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. Author manuscript; available in PMC: 2020 Dec 26.
Published in final edited form as: Am J Surg. 2018 May 12;215(6):1046–1050. doi: 10.1016/j.amjsurg.2018.05.011

Racial Disparities Exist in Surgical Outcomes for Patients with Inflammatory Bowel Disease (IBD)

Isabel C Dos Santos Marques 1, Lauren M Theiss 1, Lauren N Wood 1, Drew J Gunnells 1, Robert H Hollis 1, Karin M Hardiman 1, Jamie A Cannon 1, Melanie S Morris 1, Gregory D Kennedy 1, Daniel I Chu 1,*
PMCID: PMC7764563  NIHMSID: NIHMS1654308  PMID: 29803499

Abstract

Background:

Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients.

Methods:

This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005–2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes.

Results:

Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p<0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1–1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1–2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4–1.9), and sepsis (OR: 1.7; 95% CI 1.4–2.02) compared to White patients.

Conclusions:

Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.

Keywords: IBD, surgery, outcomes, disparities

Introduction

Inflammatory bowel disease (IBD), which includes Crohn’s disease (CD) and Ulcerative Colitis (UC), affects over 3.1 million people in the United States1. IBD outcomes have been described most commonly in White patients. However, over 30% of patients in contemporary IBD populations may now be Black2,3 and the incidence and prevalence of IBD is also increasing among Asians4 and Hispanics5. While disparities between Black and White patients with IBD have been previously described6, data from other racial/ethnic groups such as Asians and Hispanics are few. Existing studies are limited to small sample sizes, selection bias, and incomplete documentation7–9. Major opportunities therefore exist to better understand the disparities experienced by other racial/ethnic populations with IBD.

Racial/ethnic disparities have been observed in many surgical outcomes including complication rates after surgical procedures10,11, lengths-of-stay (LOS)12 and readmissions13. In IBD, Black patients have been shown to experience significantly higher readmission rates and longer LOS after major surgery compared to White IBD patients14. A recent systematic review examining the role of race in IBD found additional evidence for disparities in study participation and inclusion in IBD studies. While Black patients were included in 95% of race-related studies, Hispanics and Asians were studied much less frequently2. These limitations do not allow for substantial conclusions to be drawn regarding IBD outcomes in Hispanic and Asian patients.

Identification of high-risk populations in addition to Black patients would better inform the development of interventions to reduce surgical disparities in post-operative complications, readmissions and lengths-of-stay. Therefore, the aim of this study was to identify and characterize surgical disparities in IBD for Hispanic and Asian populations in addition to Black patients. We hypothesized that surgical disparities would exist in IBD for Hispanic, Asian and Black populations when compared to White IBD patients.

Methods

A retrospective cohort of patients undergoing colorectal surgery for IBD from 2005–2017 was identified using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. ACS-NSQIP is a random sample of de-identified patient data from across the country. Trained nurses abstract information from patient charts and populate predefined variables that include the inpatient stay up to 30 days post-discharge. We included all patients over the age of 18 who were diagnosed with IBD (Crohn’s Disease or Ulcerative Colitis) who underwent a surgical procedure. Patients of White, Black, or Asian race were included, with White patients being further classified as Hispanic White or Non-Hispanic White. IBD diagnosis was determined using International Statistical Classification of Diseases (ICD-9 and ICD-10) diagnosis codes: 555, 555.0–555.9, 556, 556.0–556.9, K50, K50.0–K50.1, K51, K51.0, K51.9. Black and Asian patients who also self-identified as Hispanic ethnicity were excluded (n=32).

Our primary classification was race/ethnicity (Non-Hispanic White, Hispanic White, Black, and Asian). Other recorded ACS-NSQIP defined characteristics included the following patients level characteristics: age (>18), gender, diabetes mellitus, current smoker within one year, alcohol consumption, dyspnea, functional health status prior to surgery, ventilator dependent, history of severe COPD, ascites, congestive heart failure, history of myocardial infarction, history of angina, hypertension requiring medication, history of revascularization, acute renal failure, currently on pre-operative dialysis, history of transient ischemic attacks, CVA or stroke with neurological deficit, disseminated cancer, open wound infection, steroid use for chronic condition, >10% loss of body weight within the prior 6 months, bleeding disorders, transfusions >4 PRBCs in 72 hours prior to surgery, chemotherapy for malignancy within 30 days prior to surgery, systemic sepsis, wound classification, and ASA classification.

