Social risk factors ‘heavily influence’ racial disparities in cancer surgical care
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Black Medicare beneficiaries who underwent elective cancer surgery had higher rates of mortality than their white counterparts, irrespective of neighborhood deprivation or dual eligibility status, according to study results.
The findings, presented at Society of Surgical Oncology International 2022 Conference on Surgical Cancer Care, also showed a more pronounced effect of race among those with more resources, and associations of high deprivation levels with higher mortality among both white and Black beneficiaries.
“One of the more interesting findings in our study was that neighborhood-level poverty was more strongly associated with mortality than individual-level poverty, measured by dual eligibility in our cohort for both Black and white patients,” Sidra Bonner, MD, MPH, general surgery resident at University of Michigan, told Healio. “We additionally found that the disparity in mortality between Black and white patients occurred among those living in the most deprived neighborhoods and who were dual-eligible. The fact that the disparity was wider among beneficiaries with more resources suggests that socioeconomic status at the individual and community level does not account for the entirety of the racial disparity.”
Rationale
Although racial disparities in mortality and other outcomes after cancer surgery have been well-documented, few studies have examined social factors that may contribute to the persistent inequities, Bonner said.
“Ultimately, the identification of the interaction of social factors that may put a given patient at risk for worst postoperative outcomes allows for better identification of the most at-risk patients for interventions,” she said.
Bonner added that CMS has made elimination of racial and ethnic disparities and achievement of health equity a strategic priority over the next decade, which has implications for quality measurement and payments.
“Therefore, it is very likely that surgeons, surgical practices and hospitals will increasingly be held accountable for disparities in their outcomes,” she said.
Methods
Bonner and colleagues used 100% Medicare inpatient claims to identify Medicare beneficiaries who had elective pancreatic, lung, colon and rectal cancer surgery between January 2016 and December 2018.
The researchers verified dual Medicare/Medicaid enrollment using Medicare data. They stratified beneficiaries, who self-identified as Black or white, into quartiles based on their neighborhood Area Deprivation Index score, a combined measure of census tract-level housing, education and employment.
To assess the association of race, neighborhood deprivation and dual eligibility (Medicare and Medicaid) with 30-day mortality, the investigators employed logistic regression after risk adjustment for sex, age, comorbidities and type of procedure.
Results
Results showed Black beneficiaries with dual eligibility from neighborhoods with the highest deprivation levels had the highest probability of mortality (3.6%; 95% CI, 2.34-4.98). The largest difference in mortality between Black vs. white beneficiaries occurred among those without dual eligibility who lived in areas with low deprivation levels (2.3%; 95% CI, 1.3-3.4 vs. 1.7%; 95% CI, 1.5-1.8). Researchers observed a smaller difference in mortality between Black vs. white beneficiaries with dual eligibility in areas with high deprivation levels (3.6%; 95% CI, 2.9-4.3 vs. 3.7%; 95% CI 2.9-4.3).
Black beneficiaries had a higher probability of mortality across all combinations of neighborhood deprivation and dual-eligibility status.
Implications, next steps
“Persistent racial disparities in surgical care are heavily influenced by modifiable social risk factors,” Bonner told Healio. “Meaningful interventions to address social risk among patients will not improve outcomes for all but may help reduce racial inequities in care.”
Bonner added that surgeons and health care systems must consider social risk just as they do medical risk.
“Patients should have social risk factors optimized during the phases of surgical care to improve overall outcomes,” she said.
The next phase of research should focus on interventions to reduce and eliminate disparities in cancer surgical care, according to Bonner.
“Most of the implementation work around racial disparities has centered on medical diagnoses, such as heart failure, asthma or chronic obstructive pulmonary disease,” she said. “Identifying and studying multilevel interventions that leverage electronic health record data and alerts, telehealth, nurse coordinators, and connections with community-based resources to target and address the most socially-at risk patients undergoing surgery could be considered as first steps.”
Perspective
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Haejin In, MD, MPH, MBA, FACS, FSSO
Long-existing structural racism — from slavery to Jim Crow, redlining, school segregation and mass incarceration — has resulted in a 10-fold gap in wealth between Blacks and whites in the United States. Racism also has resulted in segregated neighborhoods that have poor access to healthy foods, less green spaces, fewer hospitals and unequal access to health care. These factors have resulted in Black-white mortality differences that are pervasive.
This study adds to the growing body of evidence that differences in mortality between Black and white individuals exist, but there also is a unique finding that the mortality gap is not present for the poorest individuals (expressed as dual eligibility) living in the poorest neighborhoods (expressed as lowest quartile of Area Deprivation Index).
Although this study did not explicitly investigate the reason for these findings, researchers hypothesize that this finding signifies the existence of structural racism. Although further investigation into this will be needed, this hypothesis has some merit. In the US, individuals in extreme poverty largely are supported by the government for living expenses, housing and health care, while those who are not in such extremes of poverty benefit less from such subsidies. The absence of Black-white differences in mortality among people who benefit from such equitable polices designed for the extremely poor suggests that there is no biologic reason for mortality gap and any observed mortality gap is due to structural racism. This, in turn, supports the evidence that observed Black-white differences in mortality likely are due to structural racism.
Further studies will be needed to validate these findings and better understand the reasons for this observation. In the meantime, this study eloquently showed suggestion of structural racism using a large publicly available dataset. Continuous efforts are desperately needed to create solutions to close the Black-white health outcomes gap, including the elephant in the room — structural racism.
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Bonner S, et al. Abstract 56. Presented at: Society of Surgical Oncology 2022 International Conference on Surgical Cancer Care; March 9-12, 2022; Dallas.
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