding or conflicts of interest relevant to the analysis to report. Cheryl K. Zogg is supported by NIH Medical Scientist Training Program Training Grant T32GM007205. Adil H. Haider is the PI of a contract (AD-1306-03980) with PCORI entitled “Patient-Centered Approaches to Collect Sexual Orientation/Gender Identity in the Emergency Department (ED),” a Harvard Surgery Affinity Research Collaborative (ARC) Program Grant entitled “Mitigating Disparities Through Enhancing Surgeons’ Ability To Provide Culturally Relevant Care,” and a collaborative research grant from the Henry M. Jackson Foundation for the Advancement of Military Medicine in conjunction with the Uniformed Services University of the Health Sciences. Adil H. Haider is also the cofounder and an equity holder in Patient Doctor Technologies Inc., which owns and operates the website www.doctella.com.

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