The procedure level characteristics included were: surgical approach, emergency case, procedure type, and operation time. Procedure type was included using Current Procedural Terminology (CPT) codes to categorize procedures into abdominoperineal resection (APR)/low anterior resection (LAR)/Hartmann, partial colectomy, small bowel, stoma reversal, stoma revision, total abdominal colectomy (TAC)/total proctocolectomy (TPC), and other. Operative approach was categorized as robotic, laparoscopic, open, and unplanned conversion to open.

Primary and Secondary Outcomes

Our primary outcome was total length of stay (LOS). This was defined as time between hospital admission to hospital discharge for the initial surgical encounter. Secondary outcomes were 30-day readmission, 30-day mortality, and post-surgical complications. Readmission was characterized as at least one readmission within 30 days of discharge. Mortality included inhospital death or death within 30 days of discharge. We utilized ACS-NSQIP defined post-surgical complications including superficial wound infection, deep incisional SSI, organ space SSI, wound disruption, pneumonia, unplanned intubation, pulmonary embolism, on ventilator >48 hours, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke or CVA, coma >24 hours, peripheral nerve injury, cardiac arrest requiring CPR, myocardial infarction, bleeding requiring transfusion, graft failure, DVT, sepsis, or septic shock. Complications were assessed individually and as a composite variable when a patient had at least one complication.

Statistical Analysis

Descriptive statistics were performed on the characteristics and outcomes stratified by race/ethnicity. Bivariate comparisons were performed using Wilcoxon for categorical data and Kruskal-Wallis for continuous data. Variables that demonstrated statistically significant differences (p<0.05) were then used in adjusted multivariate regression models with stepwise selection for each outcome. In our multivariable models, we controlled for age, gender, IBD type, ASA classification, open vs. laparoscopic procedure, procedure type, elective surgery, obesity, smoking status and steroid use. Each outcome was modeled including LOS, readmission, complications, and mortality; however, the adjusted model for mortality was not significant so an unadjusted model was reported. Maximum Likelihood Estimates (MLE) were modeled for continuous outcomes (LOS) and Odds Ratios (OR) were modeled for categorical outcomes (readmission, complications, and mortality). All analysis was performed at an alpha level of 0.05 using SAS 9.4 (SAS Institute, Cary, NC).

Results

Of the 23,901 patients included in the cohort who had IBD and underwent surgery, 88.7% were White, 7.6% Black, 2.4% Hispanic, and 1.4% Asian. The overall mean age was 43 years (SD 16) and 50% were female. The majority of patients (56.9%) were diagnosed with Crohn’s Disease. The overall characteristics of the entire cohort is presented in Table 1.

Table 1:

Patient and procedure characteristics by race n (%)

