Key result
Racial disparities in surgical survival (e.g., 6.7% vs 5.6% 30-day mortality) were explained by patient factors, while better nurse resources reduced 30-day mortality (OR 0.60, 95% CI 0.46-0.78).
Why the study?
It was unknown whether hospital factors, including nurse resources, explain racial differences in Medicare black and white patient surgical outcomes and whether disparities changed over time.
Do hospital factors and patient characteristics explain racial disparities in 30-day and 1-year surgical mortality between black and white Medicare patients?
Observational (n=46,864)
Yes
Do hospital factors and patient characteristics explain racial disparities in 30-day and 1-year surgical mortality between black and white Medicare patients?
Absolute Event Rate: 6.7% vs 5.6%
Racial disparities in surgical survival are largely explained by patient presentation and procedure factors, while better hospital nurse resources independently improve survival for all patients.
Patient and procedural factors largely explain racial survival gaps after surgery; extends observational data linking nurse resources to lower mortality while leaving causality open.
OBJECTIVES: Evaluate whether hospital factors, including nurse resources, explain racial differences in Medicare black and white patient surgical outcomes and whether disparities changed over time. DESIGN: Retrospective tapered-match. SETTING: 571 hospitals at two time points (Early Era 2003-2005; Recent Era 2013-2015). PARTICIPANTS: 6752 black patients and three sets of 6752 white controls selected from 107 001 potential controls (Early Era). 4964 black patients and three sets of 4964 white controls selected from 74 108 potential controls (Recent Era). INTERVENTIONS: Black patients were matched to white controls on demographics (age, sex, state and year of procedure), procedure (demographics variables plus 136 International Classification of Diseases (ICD)-9 principal procedure codes) and presentation (demographics and procedure variables plus 34 comorbidities, a mortality risk score, a propensity score for being black, emergency admission, transfer status, predicted procedure time). OUTCOMES: 30-day and 1-year mortality. RESULTS: Before matching, black patients had more comorbidities, higher risk of mortality despite being younger and underwent procedures at different percentages than white patients. Whites in the demographics match had lower mortality at 30 days (5.6% vs 6.7% Early Era; 5.4% vs 5.7% Recent Era) and 1-year (15.5% vs 21.5% Early Era; 12.3% vs 15.9% Recent Era). Black-white 1-year mortality differences were equivalent after matching patients with respect to presentation, procedure and demographic factors. Black-white 30-day mortality differences were equivalent after matching on procedure and demographic factors. Racial disparities in outcomes remained unchanged between the two time periods spanning 10 years. All patients in hospitals with better nurse resources had lower odds of 30-day (OR 0.60, 95% CI 0.46 to 0.78, p<0.010) and 1-year mortality (OR 0.77, 95% CI 0.65 to 0.92, p<0.010) even after accounting for other hospital factors. CONCLUSIONS: Survival disparities among black and white patients are largely explained by differences in demographic, procedure and presentation factors. Better nurse resources (eg, staffing, work environment) were associated with lower mortality for all patients.
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Lasater et al. (2023) conducted an observational in Surgical procedures (n=46,864). Black race vs. White race was evaluated on 30-day mortality (Early Era, demographics match). Racial disparities in surgical survival (e.g., 6.7% vs 5.6% 30-day mortality) were explained by patient factors, while better nurse resources reduced 30-day mortality (OR 0.60, 95% CI 0.46-0.78).
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