Shrinking gap in surgical safety outcomes benefits older black patients in South Carolina

Preparing for surgery can be a scary, momentous occasion in any person’s life, but a greater chance of danger because of skin color should not be part of the equation. The South Carolina Surgical Quality Collaborative (SQC) was created in 2015 to level the playing field for surgical patients, and a recent study conducted at the Medical University of South Carolina shows that the effort is paying off for both black and white patients, decreasing complications for all patients and shrinking the racial gap in outcomes.

It is well known that not all health care lands equally across populations, but understanding why this happens and how to mend it is far from straightforward. Many complicated factors influence inequities in health care across different racial and socioeconomic groups. These factors have been studied extensively and include access to quality health care, education, social connections, healthy food and housing. Disparities in everyday life can spill over into unequal outcomes after surgery as well, with some groups of patients showing a higher risk of complications and longer or more difficult recovery times.

Thomas Curran, M.D., MPH, a colorectal surgeon and assistant professor of surgery at MUSC, led the study to examine how the SQC’s quality improvement efforts affected patients over a 5-year period. Curran is passionate about providing equitable care to patients, and he wanted to know more about the impact of the collaborative’s programs.

“We know that disparities exist in health care, specifically as they relate to race in this case,” Curran said. “These inequities have been a persistent and challenging problem, but we're really excited to see that we can chip away at things at the systems level.”

He and his team hypothesized that quality improvement initiatives may not impact everyone in the same way, and since racial disparities within a regional SQC have not been explored before, they wondered if such initiatives might help some people more than others.

To find out, the team tapped into the wealth of data being collected by the South Carolina SQC, a consortium of hospitals that have banded together to share data and best practices so that surgical professionals across the state can learn from each other and improve care for all their patients.

The team gathered and analyzed data from more than 30,000 patients who underwent surgery in the period from 2015 to 2020. They looked at the rates of adverse events in all the patients together, and they also looked at groups divided according to race and age.

They discovered that black patients across both older (65 years and up) and younger (less than 65 years) age groups had higher rates of complication than white patients, and this was true even when the researchers accounted for other known factors, such as other medical problems, poverty or diminished access to care. The reason for the difference is not known, but the good news for the researchers was that the overall complication risk decreased for all patients over the first five years of quality improvement efforts.

And indeed, the reductions in risk were actually most pronounced for black patients, especially older black patients.

“Over the five-year period of the study, while outcomes for white patients were still better relative to black patients, the gap had narrowed,” said Curran. “The patients at most risk seem to stand to benefit the most from quality improvement initiatives, and that is very promising.”

One of the foremost initiatives of the SC SQC has been the use of enhanced recovery programs – known as ERP or ERAS (enhanced recovery after surgery). These are bundles of programs that include clinical interventions like checking hemoglobin levels before surgery, educational interventions to make sure patients understand their surgery, and defined recovery protocols that happen both during and after surgery.

Curran cannot attribute all of the study results to these programs, but he believes that they played a large role. And moving forward, the collaborative will be leaning heavily into a concept called prehabilitation, which prepares patients for surgery by doing work in advance to set them up for success. This can include things like education, physical therapy and diabetes control — the last of which is important because improved glucose control has been shown to lead to more successful operations.

By validating the effectiveness of the SQC’s improvement efforts, Curran and his team help to pave the way for further improvement in all patients. “We’ve now seen that there are patients in whom we can do some straightforward, simple things that can help them a lot,” he said. “And especially for high-risk groups like older patients, this is really encouraging.”

The collaborative is set to expand this year, with several institutions poised to join, and the new emphasis on prehabilitation holds promise for continuing the positive trend in closing the racial disparity gap.