Study adds to evidence that racial and economic factors affect surgical pain managementSeptember 14, 2017
A "look back" analysis of more than 600 major colorectal surgeries using a "checklist" tool has added further evidence that racial and socioeconomic disparities may occur during many specific stages of surgical care, particularly in pain management.
A report of the study's findings by researchers at Johns Hopkins Medicine, published Sept. 11 in Diseases of the Colon & Rectum, documents the specific ways in which historically disadvantaged populations receive less optimal pain management and are placed on "enhanced recovery" protocols later than their wealthier and white counterparts.
"This study demonstrates that process measures, which guide and document each step of care, may be critical factors in preventing differences in care, particularly those due to race and socioeconomic status" says Ira Leeds, M.D., research fellow at the Johns Hopkins University School of Medicine and the paper's co-first author. "We can't fix what we don't measure," he adds.
Enhanced recovery after surgery (ERAS) protocols are predefined pathways designed to standardize some aspects of surgical care in order to reduce complications, decrease lengths of stay and improve overall patient satisfaction.
To determine whether ERAS had an impact, or revealed any racial and socioeconomic disparities after surgery, Leeds and colleagues performed a retrospective analysis of information gathered before and after the implementation of a colorectal ERAS pathway at The Johns Hopkins Hospital.
A total of 639 patient experiences (199 pre-ERAS implementation and 440 post-implementation) were used in the analysis, all surgeries performed between Jan. 1, 2013 and June 30, 2016. The research team collected socioeconomic information, medical diagnoses in addition to colorectal disease, and surgical outcomes information housed in Johns Hopkins' National Surgical Quality Improvement Program's internal database.
Data about participation in ERAS and adherence to process measures were obtained from the Johns Hopkins University School of Medicine's Department of Surgery quality improvement database.
Patients were categorized as either white or nonwhite patients, and low socioeconomic status or high socioeconomic status was determined by zip code. Some 75.2 percent of all patients were white and 91.7 percent were categorized as having a high socioeconomic status.
The researchers found that white patients were more likely to have transverse abdominis plane (TAP) blocks or epidurals initiated and maintained than nonwhite patients (57.1 versus 44.1 percent for initiation; 47.3 versus 34.3 percent for maintenance).
A similar trend for initiation of pain management was seen for high socioeconomic status patients (55.4 versus 41.5 percent). Leeds says this suggests that either nonwhite patients declined epidural blocks for pain management at higher rates due to inadequate counseling on the benefits, or that doctors carried implicit biases that led them to offer such pain management options less often to minorities and the poor.
Patients with a high socioeconomic status were placed on an ERAS pathway during scheduling more often than low socioeconomic status patients (69.7 versus 58.5 percent).
Prior to ERAS implementation, median lengths of stay, complication rates and total number of complications were not statistically different between white and nonwhite patients. Following ERAS implementation, median lengths of stay improved in both whites (a decrease of 1.5 days) and nonwhites (-1 days) and in patients with high socioeconomic status (-1 days) and low socioeconomic status (-2.0 days).
Following pathway implementation, the median lengths of stay improved in all subgroups with an overall decrease of 1 day, with no statistical difference by race or socioeconomic status. There were no significant differences in complication rates between racial (26.4 versus 28.8 percent) and socioeconomic groups (27.3 versus 25.0 percent) before ERAS implementation, and this was unchanged after ERAS implementation.
Leeds says the study results do not prove implicit racial or other bias as the cause of the differences in care, but they should, he says, heighten concern about the existence of such disparities and renew attention toward identifying and addressing bias.
While Leeds acknowledges the study's limitations of only including one institution and drawing from two datasets not designed to be merged for analysis, he notes that the findings add evidence regarding the efficacy of ERAS pathways in identifying disparities and highlight how short-term disparities can be mitigated by quality monitoring.
Other authors on this paper include Yewande Alimi, Jonathan E. Efron, Elliott R. Haut and Fabian Johnston from the Johns Hopkins University School of Medicine.
Cancer Institute T32 training grant 5T32CA126607. Leeds received additional support for research expenses from the American Society of Colon and Rectal Surgeons Research Foundation General Surgery Resident Research Initiation Grant GSSRIG-031. Haut was supported as the primary investigator of an Agency for Healthcare Research and Quality grant (1R01HS024547-01) and a Patient Centered Outcomes Research Institute contract (CE-12-11-4489). Johnston was supported as the primary investigator of an Agency for Healthcare Research and Quality grant (1K08HS024736-01) from the Agency for Healthcare Research and Quality.
Johns Hopkins Medicine
Related Socioeconomic Status Articles:
The multicenter trial coordinated by the Research Centre of Applied and Preventive Cardiovascular Medicine at the University of Turku, Finland, shows that low socioeconomic status in childhood increases the risk of higher left ventricular mass and poorer diastolic function in adulthood.
Socioeconomic inequalities are a public health challenge in cardiovascular disease and a new study published by JAMA Pediatrics examined the association of childhood family socioeconomic status in youth on measures of left ventricular mass and diastolic function 31 years later in adulthood.
A study of all 3rd-5th grade youth in one US county examined differences in access to playgrounds and associations between youth weight and playground accessibility and quality.
MIT neuroscientists have found that dyslexic children from lower income families responded much better to a summer reading program than children from a higher socioeconomic background.
Between 1999 to 2014, there was a decline in average systolic blood pressure, smoking, and predicted cardiovascular risk of 20 percent or greater among high-income US adults, but these levels remained unchanged in adults with incomes at or below the federal poverty level, according to a study published by JAMA Cardiology.
