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Setting a National Agenda for Surgical Disparities Research: Recommendations From the National Institutes of Health and American College of Surgeons Summit

Setting a National Agenda for Surgical Disparities Research: Recommendations From the National... Abstract Health care disparities (differential access, care, and outcomes owing to factors such as race/ethnicity) are widely established. Compared with other groups, African American individuals have an increased mortality risk across multiple surgical procedures. Gender, sexual orientation, age, and geographic disparities are also well documented. Further research is needed to mitigate these inequities. To do so, the American College of Surgeons and the National Institutes of Health–National Institute of Minority Health and Disparities convened a research summit to develop a national surgical disparities research agenda and funding priorities. Sixty leading researchers and clinicians gathered in May 2015 for a 2-day summit. First, literature on surgical disparities was presented within 5 themes: (1) clinician, (2) patient, (3) systemic/access, (4) clinical quality, and (5) postoperative care and rehabilitation-related factors. These themes were identified via an exhaustive preconference literature review and guided the summit and its interactive consensus-building exercises. After individual thematic presentations, attendees contributed research priorities for each theme. Suggestions were collated, refined, and prioritized during the latter half of the summit. Breakout sessions yielded 3 to 5 top research priorities by theme. Overall priorities, regardless of theme, included improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery. The National Institutes of Health and American College of Surgeons Summit on Surgical Disparities Research succeeded in identifying a comprehensive research agenda. Future research and funding priorities should prioritize patients’ care perspectives, workforce diversification and training, and systematic evaluation of health technologies to reduce surgical disparities. Introduction Health care disparities, ie, differences in the burden of disease, injury, violence, or opportunities to achieve optimal health experienced by socially disadvantaged populations, have been well documented.1-3 Disparities are historically linked to race/ethnicity, socioeconomic status (SES), disability, and sexual orientation/gender identity. For example, a 2006 Medicare study4 found that African American individuals had higher mortality rates for 88% of surgical procedures. However, hospital volume accounted for some of this disparity, illustrating the interconnectedness of surgical disparities.4,5 Similarly, a 2010 study6 of national inpatient data found that each incremental increase in SES was associated with a 7% decrease in mortality risk across numerous cardiovascular and oncologic procedures. Surgical disparities can occur along any part of the patient care continuum including access, quality of care, and outcomes. They are documented in numerous specialties7 and are associated with race/ethnicity,1,3,8-12 sex,13-15 age,10,16-18 and geography.19-21 Further research and interdisciplinary collaboration are needed to understand the interrelated factors that affect patient experiences in the surgical setting.1,3,4,7,8 In acknowledgment of these issues, the National Institutes of Health (NIH) and American College of Surgeons (ACS) came together to create a national research agenda to inform surgical disparities research. The NIH-ACS Summit on Surgical Disparities Research was held May 7 to 8, 2015, at the NIH campus in Bethesda, Maryland. Partnership: NIH and ACS Both the ACS and the NIH (across its various institutes and particularly through the National Institute of Minority Health and Disparities) prioritize research to mitigate surgical disparities. The ACS formed the Committee on Optimal Access in 2013, stating that “optimal access is the key to quality of care.”22 The committee’s goals are to develop metrics to assess health care disparities in the various disciplines of surgery, strategies for addressing health care disparities in select surgical environments, best practices in combating surgical disparities, and resources to address health care disparities in surgical patient care.22 The NIH established the National Institute of Minority Health and Disparities in 2000, with the mission to lead research to improve health disparities by planning, coordinating, and evaluating health disparities research; conducting and supporting research in health disparities; promoting and supporting the procurement of a diverse research workforce; translating research information; and fostering collaborations.23 On the basis of this shared vision for procuring equity for all patients, the NIH and ACS identified joint deliverables to inform their shared aims.24 Among these were formation of a research agenda to guide future investigation of surgical disparities and funding priorities to assist federal, state, and private organizations in their support of surgical disparities research.24 Planning for the NIH-ACS Summit on Surgical Disparities Research The planning committee for the summit consisted of leadership from both organizations. They jointly identified and invited experts to the summit that had extensively published peer-reviewed disparities research (eAppendix in the Supplement) and were nationally recognized in the field. The literature review was used to help identify participants. To organize the content discussed in the summit, the planning committee conducted an exhaustive literature review to identify potential thematic areas of surgical disparities research. Further details on our methods and results of this search are now available on the ACS website.24Quiz Ref ID Planning committee researchers synthesized findings into 5 thematic topics: (1) clinician factors (including physicians, surgeons, nurses, nurse practitioners, physician assistants, and students), (2) patient/host factors, (3) systemic factors and access factors, (4) clinical care and quality factors, and (5) postoperative care and rehabilitation factors. This article presents the thematic areas that guided the summit, organization of thematic and breakout sessions at the summit, and the outcomes of these sessions. Summit Format Attendees of the 2015 NIH-ACS Summit on Surgical Disparities Research represented a diverse group of surgeons, researchers, and staff with knowledge and practical experience with surgical disparities research or were content experts from other fields within health care disparities research. Many attendees and planning committee members had diverse clinical experiences and represented multiple countries and racial/ethnic groups. Approximately half of attendees were women. Attendees were also diverse in their experiences in providing care in urban, suburban, and rural settings across multiple geographic regions of the United States, both in community hospitals and academic medical centers. Following an introduction to the summit and overview of deliverables, the summit conducted an interactive discussion of 5 empirically based thematic areas derived from the literature described earlier. For each theme, a surgical research fellow presented an overview of literature in that field. Next, a nonsurgeon expert in the field presented an elaboration of the literature in each theme, commenting on knowledge gaps and proposing future directions. A video giving further details of this summit format can be found at the ACS website.24 Synopsis of Thematic Presentations Clinician Factors Clinician-level factors in surgical disparities refer to variations in physician practice related to factors such as level of training.4 Disparities in clinician factors have been reported, with African American patients receiving less colon, prostate, and lung resections than other groups.25-30 Simulated studies demonstrated the effect of implicit bias on physician decision making and require real-world clinical assessment.31-34 Extant research suggests that racial/ethnic minorities receive more racially discordant health care than white patients,1,3 which may contribute to poor physician-patient communication. This can affect ascertainment of informed consent, collection of social histories, and adherence to postoperative care instructions.35 Research is needed to understand the role of cultural dexterity, defined as knowledge, skills, and awareness of physicians in patient interactions in surgical care.36 Patient Factors Numerous patient factors have been identified as contributors to surgical disparities, including demographic (eg, race/ethnicity), physiologic (eg, immune status), and culture (eg, language). Compared with white patients, when African American patients undergo surgery, they have higher operative mortality and morbidity than white patients.37-46 Compared with more affluent patients, patients with low SES are less likely to receive appropriate surgical services.47,48 Disparities have also been demonstrated for coronary artery bypass grafting, mitral valve procedures, and other surgical outcomes for women compared with men.49,50 Future research must focus on mitigation of disparities via patient-clinician education and systematic approaches to health care equity. Systemic and Access Factors Systemic and access factors are issues related to patient access to care including health care coverage policies and clinical protocols.5,51 Systemic and access factors often interact. For example, while universal health care coverage in Massachusetts reduced disparities in the receipt of minimally invasive operations for common abdominal ailments,52 other systems-level policies to increase access have exacerbated disparities among low-income and disadvantaged populations.53,54 Race/ethnicity and/or SES disparities have been demonstrated in care access and procedures such as emergent vs elective hernia repairs and limb salvage vs amputation in critical limb ischemia.55-62 Future research is needed to understand factors, such as time between diagnosis and surgical referral and delays in seeking acute care, to reduce surgical disparities.57,60-63 Clinical Care and Quality Factors The Institute of Medicine defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”64 Disparities can be conceptualized as factors related to structure, process, and outcomes.65 Structural variation accounts for some