Variable Overall White African-American Asian Hispanic P Value
(N=23901) (N=21194) (N=1805) (N=337) (N=565)
Patient Level Characteristics
Age, median (Q1, Q3) 40 (29.0–54.0) 40 (29.0–55.0) 36 (27.0–48.0) 39 (28.0–52.0) 35 (26.0–48.0) <.001
BMI, median (Q1, Q3) 24.7 (21.3–29.0) 24.8 (21.4–29.0) 24.4 (20.7–29.5) 22.2 (19.6–25.2) 24.8 (21.528.6) <.001
Gender, <.001
. Female 11914 49.9% 10521 49.6% 1009 55.9% 137 40.7% 247 43.7%
. ale 11982 50.1% 10668 50.3% 796 44.1% 200 59.4% 318 56.3%
Type of IBD
. Crohn’s 13596 56.9% 11945 56.4% 1311 72.6% 117 34.7% 233 39.5% <.001
. Ulcerative Colitis 10305 43.1% 9249 43.6% 494 27.4% 220 65.3% 342 60.5%
Diabetes mellitus, 0.032
. INSULIN 594 2.5% 524 2.5% 52 2.9% 8 2.4% 10 1.8%
. NON-INS 570 2.4% 489 2.3% 46 2.6% 14 4.2% 21 3.7%
. ORAL 67 0.3% 66 0.3% 1 0.1% 0 0.0% 0 0.0%
Current smoker within one year, 4081 17.1% 3555 16.8% 423 23.4% 33 9.8% 70 12.4% <.001
History of severe COPD, 379 1.6% 357 1.7% 20 1.1% 0 0.0% 2 0.4% 0.002
Hypertension requiring medication 4248 17.8% 3761 17.8% 380 21.1% 40 11.9% 67 11.9% <.001
Acute renal failure, 32 0.1% 27 0.1% 2 0.1% 1 0.3% 2 0.4% 0.41
Currently on dialysis (pre-op), 38 0.2% 29 0.1% 7 0.4% 1 0.3% 1 0.2% 0.07
Open wound/wound infection, 630 2.6% 533 2.5% 87 4.8% 3 0.9% 7 1.2% <.001
Steroid use for chronic condition, 12527 52.4% 11180 52.8% 910 50.4% 168 49.9% 269 47.6% 0.019
Transfusion >4 units PRBCs preop, 515 2.2% 419 2.0% 64 3.6% 14 4.2% 18 3.2% <.001
Systemic sepsis, 0.016
. SIRS 1136 4.8% 999 4.7% 94 5.2% 13 3.9% 30 5.3%
. Sepsis 616 2.6% 533 2.5% 58 3.2% 10 3.0% 15 2.7%
. Septic Shock 151 0.6% 119 0.6% 21 1.2% 4 1.2% 7 1.2%
Emergency case, 1081 4.5% 917 4.3% 108 6.0% 20 5.9% 36 6.4% <.001
Wound classification, <.001
. 1-Clean 118 0.5% 101 0.5% 12 0.7% 4 1.2% 1 0.2%
. 2-Clean/Contaminated 15946 66.7% 14215 67.1% 1134 62.8% 226 67.1% 371 65.7%
. 3-Contaminated 5454 22.8% 4814 22.7% 418 23.2% 82 24.3% 140 24.8%
. 4-Dirty/Infected 2383 10.0% 2064 9.7% 241 13.4% 25 7.4% 53 9.4%
ASA classification, <.001
. 1-No Disturb 430 1.8% 392 1.9% 15 0.8% 13 3.9% 10 1.8%
. 2-Mild Disturb 14529 60.8% 12957 61.1% 1000 55.4% 204 60.5% 368 65.1%
. 3-Severe Disturb 8430 35.3% 7410 35.0% 737 40.8% 110 32.6% 173 30.6%
. 4-Life Threat 462 1.9% 396 1.9% 46 2.6% 9 2.7% 11 2.0%
. 5-Moribund 33 0.1% 23 0.1% 7 0.4% 0 0.0% 3 0.5%
. None assigned 17 0.1% 16 0.1% 0 0.0% 1 0.3% 0 0.0%
Procedure Level Characteristics
Total operation time, median (Q1, Q3) 174 (121.0–245.0) 174 (121.0–245.0) 168 (121.0–232.0) 186 (125.0–267.0) 192 (128.0–264.0) <.001
Operative approach,
. Laparoscopic 5514 61.4 4913 23.2 398 22.1 85 25.2 118 20.9
. Open 2616 29.2 2298 10.8 246 13.6 30 8.9 42 7.4 0.001
. Robotic 210 2.3 187 0.9 19 1.1 1 0.3 3 0.5
. Unplanned Conversion to open 634 7.1 559 2.6 65 3.6 3 0.9 7 1.2
Procedure, <.001
. APR/LAR/HARTMAN 4924 20.6% 4447 21.0% 239 13.2% 84 24.9% 154 27.3%
. Other 1867 7.8% 1633 7.7% 155 8.6% 28 8.3% 51 9.0%
. Partial Colectomy 10925 45.7% 9611 45.4% 1028 57.0% 109 32.3% 177 31.3%
. Small Bowel 426 1.8% 370 1.8% 38 2.1% 10 3.0% 8 1.4%
. Stoma Reversal 1233 5.2% 1067 5.0% 103 5.7% 22 6.5% 41 7.3%
. Stoma Revision 134 0.6% 110 0.5% 14 0.8% 2 0.6% 8 1.4%
. TAC/TPV 4121 17.2% 3724 17.6% 200 11.1% 79 23.4% 118 20.9%
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Black patients were more likely to be female (55.9%) and smoke (23.4% compared to 16.7% White, 12.3% Hispanic, and 9.7% Asian; p<=0.001). A higher percentage of Black patients was hypertensive (21.1% vs 17.7% White, 11.8% Hispanic, and 11.8% Asian; p<0.01). The majority of Black patients were diagnosed with Crohn’s Disease (72.6%). Hispanic patients were more likely to be male (56.2%) and more likely to have emergency surgery (6.4% compared to 4.3% White, 6.0% Black, and 5.9% Asian; p<0.01). The majority of Hispanic patients were diagnosed with Ulcerative Colitis (60.5%) and were more likely to have an APR/LAR/Hartmann procedure (27.3% compared to 21% White, 13.2% Black, and 24.9% Asian; p<0.01) as well as a longer median surgery time duration (192 minutes compared to 174 min for White, 168 min for Black, and 186 min for Asian; p<0.001). Asian patients were more likely to be male (59.4%) and were slightly more likely to have had a transfusion before surgery (4% compared to 2% White, 5.5% Black and 3.1% Hispanics; p=<0.001). The majority of Asian patients were diagnosed with Ulcerative Colitis (65.3%). White patients represented the majority of the cohort (88.7%) and were more likely to be on steroid therapy when compared to other ethnic groups (52.7% vs 50% Black, 49.8% Asians and 47.6% Hispanics; p= 0.019). Most White patients were diagnosed with Crohn’s Disease (56.4%).

