Abstract
Objective
To evaluate national trends in racial disparities for patients undergoing head and neck reconstructive surgery.
Methods
Retrospective analysis using the 2008 to 2021 American College of Surgeons National Surgical Quality Improvement Program database. Patients receiving microvascular free tissue transfer were eligible for inclusion. Pediatric patients and those treated by non‐otolaryngologists were excluded. Outcomes were analyzed with univariate and multivariable models.
Results
A total of 5831 head and neck free flap cases were analyzed, 4869 (83.5%) were White, 560 (9.6%) were Black or African American, and 402 (6.9%) were Asian, Native American, or other groups (ANAOG). The proportion of Black or African American patients and ANAOG patients undergoing free tissue transfer increased significantly over the time period (p = 0.047 and p = 0.010, respectively). However, there was a downtrend that started around 2017. In a multivariable model, Black or African American race was not associated with readmission (OR = 0.99 [95% CI 0.74, 1.31], p > 0.05), returning to the operating room (OR = 1.20 [95% CI 0.96, 1.49], p > 0.05), or any post‐operative complication (OR = 0.83 [95% CI 0.68, 1.01], p > 0.05). There were also no significant associations found in the ANAOG population on multivariate analysis (p > 0.05 for all).
Conclusion
The percentage of free tissue transfer performed in patients from minority backgrounds with head and neck cancer has been increasing in the United States. Outcomes after head and neck microvascular reconstruction are similar when stratified by race. However, racial disparities remain and further work is necessary to reduce these disparities.
Level of Evidence
4 Laryngoscope, 135:635–640, 2025
Keywords: free flap, head and neck surgery, otolaryngology, racial disparities, reconstruction
The percentage of free tissue transfer performed in patients from minority backgrounds with head and neck cancer has been increasing in the United States. Outcomes after head and neck microvascular reconstruction are similar when stratified by race. The findings of our study are encouraging and indicate that progress has been made, but further work is required to reduce racial disparities.
INTRODUCTION
In reconstructive surgery of the head and neck, microvascular free tissue transfer is considered the gold standard for repair following oncologic ablation. Microvascular reconstruction is used to repair a range of defects, from total laryngectomies to chronic wound issues. With the overall success rate as high as 97%, free tissue transfer has become a standard of care and is known to improve both aesthetic and function outcomes. 1 , 2 However, there are well‐documented socioeconomic barriers that prevent patients from accessing a high quality of care, particularly patients from minority backgrounds. 3 , 4
Racial disparities in head and neck cancer have been well documented. 5 Studies have shown that African American or Black patients more often present with higher stage tumors and are less likely to receive preventative screening for head and neck cancer. 6 African American or Black patients are also more likely to receive care in a low‐volume hospitals and have worse overall survival compared with White patients. 7 , 8 These racial disparities persist even after adjusting for tumor, sociodemographic, and other clinically relevant factors.
To the best of our knowledge, no previous study has directly addressed racial disparities in head and neck free tissue transfer. Considering the racial disparities that have been extensively documented in head and neck cancer, it is important to understand racial disparities in head and neck free tissue transfer and the implications for the quality of cancer care. In this study, we sought to examine trends in racial disparities for patients undergoing head and neck reconstructive surgery using a nationwide sample over more than a decade. We hope that the findings of this study will clarify the extent of racial disparities that exist in head and neck free tissue transfer and provide a foundation for reducing disparities and improving outcomes after reconstructive surgery.
MATERIALS AND METHODS
Data Source and Exclusion Criteria
This study was determined to be exempt from review by the Cleveland Clinic Institutional Review Board due to the de‐identified nature of the database. The National Surgical Quality Improvement Program (NSQIP) database was queried from 2008 to 2021 to select head and neck free tissue transfer patients. Previous literature defined free tissue transfer with Current Procedural Terminology (CPT) codes: 15756, 15757, 15758, 43496, 49006, 49906, 20969, 20955, 20956, 20957, 20962, 20970, 20972, 20973, 43116, and 15842. 9 Patients not treated by an otolaryngologist, patients with unknown race, patients with missing data, and pediatric patients were excluded.