between-hospital quality differences in outcomes, such that minority patients living in low-SES zip codes are more likely to present to hospitals with low structural quality and experience worse outcomes.66-70 Process variations, including choice of procedure, adherence to guidelines, and specialty referral, have all been linked to minority patient status.67,71-77 Less is known about other demographic associations with clinical care and quality, including immigration status, language, rurality, sexual orientation, and gender identity. Future research is needed to understand and promote redesigned care pathways, systems demonstrations, and enhanced measurement and incentives to yield high-value, equitable care. Postoperative Care and Rehabilitation Factors Relative to other areas of disparities, little is known about disparities in postoperative and rehabilitative care. Previous research provides evidence of racial, ethnic, and insurance disparities related to access to postacute care after traumatic brain injury, spinal cord injury, and orthopedic surgery.78-82 Even among patients who receive inpatient rehabilitation, there are still disparities in functional outcomes83,84 and timing and use of adjuvant.85,86 African American and Hispanic women are more likely to have late initiation of chemotherapy and incomplete treatment, less follow-up, and increased mortality rates relative to white oncology patients,85,86 with lower life satisfaction and higher unemployment.87,88 Other studies demonstrate mismanaged care preferences among these groups as well.89 More research is needed to investigate the social determinants of health in postoperative recovery, long-term outcomes, palliative care, and end-of-life care. Identification of Research Priorities Summit attendees participated in a thematic ranking exercise over the course of the conference. The entire process was overseen by a PhD-trained health disparities researcher with expertise in qualitative methods. On day 1, a 3-step process was implemented. First, at the completion of each thematic presentation, attendees generated free-response comments by theme. These recommendations were collected at the conclusion of all of the presentations. Next, using pile sorting methods, cards were sorted and collated by facilitators trained in qualitative methods. Third, cards were sorted by similarity in qualitative content of questions, and all frequencies were recorded, yielding between 5 to 15 popular topics per theme. On day 2, attendees were assigned to 2 consecutive 1-hour breakout sessions. Attendees participated in 2 different thematic sessions so that they could contribute both within and outside their areas of expertise. Breakout sessions were each led by a trained facilitator and a surgical chair with relevant expertise. The coleaders facilitated group discussion around etiology, vulnerable populations, ethical and methodological considerations, funding priorities, workforce diversity, and surgical training recommendations. During the first breakout session, each group was asked to narrow down the list of topics that were compiled from day 1 to a list of up to 10 priority topics. This was accomplished by considering the overall popularity of the topics in day 1 and potential contributions of the topics to reducing surgical disparities, regardless of popularity. In the subsequent breakout session, a separate group of attendees assessed the list generated by the first group and further refined it to identify up to 5 priorities by theme. Results were shared with the entire summit to elicit final comments, and 5 overarching themes were determined. Final deliverables consisted of a list of 5 research priorities by theme and a list of 5 overall research priorities, regardless of theme. On day 1, nearly 60 individuals participated in identifying research priorities for each of the 5 thematic areas. In total, more than 440 comments were gathered, collated, and organized into topics for day 2. Results Recommendations are detailed by respective theme. The Figure depicts a flowchart of how conference attendees participated in each day of the summit thematic rankings. Box 1 reports the most frequent research topics and related research questions as identified on day 1, which informed day 2 sessions. The Table reports the results of the day 2 breakout sessions, and Box 2 details the top overall research priorities, regardless of theme. Box Section Ref ID Box 1. Day 1 Research Priorities Compiled in Order of Frequency (N = 440) Clinician Factors (n = 105 Initial Suggestions) • Definition of cultural competency/dexterity and its role in agency • Best practices for cultural competency training, eg, standardization, implementation, and curricula • Regional variation in culture vs uniform training • Evaluation of the effect of cultural competency training • Incentivizing cultural competency training and/or diversification of the health care workforce • Role of patient-clinician communication and trust in surgical outcomes • Patient advocacy and navigation services • Evaluation of implicit bias and “unlearning” biases interventions • Evaluating multiple levels of implicit bias, eg, individual, institutional, and setting • Race/ethnicity/sex/minority patient-clinician dis/concordance • Use of metrics to evaluate surgical quality • Effect of centralized vs regionalized care on surgical outcomes Patient Factors (n = 116 Initial Suggestions) • Patient education and health literacy • Geography, eg, access to care, travel time, and geocoding • Patient perceptions and decision making • Data collection and databases, eg, self-report data and use of proxy measures • Assessing and evaluating preoperative comorbidity and risk, eg, obesity and diabetes • Role of social support on patient engagement in care • Defining and evaluating socioeconomic status and cost to patients, eg, out-of-pocket cost to patients • Patient-clinician communication • Best practices for patient interventions to improve surgical care outcomes • Strategies to increase patient engagement in health care • Role of biology and genetics in disparities and related risk factors • Engagement of marginalized groups in research, eg, immigrant health, religious groups, and Indian Health Services • Patient behaviors, attitudes, knowledge, and beliefs about health and surgical care • Effect of technology and social media on surgical outcomes, eg, mobile health interventions • Assessing insurance-related factors among patients and outcomes Systemic and Access Factors (n = 90 Initial Suggestions) • Evaluating the effect of specific interventions, eg, regional quality metrics • Effects of various payment strategies, eg, relative value units • Data and information management/technology in health care systems • Tailored management protocols and guidelines, eg, screening guidelines • Policy checks and evaluation, eg, Medicaid expansion evaluation and outcomes • Integration and coordination of care services • Centers of excellence and regionalization of care • Use of safety net hospitals • Specific study ideas, eg, evaluation of shared health care decision making • Engagement between clinicians and patients • Adoption of technologies • Social determinants of health Clinical Care and Quality Factors (n = 70 Initial Suggestions) • Guideline creation, dissemination, and compliance, eg, best practices for screening guidelines • Effect of new and existing incentives strategies • Explanatory power of specific structural metrics, eg, effect sizes and measurement issues • Quality metric development, measurement, and implementation • Prioritization of outcomes for patients, eg, shared health care decision making • Role of technology and electronic health records in patient tracking and loss to follow-up • Tools and methods for understanding disparities, eg, patient registries, qualitative inquiry • Patient navigation and advocacy Postoperative Care and Rehabilitation Factors (n = 55 Initial Suggestions) • Study of longitudinal outcomes, eg, quality of life, functional status, and employment outcomes • Evaluation of disparities in palliative and end-of-life care • Increasing access and use of rehabilitation for underinsured populations • Postoperative care for patients in rural settings • Wraparound services and continuity of care • Role of social support (eg, in rehabilitation) and adherence • Exploring multidisciplinary approaches to disparities in functional outcomes and quality of life • Establishing best practices for rehabilitation quality and nursing facility care • Effect of patient culture and language barriers on postoperative outcomes • Culturally competent shared decision making and incorporation of functional outcomes discussion for all patients Box Section Ref ID Box 2. Five Overarching Priorities Identified for Surgical Disparities Research at the 2015 National Institutes of Health–American College of Surgeons Summit Research Should Be Directed Toward: 1. Improving patient-Clinician communication by helping clinicians deliver culturally dexterous, competent care and measuring its effect on the elimination of disparities. 2. Fostering engagement and community outreach by using technology to optimize patient education, health literacy, and shared decision making in a culturally relevant way; disseminating these technologies; and evaluating their effect on reducing surgical disparities. 3. Improving care at facilities with a higher proportion of minority surgical and trauma patients. This includes evaluation of regionalization of care vs strengthening of safety-net hospitals within the context of differential access and surgical disparities. 