A study looked into the survival rates after surgery and saw there was a stark disparity in elective (scheduled) surgeries. They saw that Black men were 50 percent more likely to pass within a month. Experts say that this could come from structural racism and the long-term health effects of stress.
Older Black men are more likely to pass within 30 days of surgery and this happened more than any other subgroup of race and sex, as per a study published March 1 in the BMJ.
This inequality in death rate was the largest when it came to elective surgeries. The death rate of Black men was 50 percent higher, which was something of note.
While they have made discoveries on inequities, this study saw how specifically Black men are the ones more affected, and they are dying more from elective surgeries as opposed to urgent or emergent surgeries. This was mentioned by the lead study author, Dan Ly, MD, PhD. He is an assistant professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA. He spoke in a press release recently.
“Our findings point to possibilities such as poorer pre-optimization of comorbidities prior to surgery, delays of care due to structural racism and physician bias, and worse stress and its associated physical burden on Black men in the United States,” Dr. Ly said.
Sadly, they weren’t surprised by the numb. Racial disparities in healthcare are known, and as for the data itself, it is becoming more granular in time, said Catherine McManus, MD. She is the surgical director of the thyroid biopsy program at Columbia University Irvine Medical Center in New York City. However, she was not part of the study.
“I think a key point made in this particular study is noting the difference between elective and nonelective surgeries. The authors found that Black men had a higher postoperative mortality for elective procedures than white men, white women, and Black women. However, that difference in mortality disappeared when considering nonelective procedures,” said Dr. McManus.
There are two types of surgery: elective surgery and urgent or emergency surgery. This was defined by the experts from Johns Hopkins Medicine. An elective surgery doesn’t always equal to optional surgery, but this term is utilized to mean any operation that can be scheduled ahead of time. The term elective is broad enough to include simple procedures like mole removal or surgery for cancer or a heart condition.
Older Black Men 50 Percent More Likely to Pass
In previous studies made, racial inequities in surgical care and outcomes, included here would be a higher death rate after surgery for Black patients, have already been documented, as per the authors of the study.
The new study is considered unique because the researchers were able to separate race and gender and looks at both elective and nonelective surgeries.
They also used nationwide Medicare data that was gathered between 2016 and 2018 on 1,868,036 adults with an average age of 75 years old. Of the total, 40.7 percent were white men, 53.4 percent were white women, 2.2 percent were Black men, and 3.7 percent were Black women. More than a million surgeries were done and around 70.3 percent were elective and 29.7 considered urgent or emergency.
Eight types of surgery were also part of the analysis: abdominal aortic aneurysm repair, appendectomy, cholecystectomy, colectomy, coronary artery bypass surgery, hip replacement, knee replacement, and lung resection. They then compared these patient outcomes via race and sex for those who received the same type of procedure and at the same hospital.
In order to isolate the potential effects of gender and race even more, they controlled other factors that impact the death rate 30 days post-surgery such as age, disability, and 27 different underlying chronic conditions.
The researchers saw that Black men had a higher death rate (3.05 percent) within a month of both urgent and elective surgery. They compared the numbers against white men (2.69 percent), white women (2.38 percent), and Black women (2.18 percent). They also found the same for elective surgery: Black men had a higher death rate (1.3 percent) when compared to white men (0.85 percent), white women (0.82 percent), and Black women (0.79 percent).
This 0.45 percentage point difference between Black and white men when it came to elective surgeries is stark, said Alejandro Garcia, MD. He is an assistant professor of surgery and the vice chair of diversity, equity, and inclusion at Johns Hopkins Medicine in Baltimore. “That’s a nearly 50 percent difference — that’s a lot,” he added.
The difference was also observed even when they compared those who had been operated on by the same surgeon, the authors noted. On the other hand, they did not find a statistically significant difference between Black and white men after urgent surgery. The death rates were 6.69 percent and 7.03 percent respectively.
On the other hand, they saw that deaths post urgent surgery were lower for both white and Black women when compared to men from either race, at 6.12 percent and 5.29 percent accordingly.
Social Factors Could be the Reason Behind the Disparity in Risk for Death
As for the differences in postoperative mortality, these show that Black men perform worse in more controlled operative settings. This means that time and preparation are considered and that they come out the same in more urgent or emergent situations, McManus stated.
“This finding illustrates the key point that there is nothing inherent about race or sex that leads to worse outcomes, but rather it is the social factors inherent to structural racism that are responsible for this disparity,” she said.
“Although the identification of the underlying mechanisms was beyond the scope of our study, there are several factors that can potentially explain the observed disparity in our study,” said a coauthor, Yusuke Tsugawa, MD, MPH, PhD. He is an associate professor of medicine at UCLA David Geffen School of Medicine in Los Angeles.
The structural racism seen in the United States could perhaps partially explain why this has happened, he said. “For example, Black patients living in neighborhoods with predominantly Black residents tend to live close to hospitals that lack resources to provide high-quality healthcare,” Dr. Tsugawa explained.
“It is interesting that these findings on the higher likelihood of postoperative mortality are very specific to Black males as opposed to Black individuals in general,” said Dr. Garcia.
“It is possible that Black men in particular face especially high cumulative amounts of stress and allostatic load, which refers to the cumulative burden of chronic stress and life events, potentially leading to a higher death rate after surgery among this population,” Tsugawa also said.
A paper published in Psychotherapy and Psychosomatics in 2021 had made a review on 267 studies that delved deeper into the consequences of allostatic load and saw that “allostatic load and overload are associated with poorer health outcomes.”
The Solution
“Further research is needed to understand better the preoperative, intraoperative, and postoperative factors contributing to this higher mortality rate among Black men after elective surgery,” said the authors.
Studies to be made after should examine findings on a more granular level, McManus said. “By looking at more patient-specific factors related to social determinants of health — education, income, insurance status — we may be able to further define where to direct our efforts and invest more resources to make healthcare more equitable for all individuals,” she said.
Garcia said that it may help to compare these groups at every step in the continuum of care so see how these differences should be addressed and improved.
“These findings are eye-opening — it’s important for surgeons as well as everyone in the public to see this,” Garcia said. “Awareness and action, on both on an individual and institutional level, is needed to begin to fix these complex problems.”
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