Variable Definitions and Statistical Analysis
The ACS‐NSQIP Data Dictionary contains over 150 variables and defines all pre‐operative and post‐operative variables. 10 The variables are maintained by continual audits by certified surgical clinical reviewers. Thirty‐day post‐operative variables, such as return to the operating room, readmission, and complication rates, were the primary outcomes. Body mass index (BMI) was calculated using height and weight variables, and groups were classified using Center for Disease Control definitions. 11 The readmission variable was only available for cases documented starting in 2011. The chi‐square test or Fisher's exact test was used to analyze the post‐operative complication rates between cohorts as well as to compare pre‐operative categorical variables between the two cohorts. Length of operation and length of hospital stay were analyzed using a Z‐test. Multivariable logistic regression models were used to examine the variables associated with the outcomes of interest. Statistical analysis was conducted in Microsoft Excel, and R version 4.2.1. p < 0.05 was considered significant.
RESULTS
Pre‐Operative Analysis in Free Tissue Transfer Patients Stratified by Race
After exclusion criteria, there were 5831 head and neck free flap cases analyzed in the multi‐institutional cohort from 2008 to 2021. 4869 (83.5%) patients identified as White, 560 (9.6%) patients identified as Black or African American, and 402 (6.9%) patients identified as Asian, Native American, or other groups (ANAOG). Table I describes all pre‐operative patient demographics and comorbidities. Age, BMI, sex, and American Society of Anesthesiologists (ASA) classification were all significantly different between the comparison groups (p < 0.05 for all). Black or African American patients were more commonly aged 35–54 (26.1% vs. 19.5%), ASA Class 4 (11.4% vs. 8.0%), and smokers (40.7% vs. 29.2%) compared with White patients. ANAOG patients were more commonly aged 35–54 (32.8% vs. 19.5%), overweight BMI (31.1% vs. 29.3%), and diabetic (20.1% vs. 13.6%) compared with White patients.
TABLE I.
Patient Characteristics.
| All patients | White | Black or AA | ANAOG | p‐value | |
|---|---|---|---|---|---|
| n = 5831 | n = 4869 | n = 560 | n = 402 | ||
| Age | <0.001 | ||||
| 18–34 | 220 (3.8%) | 153 (3.1%) | 39 (7.0%) | 28 (7.0%) | |
| 35–54 | 1228 (21.1%) | 950 (19.5%) | 146 (26.1%) | 132 (32.8%) | |
| 55–74 | 3422 (58.7%) | 2915 (59.9%) | 325 (58.0%) | 182 (45.3%) | |
| 75–90+ | 961 (16.5%) | 851 (17.5%) | 50 (8.9%) | 60 (14.9%) | |
| BMI | 0.006 | ||||
| Normal (18.51–24.99) | 2391 (41.0%) | 1973 (40.5%) | 236 (42.1%) | 182 (45.3%) | |
| Obese (≥30) | 1305 (22.4%) | 1112 (22.8%) | 121 (21.6%) | 72 (17.9%) | |
| Overweight (25–29.99) | 1669 (29.1%) | 1427 (29.3%) | 144 (25.7%) | 125 (31.1%) | |
| Underweight (≤18.5) | 439 (7.5%) | 357 (7.3%) | 59 (10.5%) | 23 (5.7%) | |
| Sex | 0.026 | ||||
| Female | 1900 (32.6%) | 1553 (31.9%) | 195 (34.8%) | 152 (37.8%) | |
| Male | 3931 (67.4%) | 3316 (68.1%) | 365 (65.2%) | 250 (62.2%) | |
| ASA classification | <0.001 | ||||
| 1‐No disturb | 90 (1.5%) | 75 (1.5%) | 10 (1.8%) | 5 (1.2%) | |
| 2‐Mild disturb | 1040 (17.8%) | 831 (17.1%) | 91 (16.2%) | 118 (29.4%) | |
| 3‐Severe disturb | 4230 (72.5%) | 3573 (73.4%) | 395 (70.5%) | 262 (65.2%) | |
