Black, Hispanic adults receive unequal treatment for adrenalectomy
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Black and Hispanic adults undergoing adrenalectomy experience higher complication rates and longer hospital stay and have decreased access to high-volume surgeons compared with white counterparts, according to a database review.
“Using a national database, the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP), we found that minority Black and Hispanic patients undergoing adrenalectomy were less likely to have their procedure performed by a high-volume surgeon, more likely to experience a complication, and more likely to have a longer hospital length of stay compared with white patients,” Abbey L. Fingeret, MD, MHPTT, FACS, assistant professor of surgery at the University of Nebraska Medical Center, told Healio. “Minority patients were also more likely to have a functional adrenal mass with hyperaldosteronism as indication for surgery compared with white patients who were more likely to have nonfunctional adrenal mass.”
In a retrospective review, Fingeret and colleagues analyzed data from 1,141 adrenalectomies, using data from the CESQIP from 2014 to April 2018. Primary outcome was complication rate. Secondary outcomes were length of stay and surgeon experience. Minority status was defined as Black or Hispanic and compared with white patients.
Within the cohort, 69.9% of patients were white and 22.6% were Black or Hispanic; Black and Hispanic adults were younger (mean, 48 years vs. 54 years) and had higher rates of diabetes (31.4% vs. 23.3%; P < .01).
Compared with white patients, Black and Hispanic patients were more likely to have an adrenalectomy performed by a low-volume surgeon (79.9% vs. 57.8%; P < .001), have higher rates of complications (7.4% vs. 3.8%; P = .025) and longer length of stay, with white patients more likely to be discharged from the hospital in less than 2 days compared with Black and Hispanic patients (P < .001).
There were no between-group differences when assessing open conversion of laparoscopic procedures, readmission rates or mortality. In multivariate logistic regression analyses adjusted for age, BMI and surgeon volume, Black or Hispanic status remained associated with complication rate (P < .0001).
“Identifying disparities in care is the first step in ameliorating disparate care for minority patients,” Fingeret said. “Endocrinologists and adrenal surgeons should be aware of these findings when evaluating patients with adrenal masses. Consideration should be given to surgical referral for nonfunctional adrenal masses for minority patients, and when referring minority patients for adrenalectomy, to determining the experience and case volume of the surgeon, which is important for providing high-quality care.”
Fingeret said the findings are limited by the available data in the CESQIP database, which does not include geographic region, payer status or household income.
“These elements may be a proxy for social determinants of health more strongly associated with outcomes than minority status,” Fingeret said. “Further study on this topic should include multi-institutional data from a variety of regional and community settings with payer and income status as well as adrenalectomy-specific disease characteristics and outcomes.”
For more information:
Abbey Fingeret, MD, MHPTT, FACS, can be reached at abbey.fingeret@unmc.edu.
Perspective
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Fiemu Nwariaku, MD, FACS
This was an interesting study. Any analysis that relies on an administrative database is challenging, as it is very difficult to get into the granular aspects. Here, we see that Black and Hispanic patients tend to have worse outcomes; however, many other factors apart from race could affect these outcomes. Are these patients seeing low-volume surgeons, for example, because of where they live? Are the low-volume surgeons not qualified? There are also potential comorbidities that the database misses, which we are unable to account for. Are the findings related to the biology of their disease? If one looks at the tumors that were resected in these patients, they don’t say much.
Striking to me was that these minority patients were younger and, theoretically, should fare better compared with older patients. Yet somehow, they fare worse after adrenalectomy. These data are surprising, as there is almost a 10-year mean age difference. This finding deserves more exploration.
My conclusion is the findings are valid. It will be helpful to get granularity around the data — for example, how long these patients have been sick, where they live.
I also did not see insurance data; this would be helpful. That has been shown to be a determinant of outcomes.
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