Race Influences Risk of Emergency Diverticulitis Surgery

A study published in Archives of Surgery [2011;146(11):1272-1276] has reported that black patients were more likely to undergo emergency surgery for diverticulitis and had a higher in-hospital mortality risk compared with white counterparts. Lack of health insurance is predictive of disease severity, suboptimal surgical treatment, and mortality in patients undergoing surgery for diverticulitis, the authors noted. To better identify any disparities in procedure type (elective surgery vs emergency surgery) and mortality among patients with medical coverage, they conducted a retrospective analysis of Medicare Provider Analysis and Review inpatient data. The analysis included all black and white patients ≥65 years of age undergoing treatment for primary diverticulitis. The analysis included 52,220 patients, of which 49,937 (95.6%) were white and 2283 (4.4%) were black. Black patients tended to be younger, were more likely to be female, and had a greater Charlson Comorbidity Index than white patients. Despite Medicare coverage in all patients included in the analysis, black patients had higher rates of emergency admission for diverticulitis surgery (67.8% vs 54.7% of white patients) and a higher rate of in-hospital mortality (6.8% vs 5.0%). Black patients had a greater mean length of hospital stay (15.2 vs 11.4 days) and greater mean total hospital charges ($93,494 vs $65,973); P<.001 for all comparisons. After adjusting for age, sex, and Charlson Comorbidity Index, the investigators found that black race was associated with a 26% increased risk of the need for emergency diverticulitis surgery and a 28% increased risk of in-hospital mortality (relative risk [RR], 1.28; 95% confidence interval [CI], 1,10-1.15). When stratifying data by admission type, the risk of in-hospital mortality was similar among black and white patients treated electively. The authors noted that in blacks and whites treated on an emergency basis, black race was significantly associated with a 28% increase in-hospital mortality risk compared with white patients (RR, 1.28; 95% CI, 1.09-1.51). The authors reported that black patients were less likely to receive intestinal diversion surgery with a colostomy (ostomy) or ileostomy procedure. Black patients undergoing emergency surgery were at a lower risk of ostomy, while those undergoing elective surgery had a greater risk of ostomy. Black patients were more likely to be readmitted for inpatient care within 30 days of discharge. In comparing elective and emergent surgeries, black patients had a higher risk of readmission, while there was no difference in readmission risk between black and white patients in those treated with an elective procedure. The authors suggested that the higher risk of readmission among black patients could be a function of poorer general medical supervision than that received by white counterparts, noting that a lower use of medical services has been observed in the black population, including patients covered by Medicare. Citing a lack of difference in adverse outcomes between black and white patients treated with elective surgery, the authors added that a “systemic underuse of medical resources” could drive the higher rates of comorbidity and increased risk of emergency diverticulitis surgery among black patients. They suggested that lower socioeconomic status and persistent racial bias could also influence treatment and outcomes, stressing that support for these conclusions was outside the scope of their analysis. The investigators also cautioned that their analysis was inherently limited by data collected for billing or administrative purposes. In addition, black patients are underrepresented in the Medicare population compared with white patients, which could have limited the strength of their findings, according to the authors.