| 4‐Life threat | 471 (8.1%) | 390 (8.0%) | 64 (11.4%) | 17 (4.2%) | |
| Inpatient | 0.381 | ||||
| Inpatient | 5746 (98.5%) | 4800 (98.6%) | 553 (98.8%) | 393 (97.8%) | |
| Outpatient | 85 (1.5%) | 69 (1.4%) | 7 (1.2%) | 9 (2.2%) | |
| Comorbidities | |||||
| Diabetes | 824 (14.1%) | 661 (13.6%) | 82 (14.6%) | 81 (20.1%) | 0.001 |
| Smoker | 1716 (29.4%) | 1422 (29.2%) | 228 (40.7%) | 66 (16.4%) | <0.001 |
| Bleeding disorder | 163 (2.8%) | 143 (2.9%) | 12 (2.1%) | 8 (2.0%) | 0.334 |
| On dialysis | 24 (0.4%) | 19 (0.4%) | 3 (0.5%) | 2 (0.5%) | 0.845 |
| Congestive heart failure | 59 (1.0%) | 44 (0.9%) | 13 (2.3%) | 2 (0.5%) | 0.004 |
| COPD | 427 (7.3%) | 363 (7.5%) | 52 (9.3%) | 12 (3.0%) | 0.001 |
| Chronic steroids | 253 (4.3%) | 217 (4.5%) | 24 (4.3%) | 12 (3.0%) | 0.379 |
| Dyspnea | 420 (7.2%) | 353 (7.2%) | 56 (10.0%) | 11 (2.7%) | <0.001 |
| Hypertension | 2839 (48.6%) | 2365 (48.6%) | 310 (55.4%) | 164 (40.8%) | <0.001 |
| Disseminated cancer | 364 (6.2%) | 321 (6.6%) | 35 (6.2%) | 8 (2.0%) | 0.001 |
| >10% Weight loss | 481 (8.3%) | 403 (8.3%) | 59 (10.5%) | 19 (4.7%) | 0.005 |
AA = African American; ANAOG = Asian, Native American, and Other Groups; BMI = body mass index; ASA = American Society of Anesthesiologists; COPD = chronic obstructive pulmonary disease.
Temporal Trends in Free Tissue Transfer
Figure 1 illustrates the change in proportion of patients undergoing free tissue transfer stratified by race from 2008 to 2021. The proportion of free tissue transfer patients who identified as Black or African American was 5.6% in 2008 and increased to a peak of 12.0% in 2016 (p = 0.0052, for 2008 to 2016). In 2019, there was a decrease in the proportion to 10.7% followed by a further drop to 7.7% in 2021 (p = 0.047, whole time period). The absolute number of free flaps performed for head and neck patients increased significantly over the study period (p < 0.001). The proportion of free tissue transfer patients who identified as ANAOG started at 4.2% and rose to 7.1% by 2021, which was a significant positive trend (p = 0.010).
Fig. 1.
Temporal trends in the proportion of patients undergoing free tissue transfer broken down by race. Triangle = ANAOG population (solid trend line). Diamond = Black or African American population (dashed trend line).
Post‐Operative Complications in Free Flap Stratified by Race
The length of stay was 9.86 ± 6.28 (mean days ± standard deviation) for White patients, 11.12 ± 6.47 for Black or African American patients, and 9.93 ± 8.07 for ANAOG patients (p < 0.001). Total operation time also differed significantly between comparison groups (p < 0.001). All analyzed post‐operative outcomes are displayed in Table II. The rate of any surgical complication was 17.5%, 16.4%, and 17.2% for White, Black or African American, and ANAOG patients, respectively (p > 0.05). Only superficial surgical site infections showed a significant difference at 7.7% for White patients, 4.5% for Black or African American patients, and 8.7% for ANAOG patients (p = 0.014). No significant difference was found in the rate of medical complications, and no significant difference was found overall for any complication (p > 0.05 for all).
TABLE II.
Post‐Operative Outcomes After Head and Neck Free Tissue Transfer Stratified by Race.