4. Evaluating the longer-term effect of acute interventions and rehabilitation support within the critical period of injury or illness on functional outcomes and patient-defined perceptions of quality of care. 5. Improving patient centeredness by identifying expectations for postoperative and postinjury recovery. This includes adhering to patient values regarding advanced health care planning and palliative care needs. Clinician Factors Day 1 thematic rankings yielded 105 questions related to clinician factors that contribute to surgical disparities (Box 1). Twelve themes emerged after data collation including cultural competence/dexterity, patient advocacy and navigation services, clinician communication, implicit bias/mindfulness, surgical quality metrics, and racial and sex discordance. The most commonly identified topic was the effect of cultural competence and/or dexterity on surgical disparities (37.1%; n = 39), followed by the effect of biases on care (28.6%; n = 30). The top 5 thematic topics for clinician-level factors identified on day 2 were: (1) defining and evaluating standards of cultural dexterity; (2) patient-clinician communication and evaluation of clinician training; (3) implicit bias and mindfulness training and evaluation; (4) improvement and exploration of new and existing surgical quality metrics; and (5) the role and effect of patient-clinician concordance (Box 1). Recommendations for future studies call for focus on the definition and measurement of cultural dexterity training and evaluation and investigating the effect of ancillary staff on improving cultural competence. Training should provide surgeons with the tools to deliver culturally relevant, patient-centered care and adapt to patients of all different cultural backgrounds. In addition, surgical workforce diversification was discussed in breakout sessions as a method to increase cultural dexterity. Patient Factors Day 1 thematic rankings yielded 120 research questions related to patient factors (Box 1). Fifteen patient factor themes were identified including social support, socioeconomic status, incidental cost of health care to patient, patient-clinician communication, effect of interventions on outcomes, patient behaviors, technology/social media, and insurance. The most commonly identified topics were the role of patient education and health literacy in patient-clinician communication (13.3%; n = 16); geographic and other barriers to accessing care (11.7%; n = 14); and patient perceptions, decision making, and engagement in personal health/behaviors (10.8%; n = 13). Quiz Ref IDThe top-priority topics identified on day 2 were: (1) the role of patient education and health literacy in patient-clinician communication; (2) patient perceptions, decision making, and engagement in personal health/behaviors; and (3) optimizing preoperative comorbidities and partnering with primary care physicians (Table). Additional recommendations were for tools to evaluate clinician communication and patient level of understanding. Interventions should focus on allowing patients the autonomy to make informed decisions about their surgical health care based on accurate, timely, and culturally dexterous communication. Finally, technologies, including social media and handheld devices, must be leveraged to educate patients and support patient decisions in a culturally competent manner. Systemic and Access Factors Day 1 thematic rankings yielded 90 research questions related to systemic and access factors (Box 1). Thirteen systemic and access factor themes were identified including tailored management protocols and guidelines, based on factors such as hospital volume and the effect of the social determinants of health on surgical disparities in systemic and access issues. The most commonly identified topics were the effects of payment strategies on access issues (eg relative value units, 13.3%; n = 12) and the use of data and information management and technology in health care systems (11.1%; n = 10). The top-priority topics identified on day 2 were: (1) assessing the effects of payment in the context of policy reform, (2) care coordination and integration and tailored guidelines for vulnerable populations, (3) regionalization of care vs strengthening safety net hospitals, (4) role of health care as a mitigating factor of social determinants of health; and (5) the evolution of health technology and electronic health records’ effect on research and surgical outcomes (Table). Additional recommendations were to develop strategies that improve access to care for populations that experience surgical disparities. Beyond the effect of socioeconomic disadvantage, future research should assess the effect of the Affordable Care Act in access to care for these populations.90 Clinical Care and Quality Factors Day 1 thematic rankings yielded 70 questions regarding clinical care and quality (Box 1). Eight primary research themes were identified from the questions. The most commonly identified topic was best practices for developing and implementing evidence-based guidelines (22.9%; n = 16), followed by the effect of incentive strategies and payment (17.1%; n = 12). The top 5 thematic topics identified on day 2 were: (1) leveraging electronic health records to improve adoption of evidence-based care; (2) approaches for standardizing and integrating existing data repositories to mitigate disparities; (3) evaluating methods for incorporating patient preferences for treatment and expectations for outcomes in surgical decision making; (4) evaluating the effect of incentive strategies on disparities; and (5) developing and implementing standard data definitions for known and suspected risk factors for disparities (Table). Recommendations were to prioritize the establishment of effective and efficient quality improvement strategies. Future research should assess the effect of electronic health records adoption on disparities in surgical care. Research into surgical disparities often requires linking disparate data sets containing information on clinical outcomes, hospital structure, processes of care, and patient demographic information. These linkages are currently challenging because of nonstandard definitions of data elements. As the distinction between equal and equitable care becomes increasingly clear, patient preferences and cultural factors must be taken into account in surgical decision making. Finally, need for novel incentive strategies in the context of pay-for-performance, bundled payments, accountable care organizations, and public reporting was identified. Postoperative Care and Rehabilitation Factors Day 1 thematic rankings yielded 55 questions related to postoperative care and rehabilitation factors (Box 1). Ten themes emerged, including the study of longitudinal outcomes, evaluation of disparities in palliative and end-of-life care, the role of social support, and the effect of patient culture on postoperative outcomes. Quiz Ref IDThe most commonly identified topic was developing longitudinal methods for assessing outcomes, such as quality of life and functional status (25.5%; n = 14), followed by improving access to outpatient, end-of-life care, palliative care, and advanced care planning (16.4%; n = 9). The top research areas were: (1) leveraging existing databases to prospectively collect data on long-term functional, quality-of-life, and employment outcomes and develop methods for this purpose; (2) evaluating communication approaches regarding end-of-life care, palliative care, and postoperative or postinjury expectations for recovery; (3) exploring barriers to prioritizing patients’ values and measuring the effectiveness of these strategies; (4) exploring the value of postinjury and postoperative recovery and rehabilitation services in terms of cost, quality, and patient-oriented outcomes; and (5) improving access to physical therapy, occupational therapy, and speech therapy with sustainable payment models (eg, teletherapy) to improve rehabilitative outcomes during the critical postacute period (Table). Top Overall Research Questions The final deliverable for the 2015 NIH-ACS Summit on Surgical Disparities Research was the identification of 5 research questions to guide the surgical disparities research agenda (Box 2). Quiz Ref IDOverarching priorities, regardless of theme, called for the following: improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery. Discussion The overarching purpose of the 2015 NIH-ACS Summit on Surgical Disparities Research was to create a national research agenda for use by clinicians, researchers, funding organizations, policymakers, and other key stakeholders. The event established a national research agenda intended to inform not only the future of the partnership between the NIH and the ACS but also to provide research agendas and funding priorities for years to come. The 2-day summit identified nearly 30 research priorities across 5 surgical disparities–related themes (clinician, patient, systemic and access, clinical care and quality, amd postoperative care and rehabilitation factors), which were distilled into 5 overarching priority research questions. Surgical disparities represent a complex problem that the collective community of policymakers, clinicians, researchers, funding bodies, and other stakeholders must address. Evidence of this overlap can be seen in the commonality of recommendations for continued evaluation of patient-clinician communication as well as clinician training and patient education related to both patient and clinician factors. Identified research priorities also included overlap between systemic/access and clinical care/quality-related factors. Moreover, many of the known factors associated with surgical disparities were common among the themes, namely race/ethnicity,25-30 SES,49,50 culture,85,86 and geography.66-70 However, more research is needed to intervene and mitigate these factors. Much of the extant literature identifies sociodemographic factors that precipitate surgical disparities. More research is needed to evaluate these issues long term to design interventions to mitigate disparities. Specifically, research is needed to investigate sustainable models of delivering physical, occupational, and speech therapy to patients and identify effects on recovery. Although 30-day morbidity and mortality have been historically important outcome metrics, they fail to capture the information that is most important to patients because outcomes beyond 30-day morbitidy and mortality are likely the most pronounced. The effect of cultural barriers, time constraints, and staff limitations and disparities as contributing factors in poor-quality communication about postsurgical expectations for recovery is also formidable. Similarly, given that women make up more than half of the US population, more research is needed to identify sex-specific risk factors and subsequent interventions that may mitigate surgical disparities.49,50 Finally, future research and funding entities should prioritize innovation for improving patient-clinician communication via culturally dexterous approaches. Quiz Ref IDThe findings entailed in this report are not without limitations. The results represent the views of clinicians and scientists at a single research meeting (N = 60). Representatives from affiliated fields, including health