CV Risk Factor Control Cuts Post-op Nursing Home Transfer for Black Americans

Black patients who undergo surgery are significantly more likely than white patients to need nursing home care when they are discharged from the hospital, according to new data. The higher prevalence of uncontrolled diabetes and hypertension among Black patients contributes to this difference, with guideline-recommended medical therapy mitigating the risk.

“Our results emphasize the value of guideline adherence treatment of diabetes and hypertension, and we believe that optimized preoperative assessments might help with surgical outcomes and also help eliminate or decrease the impact of healthcare disparities,” senior author Matthias Eikermann, MD, PhD (Montefiore Medical Center, Bronx, NY), told TCTMD. “We should start thinking about the resources that each hospital has now but also make the case for finding and requesting additional public support, because hospitals alone are probably not sufficiently equipped with the resources to address the important disparity that we have identified.”

Commenting on the study for TCTMD, Keith Ferdinand, MD (Tulane University School of Medicine, New Orleans, LA), said that though “race is not a true genetic or scientific category,” the differences between white and Black patients observed in this study are likely affected by social determinants of health, including environment, health access, health-seeking behavior, and the quality of clinical care.

“The fact that these patients had less ability to live independently postoperatively is a surrogate for factors measured and unmeasured, with race being only a representation of those other considerations,” he added.

Hypertension, Diabetes Explain Some Risk

For the study, published online last month in the Annals of Surgery, lead author Luca Wachtendorf (Montefiore Medical Center), Eikermann, and colleagues looked at data from 368,360 adults (mean age 53 years; 65.4% women; 10.3% self-identified as Black; 89.7% self-identified as white) undergoing surgery between January 2007 and February 2020 within two New England healthcare networks. Black patients were generally younger, more often female, and had lower estimated household incomes and more comorbidities. Additionally, Black patients were more likely to undergo ambulatory surgery as well as shorter and less complex procedures, and they were less likely to receive general anesthesia.

Hospitals alone are probably not sufficiently equipped with the resources to address the important disparity that we have identified. Matthias Eikermann

In total, 7.2% of patients lost the ability to live independently postsurgery and were discharged to skilled nursing facilities. Black patients were at a higher risk than white patients of needing nursing home care (7.6% vs 7.1%; adjusted OR 1.42; 95% CI 1.35-2.5). A higher prevalence of diabetes and hypertension in Black patients mediated 30.2% and 15.6% of this association, respectively, and 43.7% in combination.

Patients who received guideline-recommended medications for their diabetes or hypertension before surgery were less likely to be discharged to nursing facilities (P < 0.001 for interaction) or be readmitted within 30 days. There were no differences in 30-day mortality by race.

In a supplemental analysis, researchers showed that Black patients were less likely to be treated by a more-experienced surgeon (P < 0.001).

Focus on Social Determinants of Health

Eikermann said he was, overall, surprised by his findings, “because I always think that there should not be a difference in surgical outcomes between Black and white patients if you control for confounders. . . . Race is not a real biological category, so the results are to some extent surprising and really point to the differences in social determinants of health.”

We need to do more as a society to ensure that guideline-directed medical care is applied equally to all patients, regardless of race, ethnicity, socioeconomic status, sex/gender, geography, or age. Keith Ferdinand

As for the mitigating factors of diabetes and hypertension, Eikermann acknowledged that it has long been known that Black patients bear a greater burden of these comorbidities. “Our study puts the pieces together and shows here [that] there are clear mediators of the bad outcome after surgery, and whatever we can do for better prevention and treatment of hypertension and diabetes in Black patients will improve surgical outcomes,” he said.

Ferdinand said it was important that the researchers controlled for income in their findings, but that this “may not be able to completely define the extent by which other factors such as education, home environment, health-seeking behavior, and how clinicians have educated or not educated the patients on the importance of guideline-based cardiovascular risk control.”

And although the study was limited by relying upon retrospective data, he continued, “the size and clear indication that the lack of control of risk factors affected outcomes is remarkable.”

Surgeons evaluating Black patients for a procedure associated with a high risk of discharge to a nursing home might even consider performing additional preoperative assessment, Eikermann suggested. “Maybe that pushes our decision-making a little bit more towards sending some patients who are at high risk and undergo elective procedures back to the general practitioner for better workup of the hypertension or better control of diabetes,” he said.

Ferdinand, too, urged cardiologists and other clinicians involved in the care of high-risk patients before surgery to recognize that conventional risk factors, like glucose and blood pressure, are important for long-term outcomes. “It is not enough to simply do any specific surgical or vascular intervention,” he said. “We must look beyond the acute care and recognize the important aspect of controlling conventional risk factors and addressing the social determinants of health.”

A follow-up study in these high-risk groups might be worthwhile, Eikermann suggested. “I would like to . . . get them that preoperative additional treatment by the general practitioners or by their cardiologists or by their endocrinologist, depending on how we design the study, such that they get the optimal preoperative treatment.”

He is involved with an ongoing follow-up study that will include patients of Hispanic origin, as well.

Ferdinand said he would like to see future studies “prospectively look at other considerations beyond self-defined race with perhaps even more emphasis on what was described as contributing considerations such as lower household income, higher rates of comorbidities, and perhaps unmeasured lack of family support. . . . We need to do more as a society to ensure that guideline-directed medical care is applied equally to all patients, regardless of race, ethnicity, socioeconomic status, sex/gender, geography, or age.”