| White n = 4869 | Black or AA n = 560 | ANAOG n = 402 | p‐value | |
|---|---|---|---|---|
| Days from operation to discharge (Mean ± SD) | 9.86 ± 6.28 | 11.12 ± 6.47 | 9.93 ± 8.07 | <0.001 |
| Total operation time (Mean ± SD) | 551.23 ± 214.72 | 596.03 ± 208.59 | 505.48 ± 183.15 | <0.001 |
| 30‐day return to OR | 910 (18.7%) | 125 (22.3%) | 73 (18.2%) | 0.105 |
| Any readmission a | 514 (10.6%) | 61 (10.9%) | 39 (9.7%) | 0.829 |
| Death within 30 days | 65 (1.3%) | 6 (1.1%) | 5 (1.2%) | 0.868 |
| Any complication | 1421 (29.2%) | 149 (26.6%) | 123 (30.6%) | 0.345 |
| Surgical complications | 853 (17.5%) | 92 (16.4%) | 69 (17.2%) | 0.806 |
| Superficial SSI | 373 (7.7%) | 25 (4.5%) | 35 (8.7%) | 0.014 |
| Deep incisional SSI | 317 (6.5%) | 25 (4.5%) | 20 (5.0%) | 0.094 |
| Organ space SSI | 147 (3.0%) | 17 (3.0%) | 8 (2.0%) | 0.499 |
| Wound dehiscence/disruption | 274 (5.6%) | 42 (7.5%) | 21 (5.2%) | 0.176 |
| Medical complication | 625 (12.8%) | 75 (13.4%) | 55 (13.7%) | 0.842 |
| Pneumonia | 286 (5.9%) | 33 (5.9%) | 32 (8.0%) | 0.238 |
| Unplanned intubations | 121 (2.5%) | 16 (2.9%) | 7 (1.7%) | 0.538 |
| Urinary tract infection | 47 (1.0%) | 6 (1.1%) | 4 (1.0%) | 0.971 |
| DVT/thrombophlebitis | 71 (1.5%) | 13 (2.3%) | 5 (1.2%) | 0.257 |
| Pulmonary embolism | 35 (0.7%) | 6 (1.1%) | 1 (0.3%) | 0.330 |
| On ventilator >48 h | 251 (5.2%) | 21 (3.8%) | 18 (4.5%) | 0.313 |
| CVA/stroke with neurological deficit | 8 (0.2%) | 1 (0.2%) | 0 (0.0%) | 0.714 |
| Cardiac arrest requiring CPR | 44 (0.9%) | 9 (1.6%) | 2 (0.5%) | 0.167 |
| Myocardial infarction | 52 (1.1%) | 4 (0.7%) | 3 (0.7%) | 0.628 |
| Sepsis | 160 (3.3%) | 17 (3.0%) | 11 (2.7%) | 0.806 |
| Progressive renal failure | 9 (0.2%) | 1 (0.2%) | 1 (0.2%) | 0.959 |
Reporting began in 2011. AA = African American; ANAOG = Asian, Native American, and Other Groups; CVA = cerebrovascular accident; CPR = cardiopulmonary resuscitation; DVT = deep vein thrombosis; OR = operating room; SD = standard deviation; SSI = surgical site infection.
In multivariable analysis, Black or African American race was not associated with readmission (OR = 0.99 [95% CI 0.74, 1.31], p > 0.05), returning to the operating room (OR = 1.20 [95% CI 0.96, 1.49], p > 0.05), or any post‐operative complication (OR = 0.83 [95% CI 0.68, 1.01], p > 0.05) relative to White patients (Table III). Similarly, ANAOG race was not associated with readmission (OR = 0.92 [95% CI 0.64, 1.29], p > 0.05), returning to the operating room (OR = 1.09 [95% CI 0.82, 1.42], p > 0.05), or any post‐operative complication (OR = 1.23 [95% CI 0.07, 1.53], p > 0.05) relative to White patients. No association with race was found in multivariate models for surgical complications or medical complications (p > 0.05 for all).
TABLE III.
Summary of Adjusted Odds Ratios in Head and Neck Free Flap Patients Stratified by Race.
| Odds ratio (95% L, 95% U) | p‐value | |
|---|---|---|
| Any complication | ||
| White | Ref. | |
| Black or AA | 0.83 (0.68, 1.02) | 0.077 |
| ANAOG | 1.23 (0.97, 1.53) | 0.078 |
| Any readmission | Ref. | |
| White | 0.99 (0.74, 1.31) | |
| Black or AA | 0.92 (0.64, 1.29) | 0.999 |
| ANAOG | 0.600 | |
| Unplanned return to OR | Ref. | |
| White | 1.20 (0.96, 1.49) | |
| Black or AA | 1.09 (0.82, 1.42) | 0.110 |
| ANAOG | 0.600 | |
| Surgical complications | Ref. | |
| White | 0.83 (0.65, 1.06) | |
| Black or AA | 1.04 (0.78, 1.37) | 0.140 |
| ANAOG | 0.800 | |
| Medical complications | Ref. | |
| White | 1.02 (0.78, 1.33) | |
| Black or AA | 1.30 (0.94, 1.75) | 0.900 |
| ANAOG | 0.100 | |
AA = African American; ANAOG = Asian, Native American, and Other Groups; OR = operating room; Ref. = reference.
