Patient Care Research

Disparities After Surgery: Readmission from Complications More Common for People of Color

While doctors work to provide the best treatment to all their patients, readmission can occur due to complications after surgery. Differences in readmission rates have been identified between groups, specifically by racial identity. Physicians from Washington University School of Medicine St. Louis Department of Surgery, Siteman Cancer Center and Barnes-Jewish Hospital collaborated on an insightful study on the existence of disparities after surgery between white and non-white Whipple procedure patients.

The study, published in the American Journal of Surgery, found that patients of color are more likely to require readmission after surgery, which may be related to other lived disparities, such as barriers to accessing equal healthcare to their white counterparts.

Washington University physicians at the “White Coats for Black Lives” demonstration, which recognizes systematic disparities in health and medical treatment as one component of racism in health outcomes for people of color

Research Background and Questions:

Readmission is when patients must return to the hospital for additional treatment associated to the procedure and condition treated. Readmission rates are used to consider how successful certain procedures are to improve patient health. Assessing patient outcomes is important to understanding how medicine has progressed or can be improved.

Pancreaticoduodenectomy or “Whipple procedure” is a complex procedure to remove the “head” of the pancreas, first section of the intestine (duodenum), gallbladder and bile duct. The remaining digestive organs are reattached to allow normal food processing after surgery. This procedure is often performed to remove cancerous tumors from the pancreas and associated areas, but it is also used to treat pancreatic or duodenal trauma and chronic pancreatitis.

The Whipple procedure has a high rate of readmission, and racial disparities in care could be an important contributor. While overall readmission is 26-27%, Black and Latinx patients are more likely to be readmitted.

To address this difference, the study asked whether the race impacted the rate of readmission after Whipple procedures, and more specifically, whether race impacted the severity of complications requiring readmission after surgery.

Research Methods and Results:

Between February 2012 and February 2020, all patients undergoing pancreaticoduodenectomy were prospectively followed, and their complications graded based on the Division of Surgery’s database on complications. The study compared patient demographics (factors like age, race and sex) with their overall health, surgery outcomes and whether the patient was readmitted post-op. Severity of complications were also compared to these factors. These assessments were meant to visualize whether certain demographics, such as race, experienced more frequent readmission or more severe complications after operation.

In the study period, 837 patients underwent Whipple procedures. The overall 90-day readmission rate was higher for non-white race patients. About half of readmissions were for non-severe complications, which appeared to happen at a higher rate for non-white patients.

Conclusions and Moving Forward:

Non-white patients are more likely to be readmitted in many major surgeries, including pancreaticoduodenectomy. This readmission was associated particularly to non-severe complications, which could potentially be avoidable with changes in how medicine is communicated, accessed and conducted. Results suggested that, because non-white patients were more likely to experience non-severe complications that can be mediated through more successful monitoring and managing in the outpatient setting.

The study outlines why these disparities may exist in current patient outcomes:

Jorge Zárate Rodriguez, MD, first author

“It is well documented in the literature that Black and Latinx patients suffer worse health outcomes compared to their white counterparts in terms of perioperative morbidity and mortality, hospital length of stay, and readmission rates. The reason for these disparities is almost certainly multifactorial and likely impacted by the barriers faced by people of color in terms of access to care. Factors that contribute to these barriers include provider biases and mistrust of the medical establishment, as well as financial and educational inequities that are the result of systemic and structural racism. As medical providers, we must acknowledge and address these barriers to improve healthcare disparities amongst communities of color. Highly complex procedures with complicated recoveries, such as PD, likely exacerbate the degree to which these disparities impact patient outcomes.” – Jorge Zárate Rodriguez, MD, first author

Heidy Cos, MD, second author

Recognizing race as a determinant for readmission is the first step to improve outcomes for patients of color. The investigators concluded that, to prevent these disparities from continuing to negatively impact patients, follow-up protocols must be tailored to address race disparities to reduce readmission for less severe complications. Washington University offers all patients home health upon discharge from a PD procedure to bridge the transition of care to home. Physicians conducting PD surgery have also call patients the day after discharge and in the first post-discharge week to screen for early complications that can be intervened upon in the outpatient setting to avoid preventable readmissions.

Washington University – Serving All Patients, Equally

This study reinforces the idea that race is an important factor in the delivery of healthcare and calls for providers to pay special attention to communities of color, who are at higher risk for worse outcomes due to systemic inequity.

The Department of Surgery is committed to addressing health disparities that exist across our community, which is why we conduct research to understand how they begin and how we can contribute to resolving them. Although systemic change is necessary for racial disparities to be improved nationally, Washington University is dedicated to providing the best care to all patients and works to improve outcomes for people of color who have been historically neglected by healthcare systems. We work with our patients to overcome barriers that may otherwise prevent them from accessing the highest level of treatment. Learn more about our mission to serve and support all members of our community, including our Black patients, staff and faculty.

From left: William G. Powderly, MD, the J. William Campbell Professor of Medicine & Co-director of the Division of Infectious Diseases; and David H. Perlmutter, MD, Executive Vice Chancellor for Medical Affairs and Dean of Washington University School of Medicine at the “White Coats for Black Lives” demonstration

To read the original publication of this article, “Inability to manage non-severe complications on an outpatient basis increases non-white patient readmission rates after pancreaticoduodenectomy: A large metropolitan tertiary care center experience,” visit the National Library of Medicine.

Physicians responsible for this study include:

Jorge G Zárate Rodriguez, MD

Heidy Cos, MD

Gregory A Williams

Cheryl A Woolsey

Ryan C Fields, MD

Steven M Strasberg, MD

Majella B Doyle, MD, MBA

Adeel S Khan, MD, MPH, FACS

William C Chapman, MD, FACS

Chet W Hammill, MD, MCR

William G Hawkins, MD, FACS

Dominic E Sanford, MD

Publication citation: Zárate Rodriguez JG, Cos H, Williams GA, Woolsey CA, Fields RC, Strasberg SM, Doyle MB, Khan AS, Chapman WC, Hammill CW, Hawkins WG, Sanford DE. “Inability to manage non-severe complications on an outpatient basis increases non-white patient readmission rates after pancreaticoduodenectomy: A large metropolitan tertiary care center experience.” American Journal of Surgery. 2021 Apr 16.