policymakers, educators, higher education and administrative officials, and philanthropic grant-funding organizations must be included in the ongoing dialogue and take steps to address surgical disparities. Additionally, representation of experts in a wider array of surgical disparities would have been beneficial. For example, researchers and clinicians from Indian Health Services, social scientists, women’s health groups, and integrated care and critical care access hospitals would have led to more diversity in perspectives. Also, because the NIH (National Rural Health Association) holds an annual quality and clinical conference on rural health, we opted to reach more researchers at academic medical centers to gain their insights on research agenda setting. Prioritization of topics was based on a priori identification of themes. Given the interrelated nature of multiple causative agents in health care disparities, other forms of categorization could also apply. Other methods of data collation could also have been used such as a larger online survey of scientists and clinicians or inclusion of nonphysicians/surgeons/research professionals. All health care clinicians related to the surgical field, including nurses, medical assistants, physician assistants, nursing aids, and registrars, offer a unique perspective on research in surgical disparities. Ongoing efforts are warranted to further engage these voices. Moreover, long-term care outcomes research is urgently needed to understand the needs of patients, their families, and their caregivers beyond events happening in the perioperative setting. Conclusions As a first step in setting the research agenda of the NIH-ACS partnership, the inaugural 2015 NIH-ACS Summit on Surgical Disparities was tasked with developing a pivotal research agenda to guide the future of surgical disparities research. This goal was accomplished thanks to interdisciplinary collaboration between surgeon-scientists, health disparities researchers, federal funding organizations, and policymakers. The findings of this summit will be used to inform funding priorities for key partners owing to a critical interinstitutional alliance among the NIH, the ACS, the Patient-Centered Outcomes Research Institute, and the Agency for Healthcare Research and Quality. The collaboration inspired by these institutions represents a call for the development of further innovative partnerships to address surgical disparities. We challenge researchers and funding entities to take these priorities to heart and begin moving research in the field of surgical disparities “from knowing to doing.” Within the context of the larger literature, summit results also call for ongoing evaluation of evidence-based practice, rigorous research methodols, incentives for standardization of care, and building on existing infrastructure to support these advances. With ongoing support and collaboration from the NIH, ACS, and affiliates, best practices for implementation of identified research priorities can be achieved and be used to create more optimal access to equitable quality care for all patients. Back to top Article Information Corresponding Author: Adil H. Haider, MD, MPH, Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, 1620 Tremont St, Ste 4-020, Boston, MA 02120 (ahhaider@partners.org). Accepted for Publication: December 1, 2015. Published Online: March 16, 2016. doi:10.1001/jamasurg.2016.0014. Conflict of Interest Disclosures: None reported. Funding/Support: The American College of Surgeons provided financial support for travel expenses and conference organization materials for our invited guests. Summit attendees were not provided honoraria for their attendance and participation. Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: We thank the conference planning committee, keynote speakers, participants, stakeholder panelists, federal observers, and research support staff listed in the eAppendix of the Supplement for their invaluable contributions during the conference that led to the preparation of this manuscript. We also thank the National Institutes of Health and its staff for their provision of meeting space and onsite resources during the 2 day summit on Surgical Disparities Research and The Center for Surgery and Public Health in Boston and its staff including Tammy Gilson-Ballard, MS, and Emily Wilson, BA, for their generous support in planning, conducting and reporting this conference. References 1. Schwartz D, Haider A. Studying surgical disparities: it’s not all black and white. In: DimickJB, Greenberg CC, eds. Success in Academic Surgery: Health Services Research. London, England: Springer-Verlag; 2014:47-61. 2. Egbert LD, Rothman IL. Relation between the race and economic status of patients and who performs their surgery. N Engl J Med. 1977;297(2):90-91.PubMedGoogle ScholarCrossref 3. Smedley B, Stith A, Nelson A, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academic Press; 2003. 4. 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Surg Clin North Am. 2009;89(6):1279-1284, vii.PubMedGoogle ScholarCrossref 22. American College of Surgeons. Goals of the ACS Committee on Health Care Disparities. https://www.facs.org/health-care-disparities. Published 2015. Accessed February 9, 2016. 23. National Institutes of Health. Vision and mission of the National Institute on Minority Health and Health Disparities. http://www.nimhd.nih.gov/about/visionMission.html. Published 2015. Accessed February 9, 2016. 24. American College of Surgeons. Committee on Health Care Disparities, ACS statement: there is no quality without access. https://www.facs.org/health-care-disparities. Accessed July 22, 2015. 25. Ball JK, Elixhauser A. Treatment differences between blacks and whites with colorectal cancer. Med Care. 1996;34(9):970-984.PubMedGoogle ScholarCrossref 26. Lee AJ, Gehlbach S, Hosmer, Reti M, Baker CS. Medicare treatment differences for blacks and whites. Med Care. 1997;35(12):1173-1189.PubMedGoogle ScholarCrossref 27. Shavers VL, Brown ML, Potosky AL, et al. Race/ethnicity and the receipt of watchful waiting for the initial management of prostate cancer. J Gen Intern Med. 2004;19(2):146-155.PubMedGoogle ScholarCrossref 28. Suga JM, Nguyen DV, Mohammed SM, et al. Racial disparities on the use of invasive and noninvasive staging in patients with non-small cell lung cancer. J Thorac Oncol. 2010;5(11):1772-1778.PubMedGoogle ScholarCrossref 29. Bristow RE, Powell MA, Al-Hammadi N, et al. Disparities in ovarian cancer care quality and survival according to race and socioeconomic status. J Natl Cancer Inst. 2013;105(11):823-832.PubMedGoogle ScholarCrossref 30. Haider AH, Schneider EB, Sriram N, et al. Unconscious race and class bias: its association with decision making by trauma and acute care surgeons. J Trauma Acute Care Surg. 2014;77(3):409-416.PubMedGoogle ScholarCrossref 31. Haider AH, Sexton J, Sriram N, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA. 2011;306(9):942-951.PubMedGoogle ScholarCrossref 32. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60-e76. doi:10.2105/AJPH.2015.302903.PubMedGoogle ScholarCrossref 33. van Ryn M, Burgess DJ, Dovidio JF, et al. The impact of racism on clinician cognition, behavior, and clinical decision making. Du Bois Rev. 2011;8(1):199-218.PubMedGoogle ScholarCrossref 34. Hirsh AT, Hollingshead NA, Ashburn-Nardo L, Kroenke K. The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions. J Pain. 2015;16(6):558-568.PubMedGoogle ScholarCrossref 35. Haider AH, Schneider EB, Sriram N, et al. Unconscious race and class biases among registered nurses: vignette-based study using implicit-association testing. J Am Coll Surg. 2015;220(6):1077-1086.e3.PubMedGoogle ScholarCrossref 36. Paris D. Culturally sustaining pedagogy: a needed change in stance, terminology, and practice. Educ Res. 2013;41(3):93-97. doi:10.3102/0013189X12441244. Google ScholarCrossref 37. Rosson GD, Singh NK, Ahuja N, Jacobs LK, Chang DC. Multilevel analysis of the impact of community vs patient factors on access to immediate breast reconstruction following mastectomy in Maryland. Arch Surg. 2008;143(11):1076-1081.PubMedGoogle ScholarCrossref 38. Dunlop DD, Manheim LM, Song J, et al. Age and racial/ethnic disparities in arthritis-related hip and knee surgeries. Med Care. 2008;46(2):200-208.PubMedGoogle ScholarCrossref 39. Shugarman LR, Mack K, Sorbero ME, et al. Race and sex differences in the receipt of timely and appropriate lung cancer treatment. Med Care. 2009;47(7):774-781.PubMedGoogle ScholarCrossref 40. Osborne NH, Upchurch GR Jr, Mathur AK, Dimick JB. Explaining racial disparities in mortality after abdominal aortic aneurysm repair. J Vasc Surg. 2009;50(4):709-713.PubMedGoogle ScholarCrossref 41. Sosa JA, Mehta PJ, Wang TS, Yeo HL, Roman SA. Racial disparities in clinical and economic outcomes from thyroidectomy. Ann Surg. 2007;246(6):1083-1091.PubMedGoogle ScholarCrossref 42. Greenstein AJ, Litle VR, Swanson SJ, et al. Racial disparities in esophageal cancer treatment and outcomes. Ann Surg Oncol. 2008;15(3):881-888.PubMedGoogle ScholarCrossref 43. Curry WT Jr, Carter BS, Barker FG II. Racial, ethnic, and socioeconomic disparities in patient outcomes after craniotomy for tumor in adult patients in the United States, 1988-2004. Neurosurgery. 2010;66(3):427-437.PubMedGoogle ScholarCrossref 44. Breslin TM, Morris AM, Gu N, et al. Hospital factors and racial disparities in mortality after surgery for breast and colon cancer. J Clin Oncol. 2009;27(24):3945-3950.PubMedGoogle ScholarCrossref 45. Kamath AF, Horneff JG, Gaffney V, Israelite CL, Nelson CL. Ethnic and gender differences in the functional disparities after primary total knee arthroplasty. Clin Orthop Relat Res. 2010;468(12):3355-3361.PubMedGoogle ScholarCrossref 46. Singh TP, Almond C, Givertz MM, Piercey G, Gauvreau K. Improved survival in heart transplant recipients in the United States: racial differences in era effect. Circ Heart Fail. 2011;4(2):153-160.PubMedGoogle ScholarCrossref 47. Birkmeyer NJ, Gu N. Race, socioeconomic status, and the use of bariatric surgery in Michigan. Obes Surg. 2012;22(2):259-265.PubMedGoogle ScholarCrossref 48. Zak Y, Rhoads KF, Visser BC. Predictors of surgical intervention for hepatocellular carcinoma: race, socioeconomic status, and hospital type. Arch Surg. 2011;146(7):778-784.PubMedGoogle ScholarCrossref 49. Schulz P, Zimmerman L, Barnason S, Nieveen J. Gender differences in recovery after coronary artery bypass graft surgery. Prog Cardiovasc Nurs. 2005;20(2):58-64.PubMedGoogle ScholarCrossref 50. Seeburger J, Eifert S, Pfannmüller B, et al. Gender differences in mitral valve surgery. Thorac Cardiovasc Surg. 2013;61(1):42-46.PubMedGoogle Scholar 51. Haider AH, Weygandt PL, Bentley JM, et al. Disparities in trauma care and outcomes in the United States: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2013;74(5):1195-1205.PubMedGoogle ScholarCrossref 52. 