DISCUSSION
Research on racial disparities in health care is an important topic because the results provide evidence to identify disparities and to create programs that mitigate disparities. Free tissue transfer is standard of care for head and neck reconstruction and represents an important metric to judge access to health care. Having access to care through insurance does not guarantee that patients will receive high‐quality care or any care. It is well established that there are social and economic obstacles that make receiving free tissue transfer more difficult for patients from minority background. 3 , 4 According to the National Healthcare Quality Report, patients require entry to the health care system, access to sites of care, and providers with the necessary knowledge to receive health care. 12 Free tissue transfer meets all these criteria because patients need insurance (or the ability to apply for insurance), the ability to travel to specific hospitals, and surgeons with specialized skills. In this way, racial disparities in microvascular reconstruction are an informative metric for measuring both access to care and receipt of high‐quality care in a population. Previous literature has examined racial disparities in head and neck cancer, but racial disparities in head and neck free tissue transfer remain relatively unknown. 5 To the best of our knowledge, our study is the first to directly examine racial disparities in head and neck free tissue transfer.
Trends in Head and Neck Reconstructive Surgery in Black and African American Patients
Using a large national cohort, our study found that the proportion of free tissue transfer performed in Black or African American patients with head and neck cancer has been steadily increasing in the United States, although there has been some decline in recent years. The percent of Black or African American patients was only 5.6% in 2008 and more than doubled to a peak of 12.0% in 2016 before down trending to 7.7% in 2021. This trend was true despite the absolute number of free flaps increasing over the study period. It should be noted that we do not have data looking at the total number of patients who were eligible for free tissue transfer, but we are able to proportionally compare cohorts to assess relative inequities. Microvascular free tissue transfer is considered the gold standard for head and neck reconstruction after cancer resection, and we would roughly expect the race demographics to match that of head and neck cancer. A head and neck cancer study using the National Cancer Database examined 364,834 patients and found that 34,170 (9.4%) patients identified as Black. 13 For advanced stage head and neck cancer, another national study found 11.6% of the cohort identified as Black. 14 These previous national studies compared favorably with our peak findings, which is a positive indication that progress in reducing racial disparities has been made and suggests more equitable access to high‐quality head and neck cancer care.
The reduction in racial disparities for head and neck reconstruction may be secondary to changes in health care policy. In 2010, the Patient Protection and Affordable Care Act was signed into law, which sought to increase access to health care. 15 The positive impacts of this law on cancer treatment and health care equity have been well characterized across multiple fields, including otolaryngology. 16 , 17 One study specifically demonstrated reduced disparities in access to breast reconstructive surgery following Medicaid expansion through the Affordable Care Act. 18 Based on this, one explanation for the increasing rate of free tissue transfer in Black or African American patients with head and neck cancer is greater access to care leading to more patients with advanced stage disease presenting for treatment who did not previously have insurance coverage. In the most recent data, we did find a down trend that started in 2017 and further progressed around 2019/2020. Review of the literature shows that insurance coverage differences between White and minority patients decreased between 2013 and 2017, but starting in 2017, the overall uninsured rate for minority patients increased from 7.9% to 8.5% in 2018. 19 This reversal of progress was thought to be secondary to changes in policy that were passed with the aim of stunting the Affordable Care Act. The timing of the down trend also correlated with the rise of COVID‐19. It is well established in the literature that African American and Black patients were significantly more effected by the coronavirus. 20 During the period of COVID‐19, there was widening of racial disparities in health care, a finding that is mirrored in our study and may explain the loss of progress we observed in more recent years. Overall, our findings are encouraging and indicate progress toward racial parity in health care outcomes. However, our findings also show that racial disparities continue to persist and further work is required to reduce these racial disparities.
