This document summarizes a presentation on clinical care quality and its relationship to surgical disparities. It discusses how differences in healthcare structure (e.g. location, volume) and process (e.g. choice of procedure) are associated with racial disparities in surgical outcomes. It identifies gaps in understanding the causes of these differences and effective remedies. Future research should evaluate strategies to address differences in structure and process in order to reduce disparities in outcomes and improve surgical value.

1. CENTER FOR SURGERY
AND PUBLIC HEALTH
Clinical Care and Quality:
Relationships with Surgical
Disparities
Peter A. Najjar, M.D.
Harvard Medical School Fellow in Patient Safety and Quality
Arthur Tracy Cabot Fellow in Health Services Research
Center for Surgery and Public Health
Brigham and Women’s Hospital
N I H - A C S S Y M P O S I U M O N S U R G I C A L D I S PA R I T I E S R E S E A R C H

2. CENTER FOR SURGERY
AND PUBLIC HEALTH
Healthcare Quality Framework1
• Context of care
delivery.
• Easy to measure.
Structure
• Acts of healthcare
delivery.
• Harder to measure
(opacity).
Process • Effects of care
delivered.
• Harder to measure
(risk adjustment).
• Value = Quality/Cost2
Outcome
“The degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
knowledge.” –Institute of Medicine

3. CENTER FOR SURGERY
AND PUBLIC HEALTH
Importance to Disparities
Are there interventions that can reduce:
-the causes of structural differences associated with race?
-the impact of structural differences associated with race?
-the causes of associations between process and race?
What impact on value would such interventions have?
Structure Process Outcome

4. CENTER FOR SURGERY
AND PUBLIC HEALTH
Known Associations with Disparities
Structure
Volume.3-14,16
Location.10-12,15-17
Quality
Infrastructure.18-19
Specialty
Certification.20-21
Process
Choice of
Procedure.14,17,22-27
Prophylaxis.19
Referral
Patterns.4,15
Outcome
Mortality.5,7,9,13,28-36
Complications.
3,23,31,33-34,37-38
Length of
Stay.3,18,36,39
Discharge.7
Readmission.40-
42

5. CENTER FOR SURGERY
AND PUBLIC HEALTH
Gaps in the Literature
What are the differences in process that may drive disparities
in outcomes?
What might be responsible for those differences in process?
What role do structural considerations play?
What are effective remedies to structural and process
differences?
If structural and process differences are remedied, do
disparities in outcomes decrease?
What impact on surgical value would such decreases have?

6. CENTER FOR SURGERY
AND PUBLIC HEALTH
Future Directions
IOM Approach: To Err is Human (1999) and Crossing the
Quality Chasm (2001)
Further surgical disparities research in the quality arena
should be aimed at:
• Reforming health professions education.
• Redesigning care delivery.
• Encouraging information technology implementation.
• Learning from systems demonstrations.
• Furthering measurement and informed purchasing.

7. CENTER FOR SURGERY
AND PUBLIC HEALTH
Conclusions
The outcomes of surgical care are dictated by the structure
and process of care delivery.
When differences in structure and process are associated with
race, disparities in outcomes follow.
Addressing gaps in our understanding and evaluating
strategies to alleviate these differences is critical to reducing
disparities in surgical outcomes.
“The evidence is compelling. Millions of Americans are not
reached by proven effective interventions that can save lives
and prevent disability.”43

8. CENTER FOR SURGERY
AND PUBLIC HEALTH
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