Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts.
Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
JAMA Surg. 2021 Mar 1;156(3):274-281. doi: 10.1001/jamasurg.2020.6257.
The largest US federal action plan to date for reducing racial disparities in health care was implemented in 2011 and continues today. It is not known whether this program, along with other initiatives, is associated with a decrease in racial disparities in the use of major surgical procedures in the US.
To analyze whether national initiatives are associated with improvement in racial disparities between White and Black patients in the use of surgical procedures in the US.
DESIGN, SETTING, AND PARTICIPANTS: In this case-control study, the national rates of use for 9 major surgical procedures previously shown to have racial disparities in rates of performance between White and Black adult patients (including angioplasty, spinal fusion, carotid endarterectomy, appendectomy, colorectal resection, coronary artery bypass grafting, total hip arthroplasty, total knee arthroplasty, and heart valve replacement) were analyzed from January 1, 2012, through December 31, 2017. Data analysis was conducted from May 1 to June 30, 2020. Population- and sex-adjusted procedural rates during the study period were examined and standardized based on all-payer insurance status. Racial changes were further analyzed by US census division and hospital teaching status for 4 selected procedures: coronary artery bypass grafting, carotid endarterectomy, total hip arthroplasty, and heart valve replacement.
Population- and race-adjusted procedural rates by year, US census division, hospital teaching status, and insurance status.
This study included national inpatient data from 2012 to 2017. In 2012, the national incidence rate of all 9 major surgical procedures was higher in White than in Black individuals. For example, the incidence rate of total knee arthroplasty in 2012 for White males was 184.8 per 100 000 persons and for Black males was 79.8 per 100 000 persons. By 2017, these racial disparities persisted for all 9 procedures analyzed. For example, the incidence rate of total knee arthroplasty in 2017 for White males was 220.5 per 100 000 persons and for Black males was 95.6 per 100 000 persons. Although the disparity gap between White and Black patients narrowed for angioplasty (-20.1 per 100 000 persons in males, -4.2 per 100 000 persons in females), spinal fusion (-7.7 per 100 000 persons in males, -15.0 per 100 000 persons in females), carotid endarterectomy (-4.3 per 100 000 persons in males, -4.6 per 100 000 persons in females), appendectomy (-12.3 per 100 000 persons in males, -12.2 per 100 000 persons in females), and colorectal resection (-9.0 per 100 000 persons in males, -12.7 per 100 000 persons in females), the disparity remained constant for coronary artery bypass grafting and widened for 3 procedures, total hip arthroplasty (11.6 per 100 000 persons in males, 20.8 per 100 000 in females), total knee arthroplasty (19.9 per 100 000 persons in males, 12.0 per 100 000 persons in females), and heart valve replacement(12.4 per 100 000 persons in males, 9.2 per 100 000 persons in females). In 2017, racial differences persisted in all US census divisions and in both urban teaching and urban nonteaching hospitals. When rates were adjusted based on insurance status, Black patients with Medicare, Medicaid, and private insurance underwent lower rates of all procedures analyzed compared with White patients. For example, rate of spinal fusion in Black patients was 70.2% of the rate in White patients with Medicare, 56.5% to that of White patients with Medicaid, and 61.2% to that of White patients with private insurance.
Results of this study suggest that despite national initiatives, racial disparities have persisted for all analyzed procedures and worsened for one-third of the analyzed procedures. These disparities were evident regardless of US census division, hospital teaching status, or insurance status. Renewed initiatives to help diminish racial disparities and improve health care equality are warranted.
迄今为止，美国最大的联邦行动计划旨在减少医疗保健方面的种族差异，并于 2011 年实施，至今仍在继续。尚不清楚该计划以及其他举措是否与美国主要外科手术种族差异的减少有关。
分析国家倡议是否与美国白人和黑人患者在外科手术使用方面种族差异的改善相关。
设计、地点和参与者：在这项病例对照研究中，分析了此前显示白人成年患者和黑人成年患者之间手术使用率存在种族差异的 9 项主要手术（包括血管成形术、脊柱融合术、颈动脉内膜切除术、阑尾切除术、结直肠切除术、冠状动脉旁路移植术、全髋关节置换术、全膝关节置换术和心脏瓣膜置换术）的全国使用率。数据分析于 2020 年 5 月 1 日至 6 月 30 日进行。研究期间，根据所有支付方的保险状况，对人口和性别调整后的手术率进行了检查和标准化。进一步分析了 4 项选定手术（冠状动脉旁路移植术、颈动脉内膜切除术、全髋关节置换术和心脏瓣膜置换术）的美国人口普查区和医院教学状况的种族变化。
按年份、美国人口普查区、医院教学状况和保险状况划分的人口和种族调整后的手术率。
本研究纳入了 2012 年至 2017 年的全国住院数据。2012 年，白人的 9 项主要手术的全国发病率均高于黑人。例如，2012 年白人男性全膝关节置换术的发病率为每 10 万人 184.8 例，黑人男性为每 10 万人 79.8 例。到 2017 年，所有分析的 9 项手术仍然存在种族差异。例如，2017 年白人男性全膝关节置换术的发病率为每 10 万人 220.5 例，黑人男性为每 10 万人 95.6 例。虽然血管成形术（男性每 10 万人减少 20.1 例，女性每 10 万人减少 4.2 例）、脊柱融合术（男性每 10 万人减少 7.7 例，女性每 10 万人减少 15.0 例）、颈动脉内膜切除术（男性每 10 万人减少 4.3 例，女性每 10 万人减少 4.6 例）、阑尾切除术（男性每 10 万人减少 12.3 例，女性每 10 万人减少 12.2 例）和结直肠切除术（男性每 10 万人减少 9.0 例，女性每 10 万人减少 12.7 例）之间的差异缩小，但冠状动脉旁路移植术的差异保持不变，而另外 3 项手术（男性每 10 万人增加 11.6 例，女性每 10 万人增加 20.8 例）和全髋关节置换术（男性每 10 万人增加 19.9 例，女性每 10 万人增加 12.0 例）和全膝关节置换术（男性每 10 万人增加 19.9 例，女性每 10 万人增加 12.0 例）和心脏瓣膜置换术（男性每 10 万人增加 12.4 例，女性每 10 万人增加 9.2 例）的差异扩大。2017 年，所有美国人口普查区以及城市教学医院和城市非教学医院都存在种族差异。当根据保险状况调整比率时，与白人患者相比，黑人患者接受所有分析手术的比率较低，包括医疗保险、医疗补助和私人保险。例如，黑人患者脊柱融合术的比例是白人患者中医疗保险患者的 70.2%，是白人患者中医疗补助患者的 56.5%，是白人患者中私人保险患者的 61.2%。
本研究结果表明，尽管有国家倡议，但所有分析手术的种族差异仍然存在，三分之一的分析手术的种族差异恶化。这些差异无论在美国人口普查区、医院教学状况还是保险状况下都很明显。需要重新发起倡议，以帮助减少种族差异，改善医疗保健公平。