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):1116-1122.PubMedGoogle ScholarCrossref 53. 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.PubMedGoogle ScholarCrossref 54. 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):2785-2791.PubMedGoogle ScholarCrossref 55. Birkmeyer NJO, Gu N, Baser O, Morris AM, Birkmeyer JD. Socioeconomic status and surgical mortality in the elderly. Med Care. 2008;46(9):893-899.PubMedGoogle ScholarCrossref 56. Liu FW, Randall LM, Tewari KS, Bristow RE. Racial disparities and patterns of ovarian cancer surgical care in California. Gynecol Oncol. 2014;132(1):221-226.PubMedGoogle ScholarCrossref 57. 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.e1.PubMedGoogle ScholarCrossref 58. 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):220-226.PubMedGoogle ScholarCrossref 59. 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.PubMedGoogle ScholarCrossref 60. 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):776-780.PubMedGoogle ScholarCrossref 61. 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):677-697.PubMedGoogle ScholarCrossref 62. 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):221-224.PubMedGoogle ScholarCrossref 63. 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):166-178.PubMedGoogle ScholarCrossref 64. Chassin MR, Galvin RW; Institute of Medicine National Roundtable on Health Care Quality. The urgent need to improve health care quality. JAMA. 1998;280(11):1000-1005.PubMedGoogle ScholarCrossref 65. Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q. 2005;83(4):691-729.PubMedGoogle ScholarCrossref 66. Rhoads KF, Patel MI, Ma Y, Schmidt LA. How do integrated health care systems address racial and ethnic disparities in colon cancer? J Clin Oncol. 2015;33(8):854-860.PubMedGoogle ScholarCrossref 67. Francis ML, Scaife SL, Zahnd WE. Rural-urban differences in surgical procedures for Medicare beneficiaries. Arch Surg. 2011;146(5):579-583.PubMedGoogle ScholarCrossref 68. Skolasky RL, Thorpe RJ Jr, Wegener ST, Riley LH III. Complications and mortality in cervical spine surgery: racial differences. Spine (Phila Pa 1976). 2014;39(18):1506-1512.PubMedGoogle ScholarCrossref 69. SooHoo NF, Farng E, Zingmond DS. Disparities in the utilization of high-volume hospitals for total hip replacement. J Natl Med Assoc. 2011;103(1):31-35.PubMedGoogle ScholarCrossref 70. Boyd LR, Novetsky AP, Curtin JP. Ovarian cancer care for the underserved: are surgical patterns of care different in a public hospital setting? Cancer. 2011;117(4):777-783.PubMedGoogle ScholarCrossref 71. Sun M, Karakiewicz PI, Sammon JD, et al. Disparities in selective referral for cancer surgeries: implications for the current healthcare delivery system. BMJ Open. 2014;4(3):e003921.PubMedGoogle ScholarCrossref 72. Bristow RE, Chang J, Ziogas A, Randall LM, Anton-Culver H. High-volume ovarian cancer care: survival impact and disparities in access for advanced-stage disease. Gynecol Oncol. 2014;132(2):403-410.PubMedGoogle ScholarCrossref 73. Martinez SR, Shah DR, Maverakis E, Yang AD. Geographic variation in utilization of sentinel lymph node biopsy for intermediate thickness cutaneous melanoma. J Surg Oncol. 2012;106(7):807-810.PubMedGoogle ScholarCrossref 74. Barocas DA, Alvarez J, Koyama T, et al. Racial variation in the quality of surgical care for bladder cancer. Cancer. 2014;120(7):1018-1025.PubMedGoogle ScholarCrossref 75. Murphy EH, Stanley GA, Arko MZ, Davis CM III, Modrall JG, Arko FR III. Effect of ethnicity and insurance type on the outcome of open thoracic aortic aneurysm repair. Ann Vasc Surg. 2013;27(6):699-707.PubMedGoogle ScholarCrossref 76. Hughes K, Boyd C, Oyetunji T, et al. Racial/ethnic disparities in revascularization for limb salvage: an analysis of the National Surgical Quality Improvement Program database. Vasc Endovascular Surg. 2014;48(5-6):402-405.PubMedGoogle ScholarCrossref 77. Lau BD, Haider AH, Streiff MB, et al. Eliminating health care disparities with mandatory clinical decision support: the venous thromboembolism (VTE) example. 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Race and insurance disparities in discharge to rehabilitation for patients with traumatic brain injury. J Neurotrauma. 2013;30(24):2057-2065.PubMedGoogle ScholarCrossref 83. Bergés IM, Kuo YF, Ostir GV, Granger CV, Graham JE, Ottenbacher KJ. Gender and ethnic differences in rehabilitation outcomes after hip-replacement surgery. Am J Phys Med Rehabil. 2008;87(7):567-572.PubMedGoogle ScholarCrossref 84. Fyffe DC, Deutsch A, Botticello AL, Kirshblum S, Ottenbacher KJ. Racial and ethnic disparities in functioning at discharge and follow-up among patients with motor complete spinal cord injury. Arch Phys Med Rehabil. 2014;95(11):2140-2151.PubMedGoogle ScholarCrossref 85. Nurgalieva ZZ, Franzini L, Morgan RO, Vernon SW, Liu CC, Du XL. Impact of timing of adjuvant chemotherapy initiation and completion after surgery on racial disparities in survival among women with breast cancer. Med Oncol. 2013;30(1):419.PubMedGoogle ScholarCrossref 86. 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The Patient Protection and Affordable Care Act, HR 3590, 111th Cong (2010). http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Setting a National Agenda for Surgical Disparities Research: Recommendations From the National Institutes of Health and American College of Surgeons Summit

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References (101)

Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2016.0014
Publisher site
See Article on Publisher Site

Abstract

Abstract Health care disparities (differential access, care, and outcomes owing to factors such as race/ethnicity) are widely established. Compared with other groups, African American individuals have an increased mortality risk across multiple surgical procedures. Gender, sexual orientation, age, and geographic disparities are also well documented. Further research is needed to mitigate these inequities. To do so, the American College of Surgeons and the National Institutes of Health–National Institute of Minority Health and Disparities convened a research summit to develop a national surgical disparities research agenda and funding priorities. Sixty leading researchers and clinicians gathered in May 2015 for a 2-day summit. First, literature on surgical disparities was presented within 5 themes: (1) clinician, (2) patient, (3) systemic/access, (4) clinical quality, and (5) postoperative care and rehabilitation-related factors. These themes were identified via an exhaustive preconference literature review and guided the summit and its interactive consensus-building exercises. After individual thematic presentations, attendees contributed research priorities for each theme. Suggestions were collated, refined, and prioritized during the latter half of the summit. Breakout sessions yielded 3 to 5 top research priorities by theme. Overall priorities, regardless of theme, included improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery. The National Institutes of Health and American College of Surgeons Summit on Surgical Disparities Research succeeded in identifying a comprehensive research agenda. Future research and funding priorities should prioritize patients’ care perspectives, workforce diversification and training, and systematic evaluation of health technologies to reduce surgical disparities. Introduction Health care disparities, ie, differences in the burden of disease, injury, violence, or opportunities to achieve optimal health experienced by socially disadvantaged populations, have been well documented.1-3 Disparities are historically linked to race/ethnicity, socioeconomic status (SES), disability, and sexual orientation/gender identity. For example, a 2006 Medicare study4 found that African American individuals had higher mortality rates for 88% of surgical procedures. However, hospital volume accounted for some of this disparity, illustrating the interconnectedness of surgical disparities.4,5 Similarly, a 2010 study6 of national inpatient data found that each incremental increase in SES was associated with a 7% decrease in mortality risk across numerous cardiovascular and oncologic procedures. Surgical disparities can occur along any part of the patient care continuum including access, quality of care, and outcomes. They are documented in numerous specialties7 and are associated with race/ethnicity,1,3,8-12 sex,13-15 age,10,16-18 and geography.19-21 Further research and interdisciplinary collaboration are needed to understand the interrelated factors that affect patient experiences in the surgical setting.1,3,4,7,8 In acknowledgment of these issues, the National Institutes of Health (NIH) and American College of Surgeons (ACS) came together to create a national research agenda to inform surgical disparities research. The NIH-ACS Summit on Surgical Disparities Research was held May 7 to 8, 2015, at the NIH campus in Bethesda, Maryland. Partnership: NIH and ACS Both the ACS and the NIH (across its various institutes and particularly through the National Institute of Minority Health and Disparities) prioritize research to mitigate surgical disparities. The ACS formed the Committee on Optimal Access in 2013, stating that “optimal access is the key to quality of care.”22 The committee’s goals are to develop metrics to assess health care disparities in the various disciplines of surgery, strategies for addressing health care disparities in select surgical environments, best practices in combating surgical disparities, and resources to address health care disparities in surgical patient care.22 The NIH established the National Institute of Minority Health and Disparities in 2000, with the mission to lead research to improve health disparities by planning, coordinating, and evaluating health disparities research; conducting and supporting research in health disparities; promoting and supporting the procurement of a diverse research workforce; translating research information; and fostering collaborations.23 On the basis of this shared vision for procuring equity for all patients, the NIH and