Black patients face delays in surgery for adhesive small-bowel obstruction

Last Updated: 2017-12-08

By Will Boggs MD

NEW YORK (Reuters Health) - Black patients are more likely than whites to have delayed surgical management of adhesive small-bowel obstruction (SBO), according to a database study.

"Two things were particularly interesting," Dr. Kevin Y. Pei from Yale School of Medicine, in New Haven, Connecticut, told Reuters Health by email. "One, we corroborated previous guidelines that waiting more than 5 days for (for surgery for) small-bowel obstruction leads to worse outcomes; but two, surprisingly, black patients, even when controlled for patient comorbid conditions, were more likely to wait more than 5 days for surgery."

SBO, one of the most common surgical emergencies encountered by general surgeons, represents 12%-16% of all surgical admissions and costs over $2 billion a year, according to Dr. Pei and his colleagues.

Guidelines from the Eastern Association for the Surgery of Trauma recommend that patients without clinical signs of deterioration can safely undergo a trial of expectant management for up to five days. Once the decision to operate is made, the guidelines also recommend a laparoscopic approach whenever feasible.

Dr. Pei's team used data from the American College of Surgeons National Surgical Quality Improvement Program to investigate the impact race might play in surgical decision-making in patients with SBO.

They grouped race into non-Hispanic white (73.0%), non-Hispanic black (17.0%), Hispanic (6.1%), and other (4.0%), and they focused on the length of time from admission to surgery (5 days or less vs. >5 days) and the use of open surgery versus laparoscopy.

The mean time to surgery was 2.3 days, and 30-day mortality rates were significantly higher for patients waiting more than 5 days (8.2% vs. 3.1%), as were complication rates (40.6% vs. 24.2%).

After adjustment for preoperative risk factors, waiting longer than 5 days was associated with 61% greater odds of 30-day mortality and 56% greater odds of postoperative complications, the researchers report in the Journal of the American College of Surgeons, online November 20.

Compared with laparoscopy, open surgery had higher 30-day mortality rates (4.3% vs. 1.3% with laparoscopy) and more postoperative complications (30.3% vs. 10.4% with laparoscopy).

Mortality rates at 30 days were similar between black (3.9%) and white (3.7%) patients, but the complication rate was significantly higher for black patients (31.4%) than for white patients (25.3%).

In a multivariable model that controlled for comorbidities and health status, black patients had 31% higher odds than white patients of waiting longer than 5 days for an operation, and 56% higher odds of having open surgery rather than laparoscopy.

In contrast, neither Hispanic patients nor "other" patients differed from white patients in the time to surgery or in the use of open versus laparoscopic approach.

The researchers were unable to identify the precise cause of these disparities.

As for how to address these disparities, Dr. Pei said, "This is the tough question. So much so that journals now reject manuscripts about disparity that don't offer a solution. But the problem is we have to identify the problem systematically. Because many of these biases are unconscious biases, it is important to call attention to them. Awareness may be a huge part of the solution."

His advice: "First, don't wait more than 5 days for small-bowel obstruction. Second, whenever you deviate from guidelines, at least consider why."

Dr. Alexander L. Colonna from the University of Utah, in Salt Lake City, who has evaluated the nonoperative management paradigm for adhesive SBO, told Reuters Health by email, "As a clinician I'd like to think that I'm colorblind, but the fact remains that African Americans are receiving interventions later and are having more complications than other groups."

"Further prospective research is needed to identify why African Americans are treated differently," he said. "Is it truly bias from the physicians? Is it the overall difference in preoperative risk factors (NSQIP database has a good deal of information but the authors correctly identified the limitations of the data set)? Is it cultural, i.e., African American distrust of the system? Is there a difference between community hospitals vs. large tertiary care centers vs. academic medical centers?"

"Physicians should check themselves when evaluating any patient and try to understand their own biases," Dr. Colonna said. "Whether it's treating patients of color, the morbidly obese, those with substance use disorders, etc., we all have biases that we bring to work with us, and we have a responsibility to treat all patients to the best of our ability based on the evidence available."

Dr. Christopher T. Aquina from the University of Rochester Medical Center, in Rochester, New York, who has written about adhesive-SBO management, told Reuters Health by email, "There very well may be real differences in the management of small-bowel obstruction based on race. However, until further research is performed on this subject, I think the results have to be taken with a grain of salt."

"There may be inherent selection bias in this study, as black patients were more likely to have more comorbidities, higher ASA class, and worse functional status, which may be driving the delay in surgery," he said. "We also do not have information about individual surgeon case-mix and if this phenomenon is more a reflection of individual surgeon practice patterns and their baseline patient population. Therefore, it is hard to make conclusions if there is true racial bias present."

"I agree with the authors that further research investigating the influence of bias on surgical decision-making is required," Dr. Aquina. "Finally, the choice of an open vs. laparoscopic approach remains controversial in the operative management of small-bowel obstruction. A recent large, population-based study suggests that a laparoscopic approach for small-bowel obstruction may be associated with a higher risk of bowel injury compared to an open approach. Therefore, a laparoscopic approach may not be an appropriate quality measure for small-bowel obstruction cases."

SOURCE: http://bit.ly/2yOP6G2

J Am Coll Surg 2017.