Delays in and denials of care, including surgical care, are well-established factors in racial health disparities. Research has shown that Black patients are referred to specialists at lower rates, and those that do make it to a specialist are referred later in their disease course.

“This can have a big impact on a patient’s outcome and survival,” said Sanford E. Roberts, MD, from the Center for Surgery and Health Economics and the Department of Surgery at the University of Pennsylvania, Philadelphia.

Delayed or denied care can occur in the emergency room at the point of surgical consultation, a critical first step in deciding on operative or nonoperative management. Without this consultation, disease can progress in ways that complicate operative treatment and escalate risks.

So Roberts — along with a research team that included LDI Senior Fellows Rachel Kelz, Elinore Kaufman, Mark Neuman, and Matthew McHugh — investigated whether Black patients and white patients receive surgical consultations at the same rate.

The researchers examined data on more than 1.5 million Medicare patients (12.7% Black patients and 87.3% white patients) admitted to U.S. hospitals for an emergency general surgery condition between 2015 and 2018. They found Black patients were 8% less likely than white patients to receive a surgical consultation, even after statistical standardization to isolate the effect of race by controlling for medical comorbidities, rates of diagnostic imaging, socioeconomic status, and hospital-level factors.

“The results [recently published in JAMA Surgery] were surprising,” Roberts said. While external factors, like income and insurance, are often reasons for poor outcomes for minorities, he continued, “the bottom line is that we can’t attribute the disparities we observed to differences in rates of medical comorbidities or socioeconomic factors in the Black and white population, or even differences at individual hospitals.”

While this study was unable to explain why these disparities exist, there are several possible mechanisms that could explain the documented differences in rates of surgical consults. These include implicit bias of hospital staff and physicians, structural racism, and patients’ social factors that affect the likelihood of getting a surgical consult.

Roberts’ coauthor Kelz said it’s worth noting that the findings come from patients with such severe disease that hospital admission was necessary. “These findings may be even more significant in those who seek care in the emergency department for emergency surgery conditions and get sent home after evaluation,” she said. Those patients may face even more significant disparities in care.

What can be done to close the gap? At a minimum, hospitals should monitor their own data to see where there are racial differences in necessary care — and then target resources and services to close these gaps. This might include using patient navigators and holding providers accountable for care through monitoring, feedback, and training. In addition, efforts to systematically measure racism and bias in clinical care could help identify causes of disparities and ways to intervene to reduce them. More targeted efforts, such as patient navigation and targeted provider education, may be needed. Additionally, when resources permit, hospital systems might consider clinics that aim to make surgical care more accessible similar to Penn’s Center for Surgical Health model.

To learn more about the issues uncovered by their research, Roberts and Kelz said they plan to work closely with the stakeholders engaged in emergency surgical care, including their emergency medicine colleagues, patients, caregivers, and others. They hope to identify and address the root causes with evidence-based recommendations that improve surgical health equity.

The study, “Rates of Surgical Consultations After Emergency Department Admission in Black and White Medicare Patients,” was published on October 12, 2022 in JAMA Surgery. Authors include Sanford E. Roberts, Claire B. Rosen, Luke J. Keele, Christopher J. Wirtalla, Solomiya Syvyk, Elinore Kaufman, Patrick Reilly, Mark Neuman, Matthew McHugh, and Rachel Kelz.

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