Our primary outcome was LOS. Mean LOS was 8 (SD 8.2) days and significantly varied between groups (8 days for White, 10 days for Black, 8.5 days for Hispanic, and 11.1 days for Asian; p<0.001). Unadjusted LOS is shown in Table 2. On adjusted analysis, Asian, Hispanic and Black groups were all more likely to have a longer LOS compared to White IBD patients, with Asian patients having the longest at an estimated 0.5 days longer (p<0.001), followed by Black patients at an estimated 0.2 days longer (p<0.001), and Hispanics at an estimated 0.1 days longer (p=0.1). Additional risk factors associated with prolonged LOS included male gender (MLE:0.04, p=0.03), other procedures compared to partial colectomy (MLE: 0.4, p<0.001), emergency surgery (MLE: 0.1, p<0.001), totally dependent functional health status compared to independent (MLE: 0.6, p<0.001), hypertension requiring medication (MLE: 0.1, p=0.03), steroid use (MLE: 0.1, p<0.001), and ASA class 4 compared to class 1 (MLE: 0.7, p<0.001) (Table 3).

Table 2:

Outcomes in the overall cohort and by race, n %

Variable Overall Non-Hispanic White Black or African American Asian Hispanic White P Value
(N=23901) (N=21194) (N=1805) (N=337) (N=565)
Hospital LOS mean (SD) 8 −8.2 8 −7.5 10 −9.5 11 −25.3 8 −8.05 <.001
Surgical LOS mean (SD) 8 −7.7 8 −7.4 11 −10.3 12 −12.9 8 −5.3 <.001
Readmission 2696 11.3% 2339 11.0% 233 12.9% 35 10.4% 89 15.8% 0.009
Mortality 158 0.7% 139 0.7% 12 0.7% 2 0.6% 5 0.9% 0.93
Complication 5335 22.3% 4672 22.0% 455 25.2% 77 22.9% 131 23.2% 0.019
Superficial Wound Infections 1219 5.1% 1089 5.1% 91 5.0% 10 3.0% 29 5.1% 0.7
Deep Incisional SSI 316 1.3% 273 1.3% 23 1.3% 7 2.1% 13 2.3% 0.4
Organ/Space SSI 1648 6.9% 1439 6.8% 149 8.3% 27 8.0% 33 5.8% 0.16
Wound Disruption 238 1.0% 216 1.0% 19 1.1% 2 0.6% 1 0.2% 0.59
Pneumonia 392 1.6% 349 1.7% 30 1.7% 4 1.2% 9 1.6% 0.99
Unplanned Intubation 266 1.1% 239 1.1% 20 1.1% 3 0.9% 4 0.7% 0.93
Pulmonary Embolism 146 0.6% 130 0.6% 12 0.7% 2 0.6% 2 0.4% 0.045
On Ventilator > 48 Hours 315 1.3% 270 1.3% 28 1.6% 7 2.1% 10 1.8% 0.67
Progressive Renal Insufficiency 160 0.7% 131 0.6% 20 1.1% 2 0.6% 7 1.2% 0.031
Acute Renal Failure 72 0.3% 58 0.3% 9 0.5% 2 0.6% 3 0.5% 0.18
Urinary Tract infection 565 2.4% 491 2.3% 51 2.8% 8 2.4% 15 2.7% 0.84
Stroke/CVA 25 0.1% 22 0.1% 3 0.2% 0 0.0% 0 0.0% 0.66
Coma > 24 Hours 4 0.0% 3 0.0% 0 0.0% 1 0.3% 0 0.0% 0.001
Peripheral Nerve Injury 6 0.0% 5 0.0% 1 0.1% 0 0.0% 0 0.0% 0.78
Cardiac Arrest Requiring CPR 64 0.3% 54 0.3% 7 0.4% 1 0.3% 2 0.4% 0.44
Myocardial Infarction 59 0.3% 51 0.2% 6 0.3% 0 0.0% 2 0.4% 0.64
Bleeding Requiring Transfusion 2026 8.5% 1692 8.0% 227 12.6% 41 12.2% 66 11.7% <.001
Graft/Prosthesis/Flap Failure 2 0.0% 2 0.0% 0 0.0% 0 0.0% 0 0.0% 0.97
DVT/Thrombophlebitis 566 2.4% 509 2.4% 39 2.2% 5 1.5% 13 2.3% 0.89
Sepsis 1407 5.9% 1189 5.6% 166 9.2% 24 7.1% 28 5.0% <.001
Septic Shock 342 1.4% 309 1.5% 23 1.3% 2 0.6% 8 1.4% 0.55
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Table 3:

Adjusted and Unadjusted hospital Length of Stay (LOS)

Adjusted LOS Unadjusted LOS
Maximum Likelihood Estimate 95% CI p value Maximum Likelihood Estimate 95% CI p value
Hispanic 0.1 (0.0,0.2) 0.134 0.0 (−0.1,0.2) 0.5113
Asian 0.5 (0.4,0.7) <.0001 0.5 (0.4,0.7) <.0001
African-American 0.2 (0.1,0.3) <.0001 0.3 (0.2,0.3) <.0001
Age 0.0 (0.0,0.0) 0.0496 0.0 (0.0,0.0) <.0001
Female 0.0 (−0.1,0.0) 0.034 0.0 (−0.1,0.0) 0.0471
Crohn’s Disease 0.0 (0.0,0.1) 0.0722 −0.1 (−0.1,−0.1) <.0001
APR/LAR/HARTMAN 0.0 (0.0,0.1) 0.212 0.0 (−0.1,0.0) 0.1731
Other 0.4 (0.3,0.4) <.0001 0.6 (0.5,0.6) <.0001
Small Bowel −0.2 (−0.4,−0.1) 0.0007 −0.3 (−0.4,−0.2) <.0001
Stoma Reversal −0.3 (−0.3,−0.2) <.0001 −0.4 (−0.5,−0.3) <.0001
Stoma Revision −0.1 (−0.3,0.1) 0.2558 −0.2 (−0.4,0.0) 0.0413
TAC/TPV 0.2 (0.1,0.2) <.0001 0.1 (0.1,0.2) <.0001
Emergency Surgery 0.1 (0.1,0.2) 0.0007 0.6 (0.5,0.7) <.0001
Functional Status Partially 0.5 (0.4,0.7) <.0001 0.8 (0.7,0.9) <.0001
Dependent
Functional Status Totally 0.6 (0.4,0.7) <.0001 1.2 (1.0,1.3) <.0001
Dependent
Hypertension Medication 0.1 (0.0,0.1) 0.0299 0.3 (0.2,0.3) <.0001
Steroid Use 0.1 (0.1,0.1) <.0001 0.2 (0.1,0.2) <.0001
ASA Class 2 0.2 (0.1,0.3) 0.0041 0.2 (0.1,0.4) 0.0002
ASA Class 3 0.4 (0.3,0.5) <.0001 0.6 (0.5,0.8) <.0001
ASA Class 4 0.7 (0.5,0.9) <.0001 1.3 (12,1.5) <.0001
ASA Class 5 0.6 (0.3,1.0) 0.0006 1.3 (1.0,1.7) <.0001
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*

Reference categories are White, Male, UC, Partial Colectomy, Elective Surgery, Independent, No Medication, No Steroid use, and ASA Class 1

Our secondary outcomes were 30-day readmission, 30-day mortality, and 30-day complications. All unadjusted outcomes including specific complications are again shown in Table 2. The overall readmission rate was 14.9% and varied significantly between groups (11% for White, 12.9% for Black, and 15.8% for Hispanic, 10.4% for Asian; p=0.01). On adjusted modeling, Hispanic patients had the highest odds of readmission compared to White patients (OR:1.4; p=0.01). Additional risk factors for readmission included patients who underwent APR/LAR/Hartman procedures compared to partial colectomy (OR: 1.9, p<0.001), steroid use (OR: 1.1, p=0.002), and ASA class 4 compared to class 1 (OR: 1.97, p<0.001) (Table 4).