Outcomes after Head and Neck Reconstructive Surgery Stratified by Race
In an adjusted multivariate analysis, we found that race did not significantly impact the risk of readmission, complications, or returning to the operating room after head and neck reconstructive surgery. These findings are in stark contrast to the majority of previous literature that frequently demonstrates worse outcomes among minority patients with head and neck cancer care. 5 , 21 In particular, one national study of head and neck cancer showed a significantly higher risk of readmission for Black patients and a more than 100% increase in risk of readmission for Native Hawaiian and other Pacific Islander patients when compared to non‐Hispanic White patients. 13 However, there are other studies that suggest a lack of association between race and outcomes after head and neck microvascular surgery. The findings in our study are indirectly supported by two previous national studies on head and neck free flap patients, one looking at readmission and one looking at reoperation. 22 , 23 Although we can only speculate on why outcomes are similar between minority and non‐minority patients undergoing head and neck reconstructive surgery, it is possible that the quality of follow‐up care provided to surgical patients may positively influence outcomes. At our institution, reconstructive patients are typically seen weekly for 2 weeks providing a high degree of continuity of care. Additionally, most reconstructive surgeries are performed at high‐volume, academic centers, which are factors known to improve outcomes. 24 The external validity of our study is supported by analysis of a large, nationwide cohort that increases the generalizability of our findings. We demonstrated similar outcomes after head and neck microvascular reconstruction when stratified by race, which is encouraging and suggests that progress toward more equitable care has been made.
Trends in Head and Neck Reconstructive Surgery in Asian, Native American, and Other Groups
Previous studies have underscored the importance of disaggregating studies of racial disparities beyond White versus Non‐White. 13 , 21 As such, we broadened our analysis to include Asian, Native American, and Other Groups (ANAOG) but were unable to disaggregate further given limited sample size. Our analysis demonstrated a steady increase in the proportion of free tissue transfer performed in ANAOG patients with a peak in 2020. The divergence in trend compared with Black and African American patients adds to the growing body of literature emphasizing the importance of disaggregating racial minorities in research. 13 The decrease observed in the proportion of ANAOG patients undergoing free tissue transfer been 2020 and 2021 demonstrates that there is room for more progress to be made in reducing racial disparities. This provides contemporary evidence in the literature that further work is necessary to create programs to mitigate racial disparities in reconstructive surgery. Previous work has shown that current federal and state legislation has a limited effect on racial disparities and more initiatives are needed focusing on both upstream and downstream factors. 25 Upstream factors are commonly referred to as social determinants of health and are defined by systemic factors, such as socioeconomic barriers and cultural distrust of health care. 26 Downstream factors are at the individual level, including transportation to health care sites and payment assistance for services. The reconstructive community needs to work in a concerted fashion to develop programs that target both upstream and downstream factors to improve access to high‐quality health care and to reduce racial disparities in head and neck free tissue transfer.
Limitations
Our study is limited by the retrospective nature of the design, which prevents us from demonstrating causation and does not allow for elimination of pre‐existing selection bias. The variables available in the NSQIP database are limited to 30‐day complications, and the database is not specific to head and neck surgery or cancer outcomes. Therefore, we are not able to adjust for differences in TNM staging or surgery‐specific complications (e.g., flap failure rate). As noted before, we do not know the number of minority patients with head and neck cancer who are eligible for free tissue transfer and cannot determine the number of free flaps required compared with the number performed. Despite these limitations, we believe our study benefits from the multi‐institutional nature of NSQIP derived from over 700 hospitals, which provided a large cohort to stratify our analysis and examine infrequent complications.
CONCLUSION
This study represents the first study to directly examine racial disparities in head and neck free tissue transfer. We found a steady increase in the percentage of free tissue transfer performed in patients from minority backgrounds with head and neck cancer, although there was a decrease in the most recent years, predominately in the African American or Black population. Additionally, we found that outcomes after head and neck microvascular reconstruction are similar when stratified by race. The findings of our study are encouraging and indicate that progress has been made, but further work is required to reduce racial disparities.
Editor's Note: This Manuscript was accepted for publication on August 06, 2024.
The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS‐NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
The authors have no funding, financial relationships, or conflicts of interest to disclose.
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