This document summarizes research on systemic factors and access issues that contribute to disparities in surgical care. It reviews literature showing that factors like insurance status, procedure volume at hospitals, and delays in care affect outcomes for minorities and low-income patients. It also discusses gaps in understanding how interventions, social determinants, and vulnerable groups impact disparities. The document concludes by calling for more research on how policies, clinical programs, and management guidelines can help address disparities by improving access and communication between patients and providers.

1. CENTER FOR SURGERY
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Systemic Factors and Access Issues
John Rose MD MPH
Center for Surgery and Public Health
Department of Surgery
Brigham and Women’s Hospital
Center for Surgical Systems and Public Health
Department of Surgery
University of California San Diego
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
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• Systemic Factors and Access1
– Policies
– Insurance status
– Management protocols
– Data systems and EHRs
– Triage
– Accessibility of referrals
Background
Haider et al. JACS 2013; 216(3):482-92.

3. CENTER FOR SURGERY
AND PUBLIC HEALTH
Background: Systemic Factors Review
• Odds of death associated with SES after six high-risk surgeries in
nationwide Medicare population were diminished after controlling for
procedure volume.2
• Odds of death after blunt trauma 22% higher in African Americans,
33% higher in Hispanics, and 77% higher in uninsured.3
• Racial minorities and uninsured are less likely to receive counseling
about renal transplantation, be waitlisted for transplant, and receive
dialysis by fistula while waiting.4,5,6

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AND PUBLIC HEALTH
Background: Access Review
• Direct surrogates of access:
– Operation vs no operation in lung/cervical cancer resections7,8
– Delays in presentation in perforated appendix9
– Diagnosis-to-treatment time interval in breast cancer resection10
– Access to high-volume providers and centers2,11,12
• Procedural circumstances:
• Emergent vs elective care in ventral hernia repairs13
• MIS vs open techniques in appendectomy, gastric bypass14
• Outpatient vs inpatient procedures in mastectomies15

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Background: Access Review
• Appropriate procedure:
– curative intent vs palliative debulking in cervical cancer16
– breast conservation in breast cancer17
– Complete vs incomplete lymphadenectomy in GI resections18
– immediate vs interval cholecystectomies19
– limb salvage vs amputation in critical limb ischemia12
• Follow-up procedures:
• reconstruction s/p resection of breast cancer20

6. CENTER FOR SURGERY
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Gaps in the Literature: Systemic Factors
• Effect of prospective clinical
interventions
– Culturally-sensitive patient navigation
improved colonoscopy screening 30%21
• Effect of Social determinants
– Community unemployment rates
correlate with (penetrating) trauma in
California22 and Louisiana23
– Trauma epidemiology in San Diego’s level
1 trauma center changed with national
policy on border fence height24
• Effect in very vulnerable groups
– Dual-eligibles, LGBT, undocumented

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Gaps in the Literature: Access
• Effect of policy
– Registration for simultaneous pancreas and kidney transplant
improved after Medicare coverage in 1999, but no change in
disparities25
– Receipt of MIS for appendicitis/cholecystitis improved after 2006
MA healthcare expansion for minorities, resolving disparities26
• Effect of management protocols
– Proportion of minority Medicare patients undergoing bariatric
surgery declined after CMS Centers of Excellence Program27
• Effect of adoption of technology
– Racial disparities in utilization of minimally-invasive prostatactomy
decreased during adoption between 2001-200728

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Future Directions
• NIH (NIMHD)29
– “the largest numbers of the medically underserved are White
individuals”
• IOM30
– “Lack of health care is a persistent barrier to good health”
• AHRQ31
– “across a broad spectrum of access measures, most
[disparities] did not improve”

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Conclusions
• Evaluate success of clinical programs in
overcoming systemic challenges
• Bridge gap between patients and providers: patient
navigators, m-health
• Improve communication: cultural competence, workforce
diversification
• Confront social determinants: residential segregation
• Policy-relevant access research
• Test the effect of management guidelines (i.e. adoption)
• Exploit natural policy experiments: MA reform, ACA DCP,
Medicaid expansion

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1. Haider AH, Scott VK, Rehman KA, et al. Racial disparities in surgical care and outcomes in the United States: a
comprehensive review of patient, provider, and systemic factors. J Am Coll Surg. 2013; 216(3): 482-92.
2. Birkmeyer NJO, Gu N, Baser O, Morris AM, Birkmeyer JD. Socioeconomic status and surgical mortality in the
elderly. Med Care. 2008; 46: 893-9.
3. Maybury RS, Bolorunduro OB, illegas C, et al. Pedestrians struck by motor vehicles further worsen race- and
insurance-based disparities in trauma outcomes: the case for inner-city pedestrian injury prevention programs.
Surgery. 2010; 148(2): 202-8.
4. Johansen KL, Zhang R, Huang Y, Patzer RE, Kutner NG. Association of race and insurance type with delayed
assessment for kidney transplant among patients initiating dialysis in the United States. Clin J Am Soc Nephrol.
2012; 7(9):1490-7.
5. Joshi S, Gaynor JJ, Bayers S, et al. Disparities among Blacks, Hispanics, and Whites in time from starting dialysis to
kidney transplant waitlisting. Transplantation. 2013; 95(2):309-18.
6. Zarkowsky DS, Arhuidese IJ, Hicks CW, et al. Racial/ethnic disparities associated with initial hemodialysis access.
JAMA Surg. 2015; In Press.
7. Esnaola NF, Gebregziabher M, Knott K, et al. Underuse of surgical resection for localized, non-small cell lung
cancer among whites and African Americans in South Carolina. Ann Thorac Surg. 2008; 86(1):220-6.
8. Fleming S, Schluterman NH, Tracy JK, Temkin SM. Black and White women in Maryland receive different
treatment for cervical cancer. PLoS One. 2014; 9(8): e104344.
9. Boomer L, Freeman J, Landrito E, Feliz A. Perforation in adults with acute appendicitis linked to insurance status,
not ethnicity. J Surg Res. 2010; 163(2):221-4.
References