Table 4:

Adjusted and Unadjusted Readmission

Adjusted Readmission Unadjusted Readmission
OR 95% CI p value OR 95% CI p value
Hispanic 1.441 (1.1,1.8) 0.0091 0.0459 (−0.1,0.2) 0.5113
Asian 0.869 (0.6,1.3) 0.0983 0.5354 (0.4,0.7) <.0001
African-American 1.177 (1.0,1.4) 0.4012 0.2616 (0.2,0.3) <.0001
APR/LAR/HARTMAN 1.906 (1.7,2.1) <.0001 −0.0353 (−0.1,0.0) 0.1731
Other 1.415 (1.2,1.7) 0.0008 0.5634 (0.5,0.6) <.0001
Small Bowel 0.6 (0.4,0.9) 0.9183 −0.2877 (−0.4,−0.2) <.0001
Stoma Reversal 0.894 (0.7,1.2) 0.0091 −0.4034 (−0.5,−0.3) <.0001
Stoma Revision 0.499 (0.2,1.2) 0.3554 −0.2034 (−0.4,0.0) 0.0413
TAC/TPV 1.468 (1.3,1.6) 0.0776 0.128 (0.1,0.2) <.0001
Steroid Use 1.148 (1.1,1.3) 0.0017 0.1685 (0.1,0.2) <.0001
ASA Class 2 1 1.398 (0.9,2.1) 0.6504 0.2346 (0.1,0.4) 0.0002
ASA Class 3 1.785 (1.2,2.7) 0.0471 0.625 (0.5,0.8) <.0001
ASA Class 4 1.965 (1.2,3.2) 0.0309 1.3387 (12,1.5) <.0001
ASA Class 5 0.758 (0.2,3.5) 0.3672 1.3115 (1.0,1.7) <.0001
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*

Reference categories are White, Partial Colectomy, No Steroid use, and ASA Class 1

The overall complication rate was 22.3% and varied significantly between groups (22% for White, 25.2% for Black, 23.2% for Hispanic, and 22.9% for Asian; p=0.02). On adjusted analysis, however, race was not a significant factor for overall complications (p=0.5). Patients who had other procedures had higher odds of having a complication compared to partial colectomy (OR: 1.6; p<.001). Patients with a totally dependent functional health status had the highest odds of complication compared to independent functional health status (OR: 3.3; p=0.01). Also, patients requiring medication for hypertension and on steroid use had higher odds of complication compared to those who did not require medication (OR: 1.5; p<0.001) or steroids (OR: 1.2; p=0.004). ASA class 4 had the highest odds of complication compared to ASA class 1 (OR: 4.9; p<0.001) (Table 5). When looking at individual complications, Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1–2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4–1.9), and sepsis (OR: 1.7; 95% CI 1.4–2.02). Hispanic patients experienced higher odds of bleeding after surgery when compared to White patients (OR: 1.5; p=0.002) (Table 6). The overall mortality rate was 0.7% and did not vary significantly between the groups (0.7% for White, 0.7% for Black, 0.9% for Hispanic, and 0.6% for Asian; p=0.9). On adjusted modeling, Hispanic patients had the lowest odds of mortality amongst all groups (OR 0.7, p<.001).