ACS identified joint deliverables to inform their shared aims.24 Among these were formation of a research agenda to guide future investigation of surgical disparities and funding priorities to assist federal, state, and private organizations in their support of surgical disparities research.24 Planning for the NIH-ACS Summit on Surgical Disparities Research The planning committee for the summit consisted of leadership from both organizations. They jointly identified and invited experts to the summit that had extensively published peer-reviewed disparities research (eAppendix in the Supplement) and were nationally recognized in the field. The literature review was used to help identify participants. To organize the content discussed in the summit, the planning committee conducted an exhaustive literature review to identify potential thematic areas of surgical disparities research. Further details on our methods and results of this search are now available on the ACS website.24Quiz Ref ID Planning committee researchers synthesized findings into 5 thematic topics: (1) clinician factors (including physicians, surgeons, nurses, nurse practitioners, physician assistants, and students), (2) patient/host factors, (3) systemic factors and access factors, (4) clinical care and quality factors, and (5) postoperative care and rehabilitation factors. This article presents the thematic areas that guided the summit, organization of thematic and breakout sessions at the summit, and the outcomes of these sessions. Summit Format Attendees of the 2015 NIH-ACS Summit on Surgical Disparities Research represented a diverse group of surgeons, researchers, and staff with knowledge and practical experience with surgical disparities research or were content experts from other fields within health care disparities research. Many attendees and planning committee members had diverse clinical experiences and represented multiple countries and racial/ethnic groups. Approximately half of attendees were women. Attendees were also diverse in their experiences in providing care in urban, suburban, and rural settings across multiple geographic regions of the United States, both in community hospitals and academic medical centers. Following an introduction to the summit and overview of deliverables, the summit conducted an interactive discussion of 5 empirically based thematic areas derived from the literature described earlier. For each theme, a surgical research fellow presented an overview of literature in that field. Next, a nonsurgeon expert in the field presented an elaboration of the literature in each theme, commenting on knowledge gaps and proposing future directions. A video giving further details of this summit format can be found at the ACS website.24 Synopsis of Thematic Presentations Clinician Factors Clinician-level factors in surgical disparities refer to variations in physician practice related to factors such as level of training.4 Disparities in clinician factors have been reported, with African American patients receiving less colon, prostate, and lung resections than other groups.25-30 Simulated studies demonstrated the effect of implicit bias on physician decision making and require real-world clinical assessment.31-34 Extant research suggests that racial/ethnic minorities receive more racially discordant health care than white patients,1,3 which may contribute to poor physician-patient communication. This can affect ascertainment of informed consent, collection of social histories, and adherence to postoperative care instructions.35 Research is needed to understand the role of cultural dexterity, defined as knowledge, skills, and awareness of physicians in patient interactions in surgical care.36 Patient Factors Numerous patient factors have been identified as contributors to surgical disparities, including demographic (eg, race/ethnicity), physiologic (eg, immune status), and culture (eg, language). Compared with white patients, when African American patients undergo surgery, they have higher operative mortality and morbidity than white patients.37-46 Compared with more affluent patients, patients with low SES are less likely to receive appropriate surgical services.47,48 Disparities have also been demonstrated for coronary artery bypass grafting, mitral valve procedures, and other surgical outcomes for women compared with men.49,50 Future research must focus on mitigation of disparities via patient-clinician education and systematic approaches to health care equity. Systemic and Access Factors Systemic and access factors are issues related to patient access to care including health care coverage policies and clinical protocols.5,51 Systemic and access factors often interact. For example, while universal health care coverage in Massachusetts reduced disparities in the receipt of minimally invasive operations for common abdominal ailments,52 other systems-level policies to increase access have exacerbated disparities among low-income and disadvantaged populations.53,54 Race/ethnicity and/or SES disparities have been demonstrated in care access and procedures such as emergent vs elective hernia repairs and limb salvage vs amputation in critical limb ischemia.55-62 Future research is needed to understand factors, such as time between diagnosis and surgical referral and delays in seeking acute care, to reduce surgical disparities.57,60-63 Clinical Care and Quality Factors The Institute of Medicine defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”64 Disparities can be conceptualized as factors related to structure, process, and outcomes.65 Structural variation accounts for some between-hospital quality differences in outcomes, such that minority patients living in low-SES zip codes are more likely to present to hospitals with low structural quality and experience worse outcomes.66-70 Process variations, including choice of procedure, adherence to guidelines, and specialty referral, have all been linked to minority patient status.67,71-77 Less is known about other demographic associations with clinical care and quality, including immigration status, language, rurality, sexual orientation, and gender identity. Future research is needed to understand and promote redesigned care pathways, systems demonstrations, and enhanced measurement and incentives to yield high-value, equitable care. Postoperative Care and Rehabilitation Factors Relative to other areas of disparities, little is known about disparities in postoperative and rehabilitative care. Previous research provides evidence of racial, ethnic, and insurance disparities related to access to postacute care after traumatic brain injury, spinal cord injury, and orthopedic surgery.78-82 Even among patients who receive inpatient rehabilitation, there are still disparities in functional outcomes83,84 and timing and use of adjuvant.85,86 African American and Hispanic women are more likely to have late initiation of chemotherapy and incomplete treatment, less follow-up, and increased mortality rates relative to white oncology patients,85,86 with lower life satisfaction and higher unemployment.87,88 Other studies demonstrate mismanaged care preferences among these groups as well.89 More research is needed to investigate the social determinants of health in postoperative recovery, long-term outcomes, palliative care, and end-of-life care. Identification of Research Priorities Summit attendees participated in a thematic ranking exercise over the course of the conference. The entire process was overseen by a PhD-trained health disparities researcher with expertise in qualitative methods. On day 1, a 3-step process was implemented. First, at the completion of each thematic presentation, attendees generated free-response comments by theme. These recommendations were collected at the conclusion of all of the presentations. Next, using pile sorting methods, cards were sorted and collated by facilitators trained in qualitative methods. Third, cards were sorted by similarity in qualitative content of questions, and all frequencies were recorded, yielding between 5 to 15 popular topics per theme. On day 2, attendees were assigned to 2 consecutive 1-hour breakout sessions. Attendees participated in 2 different thematic sessions so that they could contribute both within and outside their areas of expertise. Breakout sessions were each led by a trained facilitator and a surgical chair with relevant expertise. The coleaders facilitated group discussion around etiology, vulnerable populations, ethical and methodological considerations, funding priorities, workforce diversity, and surgical training recommendations. During the first breakout session, each group was asked to narrow down the list of topics that were compiled from day 1 to a list of up to 10 priority topics. This was accomplished by considering the overall popularity of the topics in day 1 and potential contributions of the topics to reducing surgical disparities, regardless of popularity. In the subsequent breakout session, a separate group of attendees assessed the list generated by the first group and further refined it to identify up to 5 priorities by theme. Results were shared with the entire summit to elicit final comments, and 5 overarching themes were determined. Final deliverables consisted of a list of 5 research priorities by theme and a list of 5 overall research priorities, regardless of theme. On day 1, nearly 60 individuals participated in identifying research priorities for each of the 5 thematic areas. In total, more than 440 comments were gathered, collated, and organized into topics for day 2. Results Recommendations are detailed by respective theme. The Figure depicts a flowchart of how conference attendees participated in each day of the summit thematic rankings. Box 1 reports the most frequent research topics and related research questions as identified on day 1, which informed day 2 sessions. The Table reports the results of the day 2 breakout sessions, and Box 2 details the top overall research priorities, regardless of theme. Box Section Ref ID Box 1. Day 1 Research Priorities Compiled in Order of Frequency (N = 440) Clinician Factors (n = 105 Initial Suggestions) • Definition of cultural competency/dexterity and its role in agency • Best practices for cultural competency training, eg, standardization, implementation, and curricula • Regional variation in culture vs uniform training • Evaluation of the effect of cultural competency training • Incentivizing cultural