Outcomes of major cardiac operations are not improved for black patients at black-serving institutions
Nikhil L Chervu1, Saad Mallick1, Amulya Vadlakonda1
1Cardiovascular Outcomes Research Laboratories (CORELAB), Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Calif.
Insights
Hospitals with a higher proportion of Black patients had worse outcomes for all patients. Black patients faced even greater risks for mortality and complications in these institutions, revealing compounding racial disparities.
Area of Science:
- Health Services Research
- Health Disparities
- Racial Equity in Healthcare
Background:
- Provider-patient racial concordance is linked to better outcomes for Black patients.
- The impact of institutional-level racial representation on patient outcomes remains unclear.
Purpose of the Study:
- To investigate the association between the proportion of Black patients served by a hospital and clinical outcomes for adult cardiac surgery patients.
- To determine if higher institutional representation of Black patients exacerbates racial disparities in surgical outcomes.
Main Methods:
- Analysis of the 2016-2020 National Inpatient Sample for adults undergoing coronary artery bypass grafting and valve operations.
- Hospitals categorized into quartiles based on the annual proportion of Black patients admitted.
- Mixed regression models used to assess the association between hospital Black-serving quartile and in-hospital mortality, major complications, length of stay, and costs.
Main Results:
- Hospitals in the highest Black-serving quartile showed increased odds of mortality and major complications compared to the lowest quartile.
- Black patients in highest Black-serving quartile hospitals experienced significantly higher mortality and complication rates than non-Black patients.
- A stepwise increase in risk for major complications, longer postoperative stays, and higher costs was observed with higher Black-serving quartiles for Black patients.
Conclusions:
- Hospitals serving a higher proportion of Black patients were associated with worse overall clinical outcomes.
- Black patients face compounded risks, including increased mortality, complications, and costs, in institutions with higher Black patient representation.
- Findings underscore the impact of both patient-level and hospital-level racial disparities on surgical outcomes.
Objective:
Although provider-patient racial concordance has been associated with improved outcomes among patients of Black race, it is unclear if increased representation at the institutional level is associated with the same benefits.
Methods:
Adults undergoing coronary artery bypass grafting and valve operations were tabulated from the 2016-2020 National Inpatient Sample. Black-serving quartiles were generated using the annual proportion of Black patients admitted for all diagnoses. The primary end point was in-hospital mortality with Society of Thoracic Surgeons-defined major complications, postoperative length of stay, and costs as secondary outcomes. Mixed regression models were used to ascertain the association between Black-serving quartile designation and outcomes of interest; an interaction term was used to evaluate the incremental association of race and Black-serving quartiles.
Results:
Of an estimated 1,203,120 patients, 7.2% were Black. After adjustment, highest Black-serving quartile hospitals demonstrated higher odds of mortality (adjusted odds ratio, 1.18, 95% CI, 1.06-1.30) and major complications (adjusted odds ratio, 1.19, 95% CI, 1.11-1.28) compared with lowest Black-serving quartile hospitals. Notably, Black patients had significantly higher mortality compared with non-Black patients at highest Black-serving quartile institutions (3.3%, 95% CI, 3.0-3.7 vs 2.6, 95% CI, 2.4-2.8), but not at the lowest (3.1%, 95% CI, 1.8-4.4 vs 2.2, 95% CI, 2.1-2.4). Black patients exhibited a stepwise increase in risk of major complication rates, postoperative length of stay, and costs with higher Black-serving quartiles.
Conclusions:
Highest Black-serving quartile hospitals had worse clinical outcomes overall compared with those in the lowest Black-serving quartile. Unfortunately, Black patients had additional increased mortality, complications, postoperative length of stay, and costs at high Black-serving quartile institutions, highlighting the compounding effects of patient and hospital-level racial disparities.
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