Table 5:

Adjusted and Unadjusted Overall Complications

Adjusted Complication Unadjusted Complication
OR 95% CI p value OR 95% CI p value
Hispanic 1.1 (0.7,1.7) 0.4988 0.05 (−0.1,0.2) 0.5113
Asian 0.6 (0.3,1.2) 0.1379 0.54 (0.4,0.7) <.0001
African- American 1.1 (0.9,1.4) 0.2122 0.26 (0.2,0.3) <.0001
APR/LAR/HARTMAN 1.5 (1.3,1.8) <.0001 −0.04 (−0.1,0.0) 0.1731
Other 1.6 (1.3,19.2) <.0001 0.56 (0.5,0.6) <.0001
Small Bowel 0.5 (0.3,0.9) 0.0202 −0.29 (−0.4,−0.2) <.0001
Stoma Reversal 0.5 (0.4,0.7) <.0001 −0.40 (−0.5,−0.3) <.0001
Stoma Revision 0.8 (0.4,1.8) 0.7154 −0.20 (−0.4,0.0) 0.0413
TAC/TPV 1.3 (11,16) 0.0006 0.13 (0.1,0.2) <.0001
Functional Status Partially Dependent 2.2 (1.5,3.3) 0.4288 0.82 (0.7,0.9) <.0001
Functional Status Totally Dependent 3.3 (1.8,−6.2) 0.0144 1.17 (1.0,1.3) <.0001
Hypertension Medication Use 1.5 (1.2,1.7) <.0001 0.29 (0.2,0.3) <.0001
Steroid Use 1.2 (11,14) 0.0039 0.17 (0.1,0.2) <.0001
ASA Class 2 1.5 (0.9,2.6) 0.0376 0.23 (0.1,0.4) 0.0002
ASA Class 3 2.1 (1.2,3.6) 0.9973 0.63 (0.5,0.8) <.0001
ASA Class 4 4.9 (2.5,9.7) <.0001 1.34 (12,1.5) <.0001
ASA Class 5 2.6 (0.7,9.7) 0.6636 1.31 (1.0,1.7) <.0001
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*

Reference categories are White, Partial Colectomy, Independent, No medication use, No steroid use, and ASA Class 1

Table 6:

Individual complications by Race

Unadjusted Renal Insufficiency Unadjusted Bleeding Requiring Transfusion Unadjusted Sepsis
OR 95% CI p value OR 95% CI p value OR 95% CI p value
Hispanic 2.0 0.9 – 4.3 0.0722 1.5 1.1 – 2.0 0.0016 0.9 0.6 – 1.3 0.5044
Asian 0.96 0.2 – 3.9 0.9544 1.6 1.1 – 2.2 0.0055 1.3 0.8 – 2.0 0.2337
African - American 1.8 1.1 – 2.9 0.0147 1.7 1.4 – 1.9 <0001 1.7 1.4 – 2.0 <.0001
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Discussion

In our study, disparities in surgical outcomes for IBD patients were present not only among Black as previously reported6, but also among Asian and Hispanic patients. We found that Asian patients were more likely to have longer LOS, while Hispanic patients had increased odds of readmission when compared to White counterparts. To our knowledge, this is the first study to date of IBD surgical outcomes among four major racial/ethnic groups (White, Black, Asian and Hispanic). In addition, this study is one of the largest studies to date of IBD surgical patients as it was based on a national surgical registry spanning over 12 years. Importantly, this study establishes that disparities exist not only in the Black IBD population, but in other growing racial/ethnic minorities.

This study found significant differences in LOS following surgery for IBD between racial and ethnic groups. Specifically, Asian patients had the longest LOS when compared to White, Black and Hispanic IBD patients. This finding is novel and contradicts a previous study that found that Asian Americans have no increased risk for adverse surgical outcomes or longer LOS when compared with White patients after abdominal, thoracic, or pelvic cancer surgery11. Our findings also contradict a study on patients undergoing surgery for colorectal cancer that found that Asians have shorter LOS when compared with other racial/ethnic groups15. These study differences may occur for several reasons. First, cancer and IBD are different diseases with different operations and management algorithms. Previous studies establishing shorter LOS for Asians all focused on cancer populations. Second, the co-morbidities and complications associated with IBD patients such as steroid use and post-operative infections are unique compared with other surgical populations. Increased complication rates may drive longer LOS. Third, outcomes among Asian IBD populations are poorly understood as studies done in the US often exclude Asians16. Although the 0.5 day longer observed LOS for Asian patients appears insignificant at the individual-level, these differences matter at the population-level when considering the cumulative total differences, the costs associated with added hospital days17 and institutional emphasis on patient flow18. Our findings therefore shed new light on surgical outcomes among the Asian IBD population but also makes clear that further studies are needed to understand why this and other populations experience LOS disparities.