competency training and/or diversification of the health care workforce • Role of patient-clinician communication and trust in surgical outcomes • Patient advocacy and navigation services • Evaluation of implicit bias and “unlearning” biases interventions • Evaluating multiple levels of implicit bias, eg, individual, institutional, and setting • Race/ethnicity/sex/minority patient-clinician dis/concordance • Use of metrics to evaluate surgical quality • Effect of centralized vs regionalized care on surgical outcomes Patient Factors (n = 116 Initial Suggestions) • Patient education and health literacy • Geography, eg, access to care, travel time, and geocoding • Patient perceptions and decision making • Data collection and databases, eg, self-report data and use of proxy measures • Assessing and evaluating preoperative comorbidity and risk, eg, obesity and diabetes • Role of social support on patient engagement in care • Defining and evaluating socioeconomic status and cost to patients, eg, out-of-pocket cost to patients • Patient-clinician communication • Best practices for patient interventions to improve surgical care outcomes • Strategies to increase patient engagement in health care • Role of biology and genetics in disparities and related risk factors • Engagement of marginalized groups in research, eg, immigrant health, religious groups, and Indian Health Services • Patient behaviors, attitudes, knowledge, and beliefs about health and surgical care • Effect of technology and social media on surgical outcomes, eg, mobile health interventions • Assessing insurance-related factors among patients and outcomes Systemic and Access Factors (n = 90 Initial Suggestions) • Evaluating the effect of specific interventions, eg, regional quality metrics • Effects of various payment strategies, eg, relative value units • Data and information management/technology in health care systems • Tailored management protocols and guidelines, eg, screening guidelines • Policy checks and evaluation, eg, Medicaid expansion evaluation and outcomes • Integration and coordination of care services • Centers of excellence and regionalization of care • Use of safety net hospitals • Specific study ideas, eg, evaluation of shared health care decision making • Engagement between clinicians and patients • Adoption of technologies • Social determinants of health Clinical Care and Quality Factors (n = 70 Initial Suggestions) • Guideline creation, dissemination, and compliance, eg, best practices for screening guidelines • Effect of new and existing incentives strategies • Explanatory power of specific structural metrics, eg, effect sizes and measurement issues • Quality metric development, measurement, and implementation • Prioritization of outcomes for patients, eg, shared health care decision making • Role of technology and electronic health records in patient tracking and loss to follow-up • Tools and methods for understanding disparities, eg, patient registries, qualitative inquiry • Patient navigation and advocacy Postoperative Care and Rehabilitation Factors (n = 55 Initial Suggestions) • Study of longitudinal outcomes, eg, quality of life, functional status, and employment outcomes • Evaluation of disparities in palliative and end-of-life care • Increasing access and use of rehabilitation for underinsured populations • Postoperative care for patients in rural settings • Wraparound services and continuity of care • Role of social support (eg, in rehabilitation) and adherence • Exploring multidisciplinary approaches to disparities in functional outcomes and quality of life • Establishing best practices for rehabilitation quality and nursing facility care • Effect of patient culture and language barriers on postoperative outcomes • Culturally competent shared decision making and incorporation of functional outcomes discussion for all patients Box Section Ref ID Box 2. Five Overarching Priorities Identified for Surgical Disparities Research at the 2015 National Institutes of Health–American College of Surgeons Summit Research Should Be Directed Toward: 1. Improving patient-Clinician communication by helping clinicians deliver culturally dexterous, competent care and measuring its effect on the elimination of disparities. 2. Fostering engagement and community outreach by using technology to optimize patient education, health literacy, and shared decision making in a culturally relevant way; disseminating these technologies; and evaluating their effect on reducing surgical disparities. 3. Improving care at facilities with a higher proportion of minority surgical and trauma patients. This includes evaluation of regionalization of care vs strengthening of safety-net hospitals within the context of differential access and surgical disparities. 4. Evaluating the longer-term effect of acute interventions and rehabilitation support within the critical period of injury or illness on functional outcomes and patient-defined perceptions of quality of care. 5. Improving patient centeredness by identifying expectations for postoperative and postinjury recovery. This includes adhering to patient values regarding advanced health care planning and palliative care needs. Clinician Factors Day 1 thematic rankings yielded 105 questions related to clinician factors that contribute to surgical disparities (Box 1). Twelve themes emerged after data collation including cultural competence/dexterity, patient advocacy and navigation services, clinician communication, implicit bias/mindfulness, surgical quality metrics, and racial and sex discordance. The most commonly identified topic was the effect of cultural competence and/or dexterity on surgical disparities (37.1%; n = 39), followed by the effect of biases on care (28.6%; n = 30). The top 5 thematic topics for clinician-level factors identified on day 2 were: (1) defining and evaluating standards of cultural dexterity; (2) patient-clinician communication and evaluation of clinician training; (3) implicit bias and mindfulness training and evaluation; (4) improvement and exploration of new and existing surgical quality metrics; and (5) the role and effect of patient-clinician concordance (Box 1). Recommendations for future studies call for focus on the definition and measurement of cultural dexterity training and evaluation and investigating the effect of ancillary staff on improving cultural competence. Training should provide surgeons with the tools to deliver culturally relevant, patient-centered care and adapt to patients of all different cultural backgrounds. In addition, surgical workforce diversification was discussed in breakout sessions as a method to increase cultural dexterity. Patient Factors Day 1 thematic rankings yielded 120 research questions related to patient factors (Box 1). Fifteen patient factor themes were identified including social support, socioeconomic status, incidental cost of health care to patient, patient-clinician communication, effect of interventions on outcomes, patient behaviors, technology/social media, and insurance. The most commonly identified topics were the role of patient education and health literacy in patient-clinician communication (13.3%; n = 16); geographic and other barriers to accessing care (11.7%; n = 14); and patient perceptions, decision making, and engagement in personal health/behaviors (10.8%; n = 13). Quiz Ref IDThe top-priority topics identified on day 2 were: (1) the role of patient education and health literacy in patient-clinician communication; (2) patient perceptions, decision making, and engagement in personal health/behaviors; and (3) optimizing preoperative comorbidities and partnering with primary care physicians (Table). Additional recommendations were for tools to evaluate clinician communication and patient level of understanding. Interventions should focus on allowing patients the autonomy to make informed decisions about their surgical health care based on accurate, timely, and culturally dexterous communication. Finally, technologies, including social media and handheld devices, must be leveraged to educate patients and support patient decisions in a culturally competent manner. Systemic and Access Factors Day 1 thematic rankings yielded 90 research questions related to systemic and access factors (Box 1). Thirteen systemic and access factor themes were identified including tailored management protocols and guidelines, based on factors such as hospital volume and the effect of the social determinants of health on surgical disparities in systemic and access issues. The most commonly identified topics were the effects of payment strategies on access issues (eg relative value units, 13.3%; n = 12) and the use of data and information management and technology in health care systems (11.1%; n = 10). The top-priority topics identified on day 2 were: (1) assessing the effects of payment in the context of policy reform, (2) care coordination and integration and tailored guidelines for vulnerable populations, (3) regionalization of care vs strengthening safety net hospitals, (4) role of health care as a mitigating factor of social determinants of health; and (5) the evolution of health technology and electronic health records’ effect on research and surgical outcomes (Table). Additional recommendations were to develop strategies that improve access to care for populations that experience surgical disparities. Beyond the effect of socioeconomic disadvantage, future research should assess the effect of the Affordable Care Act in access to care for these populations.90 Clinical Care and Quality Factors Day 1 thematic rankings yielded 70 questions regarding clinical care and quality (Box 1). Eight primary research themes were identified from the questions. The most commonly identified topic was best practices for developing and implementing evidence-based guidelines (22.9%; n = 16), followed by the effect of incentive strategies and payment (17.1%; n = 12). The top 5 thematic topics identified on day 2 were: (1) leveraging electronic health records to improve adoption of evidence-based care; (2) approaches for standardizing and integrating existing data repositories to mitigate disparities; (3) evaluating methods for incorporating patient preferences for treatment and expectations for outcomes in surgical decision making; (4) evaluating the effect of incentive strategies on disparities; and (5) developing and implementing standard data definitions for known and suspected risk factors for disparities (Table). Recommendations