New research presented at this year's European Congress on Obesity in Porto, Portugal, shows that lower socioeconomic status is associated with higher body-mass index (BMI) through its effects on distress and subsequent emotional eating.
Results from 'Interaction Effects of Race/Ethnicity and Sex on Outcomes after PCI: A Subanalysis of the PLATINUM Diversity study' were presented today as a late-breaking clinical trial at the Society for Cardiovascular Angiography and Interventions (SCAI) 2017 Scientific Sessions in New Orleans.
Two new studies have uncovered socioeconomic disparities related to the health of patients with lupus.
Children who had higher blood lead levels at age 11 were more likely to have lower cognitive function, IQ and socioeconomic status when they were adults at age 38, according to a study published by JAMA.
After decades of declining US smoking rates overall, most remaining smokers have low income, no college education, no health insurance or a disability.
Related Socioeconomic Status Reading:
Cutting Class: Socioeconomic Status and Education (Culture and Education Series)
by Joe L. Kincheloe (Editor), Shirley R. Steinberg (Editor)
In these vivid, thought-provoking essays, leading scholars draw from their own life experiences to explore the ways in which socio-economic class has shaped their lives and educational practices. Some experienced the sting of poverty as students, while others tell stories of a privileged upbringing and moments of epiphany when they recognized the far-reaching effects of class privilege. Many in this volume tell stories of their successful (and not-so-successful) teaching experiences with students from various social classes, providing valuable insights for teachers and other education... View Details
Popular: The Power of Likability in a Status-Obsessed World
by Mitch Prinstein (Author)
A leading psychologist examines how our popularity affects our success, our relationships, and our happiness—and why we don’t always want to be the most popular
No matter how old you are, there’s a good chance that the word “popular” immediately transports you back to your teenage years. Most of us can easily recall the adolescent social cliques, the high school pecking order, and which of our peers stood out as the most or the least popular teens we knew. Even as adults we all still remember exactly where we stood in the high school social hierarchy, and the powerful... View Details
Community College Education and Its Impact on Socioeconomic Status Attainment (Mellen Studies in Education)
by Elizabeth Monk-Turner (Author)
This work examines the role of the community college in the United States and how community college education shapes adult income and occupational status. View Details
Socioeconomic Status, Parenting, and Child Development (Monographs in Parenting Series)
by Marc H. Bornstein (Editor), Robert H. Bradley (Editor)
Socioeconomic Status, Parenting, and Child Development presents cutting-edge thinking and research on linkages among socioeconomic status, parenting, and child development. The contributors represent an array of different disciplines, and approach the issues from a variety of perspectives. Accordingly, their "take" on how SES matters in the lives of children varies.
This volume is divided into two parts. Part I concerns the constructs and measurement of SES and Part II discusses the functions and effects of SES. Each part presents four substantive chapters on the topic... View Details
Socioeconomic Status and Health in Industrial Nations: Social, Psychological, and Biological Pathways (Annals of the New York Academy of Sciences)
by Nancy E. Adler (Editor), Michael Marmot (Editor), Bruce S. McEwen (Editor), Judith Stewart (Editor)
The Wealth of Humans: Work, Power, and Status in the Twenty-first Century
by Ryan Avent (Author)
None of us has ever lived through a genuine industrial revolution. Until now.
Digital technology is transforming every corner of the economy, fundamentally altering the way things are done, who does them, and what they earn for their efforts. In The Wealth of Humans, Economist editor Ryan Avent brings up-to-the-minute research and reporting to bear on the major economic question of our time: can the modern world manage technological changes every bit as disruptive as those that shook the socioeconomic landscape of the 19th century?
Traveling from Shenzhen, to... View Details
Socioeconomic Status and Health in Industrial Nations: Social, Psychological and Biological Pathways
by New York Academy of Sciences (Publisher)
Book by View Details
Accounting for Social Risk Factors in Medicare Payment: Criteria, Factors, and Methods
by Engineering, and Medicine National Academies of Sciences (Author), Health and Medicine Division (Author), Board on Health Care Services (Author), Board on Population Health and Public Health Practice (Author), Committee on Accounting for Socioeconomic Status in Medicare Payment Programs (Author)
Recent health care payment reforms aim to improve the alignment of Medicare payment strategies with goals to improve the quality of care provided, patient experiences with health care, and health outcomes, while also controlling costs. These efforts move Medicare away from the volume-based payment of traditional fee-for-service models and toward value-based purchasing, in which cost control is an explicit goal in addition to clinical and quality goals. Specific payment strategies include pay-for-performance and other quality incentive programs that tie financial rewards and sanctions to... View Details
Beyond Obamacare: Life, Death, and Social Policy
by James S. House (Contributor)
Health care spending in the United States today is approaching 20 percent of GDP, yet levels of U.S. population health have been declining for decades relative to other wealthy and even some developing nations. How is it possible that the United States, which spends more than any other nation on health care and insurance, now has a population markedly less healthy than those of many other nations? Sociologist and public health expert James S. House analyzes this paradoxical crisis, offering surprising new explanations for how and why the United States has fallen into this trap. In... View Details
Multicultural Education in a Pluralistic Society, Enhanced Pearson eText with Loose-Leaf Version -- Access Card Package (10th Edition) (What's New in Curriculum & Instruction)
by Donna M. Gollnick (Author), Philip C. Chinn (Author)
NOTE: Used books, rentals, and purchases made outside of Pearson
If purchasing or renting from companies other than Pearson, the access codes for the Enhanced Pearson eText may not be included, may be incorrect, or may be previously redeemed. Check with the seller before completing your purchase.
This package includes the Enhanced Pearson eText and the loose-leaf version.