Readmission rates significantly varied between groups, with Hispanic patients having the highest rate of readmission of all groups (15.8%) and higher odds of readmission compared to White patients (OR: 1.4, p=0.01). They were closely followed by Black patients with a 12.9% readmission rate. Our findings are similar to an ACS-NSQIP based study looking at patients with Ulcerative Colitis undergoing ileal pouch-anal anastomosis19. Those authors found Hispanic ethnicity and Black race to be independently associated with 30-day readmission following surgery19. One potential explanation for these findings is that minority populations often undergo surgery in centers with lower volume of cases20 and, while the ACS-NSQIP database does not have data on hospital volume, previous studies have shown that lower volume centers have higher readmission rates21. Another potential explanation for why Hispanic patients have the highest odds of readmission is that Hispanic patients were more likely to have emergency surgery when compared to other groups (6.4% vs 4.3% White, 6.0% Black, 5.9% Asian; p<0.01). Emergency surgery represents a major risk factor for readmissions and complications following surgery22. Ultimately, our findings on Hispanic IBD patients show that there are vulnerable populations in addition to Black patients that must be targeted in readmission reduction programs.

In our cohort, Black patients experienced disproportionately worse outcomes, with the highest complication rates of all groups at 25.2%. These findings are consistent with previous studies establishing that Black IBD patients are a unique and high-risk population for complications14,23. When focused on infectious complications, Black patients had higher odds of sepsis (OR: 1.7; 95% CI 1.4–2.02) after surgery. The reasons for these findings are likely multifactorial, but smoking is one major risk factor. In our study, Black patients were much more likely to smoke (23.4%). Studies have clearly linked smoking with a twofold increased risk for surgical site infections after stoma reversals, a fourfold higher risk for anastomotic leak after left colectomy, and 50% higher risk for hospital readmission after surgery for Crohn’s disease24–26. Additionally, the majority of Black patients included in this study were diagnosed with Crohn’s disease (72.63%), while Asians and Hispanic patients were mostly diagnosed with Ulcerative Colitis (65.28% and 60.53%). These observations are consistent with previous literature5,27,28 and evidence that surgical outcomes may differ between Crohn’s disease and Ulcerative Colitis29. Efforts to eliminate these disparities are needed and the best intervention(s) will have to work at multiple levels. Interventions such as Enhanced Recovery Programs (ERPs), for example, which span the continuum of surgical care, have shown promise in eliminating disparities in LOS and may also apply in IBD18,30–32. Similarly, interventions based on health literacy have also shown promise in addressing health disparities and may be applicable to surgery33,34. More research is needed, however, to best identify, develop and deliver multilevel care in IBD and surgery.

Our study has several limitations. First, our study is subject to selection bias as it is based on a retrospective database and not all patients are prospectively enrolled. Second, confounders such as social determinants of health, health literacy and insurance status are not captured by ACS-NSQIP. These factors have been shown to be important drivers of observed disparities. Third, race/ethnicity is self-reported and its accuracy in the ACS-NSQIP database cannot be confirmed. Fourth, our data is derived from ACS-NSQIP participating hospitals which limits the generalizability of our study results to other practice environments.

Conclusion

Surgical disparities exist for Black, Hispanic and Asian populations with IBD. These disparities manifest as significant variations in post-operative complications, readmissions, and LOS. Future research is needed to better understand the mechanisms of these disparities in IBD. Such understanding will then best inform the development of tailored, patient-centered and comprehensive interventions to eliminate surgical disparities for all populations.

Highlights:

  • Racial disparities in surgical outcomes exist among IBD patients.

  • Asian patients had significantly longer postoperative length of stay. Hispanic patients had significantly higher odds of readmission after surgery.

  • Black patients had the highest odds of renal insufficiency, bleeding requiring transfusions, and sepsis after surgery.

Acknowledgement

DIC is supported in part by a K12 HS023009 (2017–2019) from the Agency for Healthcare Research and Quality (AHRQ) through the UAB Center for Outcomes and Effectiveness Research and Education (COERE) and Minority Health and Health Research Center (MHRC) and a K23 MD013903 (2019–2022) from the National Institute on Minority Health and Health Disparities (NIMHD). The content is solely the responsibility of the authors and does not necessarily represent the official views of the AHRQ or the NIH.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

This work was accepted as an oral presentation at the 2020 Annual Meeting of the Society of Black Academic Surgeons

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