were to prioritize the establishment of effective and efficient quality improvement strategies. Future research should assess the effect of electronic health records adoption on disparities in surgical care. Research into surgical disparities often requires linking disparate data sets containing information on clinical outcomes, hospital structure, processes of care, and patient demographic information. These linkages are currently challenging because of nonstandard definitions of data elements. As the distinction between equal and equitable care becomes increasingly clear, patient preferences and cultural factors must be taken into account in surgical decision making. Finally, need for novel incentive strategies in the context of pay-for-performance, bundled payments, accountable care organizations, and public reporting was identified. Postoperative Care and Rehabilitation Factors Day 1 thematic rankings yielded 55 questions related to postoperative care and rehabilitation factors (Box 1). Ten themes emerged, including the study of longitudinal outcomes, evaluation of disparities in palliative and end-of-life care, the role of social support, and the effect of patient culture on postoperative outcomes. Quiz Ref IDThe most commonly identified topic was developing longitudinal methods for assessing outcomes, such as quality of life and functional status (25.5%; n = 14), followed by improving access to outpatient, end-of-life care, palliative care, and advanced care planning (16.4%; n = 9). The top research areas were: (1) leveraging existing databases to prospectively collect data on long-term functional, quality-of-life, and employment outcomes and develop methods for this purpose; (2) evaluating communication approaches regarding end-of-life care, palliative care, and postoperative or postinjury expectations for recovery; (3) exploring barriers to prioritizing patients’ values and measuring the effectiveness of these strategies; (4) exploring the value of postinjury and postoperative recovery and rehabilitation services in terms of cost, quality, and patient-oriented outcomes; and (5) improving access to physical therapy, occupational therapy, and speech therapy with sustainable payment models (eg, teletherapy) to improve rehabilitative outcomes during the critical postacute period (Table). Top Overall Research Questions The final deliverable for the 2015 NIH-ACS Summit on Surgical Disparities Research was the identification of 5 research questions to guide the surgical disparities research agenda (Box 2). Quiz Ref IDOverarching priorities, regardless of theme, called for the following: improving patient-clinician communication, fostering engagement and community outreach by using technology, improving care at facilities with a higher proportion of minority patients, evaluating the longer-term effect of acute intervention and rehabilitation support, and improving patient centeredness by identifying expectations for recovery. Discussion The overarching purpose of the 2015 NIH-ACS Summit on Surgical Disparities Research was to create a national research agenda for use by clinicians, researchers, funding organizations, policymakers, and other key stakeholders. The event established a national research agenda intended to inform not only the future of the partnership between the NIH and the ACS but also to provide research agendas and funding priorities for years to come. The 2-day summit identified nearly 30 research priorities across 5 surgical disparities–related themes (clinician, patient, systemic and access, clinical care and quality, amd postoperative care and rehabilitation factors), which were distilled into 5 overarching priority research questions. Surgical disparities represent a complex problem that the collective community of policymakers, clinicians, researchers, funding bodies, and other stakeholders must address. Evidence of this overlap can be seen in the commonality of recommendations for continued evaluation of patient-clinician communication as well as clinician training and patient education related to both patient and clinician factors. Identified research priorities also included overlap between systemic/access and clinical care/quality-related factors. Moreover, many of the known factors associated with surgical disparities were common among the themes, namely race/ethnicity,25-30 SES,49,50 culture,85,86 and geography.66-70 However, more research is needed to intervene and mitigate these factors. Much of the extant literature identifies sociodemographic factors that precipitate surgical disparities. More research is needed to evaluate these issues long term to design interventions to mitigate disparities. Specifically, research is needed to investigate sustainable models of delivering physical, occupational, and speech therapy to patients and identify effects on recovery. Although 30-day morbidity and mortality have been historically important outcome metrics, they fail to capture the information that is most important to patients because outcomes beyond 30-day morbitidy and mortality are likely the most pronounced. The effect of cultural barriers, time constraints, and staff limitations and disparities as contributing factors in poor-quality communication about postsurgical expectations for recovery is also formidable. Similarly, given that women make up more than half of the US population, more research is needed to identify sex-specific risk factors and subsequent interventions that may mitigate surgical disparities.49,50 Finally, future research and funding entities should prioritize innovation for improving patient-clinician communication via culturally dexterous approaches. Quiz Ref IDThe findings entailed in this report are not without limitations. The results represent the views of clinicians and scientists at a single research meeting (N = 60). Representatives from affiliated fields, including health policymakers, educators, higher education and administrative officials, and philanthropic grant-funding organizations must be included in the ongoing dialogue and take steps to address surgical disparities. Additionally, representation of experts in a wider array of surgical disparities would have been beneficial. For example, researchers and clinicians from Indian Health Services, social scientists, women’s health groups, and integrated care and critical care access hospitals would have led to more diversity in perspectives. Also, because the NIH (National Rural Health Association) holds an annual quality and clinical conference on rural health, we opted to reach more researchers at academic medical centers to gain their insights on research agenda setting. Prioritization of topics was based on a priori identification of themes. Given the interrelated nature of multiple causative agents in health care disparities, other forms of categorization could also apply. Other methods of data collation could also have been used such as a larger online survey of scientists and clinicians or inclusion of nonphysicians/surgeons/research professionals. All health care clinicians related to the surgical field, including nurses, medical assistants, physician assistants, nursing aids, and registrars, offer a unique perspective on research in surgical disparities. Ongoing efforts are warranted to further engage these voices. Moreover, long-term care outcomes research is urgently needed to understand the needs of patients, their families, and their caregivers beyond events happening in the perioperative setting. Conclusions As a first step in setting the research agenda of the NIH-ACS partnership, the inaugural 2015 NIH-ACS Summit on Surgical Disparities was tasked with developing a pivotal research agenda to guide the future of surgical disparities research. This goal was accomplished thanks to interdisciplinary collaboration between surgeon-scientists, health disparities researchers, federal funding organizations, and policymakers. The findings of this summit will be used to inform funding priorities for key partners owing to a critical interinstitutional alliance among the NIH, the ACS, the Patient-Centered Outcomes Research Institute, and the Agency for Healthcare Research and Quality. The collaboration inspired by these institutions represents a call for the development of further innovative partnerships to address surgical disparities. We challenge researchers and funding entities to take these priorities to heart and begin moving research in the field of surgical disparities “from knowing to doing.” Within the context of the larger literature, summit results also call for ongoing evaluation of evidence-based practice, rigorous research methodols, incentives for standardization of care, and building on existing infrastructure to support these advances. With ongoing support and collaboration from the NIH, ACS, and affiliates, best practices for implementation of identified research priorities can be achieved and be used to create more optimal access to equitable quality care for all patients. Back to top Article Information Corresponding Author: Adil H. Haider, MD, MPH, Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, 1620 Tremont St, Ste 4-020, Boston, MA 02120 (ahhaider@partners.org). Accepted for Publication: December 1, 2015. Published Online: March 16, 2016. doi:10.1001/jamasurg.2016.0014. Conflict of Interest Disclosures: None reported. Funding/Support: The American College of Surgeons provided financial support for travel expenses and conference organization materials for our invited guests. Summit attendees were not provided honoraria for their attendance and participation. Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: We thank the conference planning committee, keynote speakers, participants, stakeholder panelists, federal observers, and research support staff listed in the eAppendix of the Supplement for their invaluable contributions during the conference that led to the preparation of this manuscript. 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Journal

JAMA SurgeryAmerican Medical Association

Published: Jun 1, 2016

Keywords: communication,consensus development conferences, nih,health priorities,health services research,minority groups,patient education,health literacy,health care disparities,safety-net providers,american college of surgeons,surgical procedures, operative,united states agency for healthcare research and quality,postoperative care,rehabilitation

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