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10. Bradley CJ, Dahman B, Shickle LM, Lee W. Surgery wait times and specialty services for insured and uninsured
breast cancer patients: does hospital safety net status matter? Health Serv Res. 2012; 47(2):677-97.
11. Liu FW, Randall LM, Tewari KS, Bristow RE. Racial disparities and patterns of ovarian cancer surgical care in
California. Gynecol Oncol. 2014; 132(1): 221-6.
12. Henry AJ, Hevelone ND, Belkin M, Nguyen LL. Socioeconomic and hospital-related predictors of amputation for
critical limb ischemia. J Vasc Surg. 2011; 53(2):330-9.
13. Bowman K, Telem DA, Hernandez-Rosa J, Stein N, Williams R, Divino CM. Impact of race and socioeconomic
status on presentation and management of ventral hernias. Arch Surg. 2010; 145(8):776-80.
14. Ricciardi R, Selker HP, Baxter NN, Marcello PW, Roberts PL, Virgnig BA. Disparate use of minimally invasive
surgery in benign surgical conditions. Surg Endosc. 2008; 22(9): 1977-86.
15. Salasky V, Yang RL, Datta J, et al. Racial disparities in the use of outpatient mastectomy. J Surg Res. 2014;
186(1):16-22.
16. Brookfield KF, Cheung MC, Lucci J, Fleming LE, Koniaris LG. Disparities in survival among women with invasive
cervical cancer: a problem of access to care. Cancer. 2009; 115(1): 166-78.
17. Alderman AK, Bynum J, Sutherland J, Birkmeyer N, Collins ED, Birkmeyer J. Surgical treatment of breast cancer
among the elderly in the United States. Cancer. 2011; 117(4):698-704.
18. Dubecz A, Solymosi N, Schweigert M, et al. Time trends and disparities in lymphadenectomy for gastrointestinal
cancer in the United States: a population-based analysis of 326,243 patients. J Gastrointest Surg. 2013; 17(4):611-8.
19. Loehrer AP, Song Z, Auchincloss HG, Hutter MM. Influence of health insurance expansion on disparities in the
treatment of acute cholecystitis. Ann Surg. 2015; In Press.
References

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20. Kruper L, Xu X, Henderson K, Bernstein L. Disparities in reconstruction rates after mastectomy for ductal
carcinoma in situ (DCIS): patterns of care and factors associated with the use of breast reconstruction for DCIS
compared with invasive cancer. Ann Surg Oncol. 2011; 18(11):3210-9.
21. Braschi CD, Sly JR, Singh S, Villagra C, Jandorf L. Increasing colonoscopy screening for Latino Americans through a
patient navigation model: a randomized clinical trial. J Immigr Minor Health. 2014; 16(5):934-40.
22. Cinat, ME, Wilson SE, Lush S, Atkins C. Significant correlation of trauma epidemiology with the economic
conditions of a community. Arch Surg. 2004; 139(12):1350-5.
23. Madan AK, Sapozhnik J, Tillou A, Raafat A, McSwain NE. Unemployment rates and trauma admissions. World J
Surg. 2007; 31(10):1930-3.
24. Kelada AM, Hill LL, Lindsay S, Slymen D, Fortlage D, Coimbra R. The U.S.-Mexico border: a time-trend analysis of
border-crossing injuries. Am J Prev Med. 2010; 38(5): 548-50.
25. Melancon JK, Kucirka LM, Boulware LE, et al. Impact of Medicare coverage on disparities in access to
simultaneous pancreas and kidney transplantation. Am J Transplant. 2009; 9(12):2785-91.
26. Loehrer AP, Song Z, Auchincloss HG, Hutter MM. Massachusetts health care reform and reduced racial
disparities in minimally invasive surgery. JAMA Surg. 2013; 148(12):1116-22.
27. Nicholas LH, Dimick JB. Bariatric surgery in minority patients before and after implementation of a Centers of
Excellence Program. JAMA. 2013; 310(13): 1399-1400.
28. Trinh QD, Schmitges J, Sun M, et al. Improvement of racial disparities with respect to the utilization of minimally
invasive radical prostatectomy in the United States. Cancer. 2012; 118(7): 1894-900.
29. Institute of Medicine. http://www.iom.edu/Global/Topics/Health-Services-Coverage-Access.aspx.
References

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30. National Institute on Minority Health and Health Disparities.
http://www.nimhd.nih.gov/documents/Strategic%20Plan%20FY%202004-2008%20vol%201.pdf.
31. Agency for Healthcare Research and Quality. National Healthcare Quality and Disparities Report. 2014.
References