Study finds higher mortality rate among Black men after elective surgery

Black men have a higher death rate within 30 days of surgery compared with any other subgroup of race and sex, finds a study of adults in the United States published in The BMJ.

This inequality in death rate was mainly observed for elective, or planned, surgeries, where the death rate for Black men was 50% higher than that of White men.

The researchers say further research is needed to understand better the "factors contributing to this higher mortality rate among Black men after elective surgery."

In previous studies, racial inequities in surgical care and outcomes, including a higher death rate following surgery for Black patients, have been well documented.

However, less is known of how surgical outcomes differ by the race and sex of patients undergoing both elective or non-elective (urgent or emergency) surgeries.

To fill in this knowledge gap, the researchers used nationwide Medicare data on 1,868,036 adults with an average age of 75 years who underwent one of eight surgeries —abdominal aortic aneurysm repair, appendectomy, cholecystectomy, colectomy, coronary artery bypass surgery, hip replacement, knee replacement, and lung resection—between 2016-2018.

They analysed data for differences in death rates between subgroups of race and sex, following elective or urgent surgeries

Of the adults included in this study, 40.7% were White men, 53.4% were White women, 2.2% were Black men, and 3.7% were Black women. Just over 70% of the surgeries were elective.

After accounting for other potentially influential factors such as age, disability, and a range of underlying chronic conditions, the researchers found that Black men had a higher death rate (3.05%) within 30 days of both urgent and elective surgery than White men (2.69%), White women (2.38%), and Black women (2.18%).  

A similar pattern was found for elective surgery: Black men had a higher death rate (1.3%) than White men (0.85%), White women (0.82%), and Black women (0.79%).

This 0.45 percentage point difference between Black and White men "implies that mortality after elective procedures was 50% higher in Black men compared with White men", say the researchers.

And much of this difference persisted even when patients operated on by the same surgeon were compared, they note.

The researchers did not find a statistically significant difference between Black and White men following urgent surgery, with death rates of 6.69% and 7.03%, respectively.  

They did, however, find that deaths after urgent surgery were lower for both White and Black women, than men of either race, at 6.12% and 5.29%, respectively.

This is an observational study, so cannot establish cause, and the researchers acknowledge that their results were limited to Black and White Medicare patients undergoing certain procedures, so may not apply to other groups or types of surgery.

However, results remained largely unchanged after further sensitivity analyses, suggesting that they are robust.

The researchers suggest that structural racism within society, such as higher rates of poverty among Black patients, which can lead to poorer underlying health and challenges accessing care, may, at least partially, explain their findings, and say better standardization of care is needed to help mitigate some of these factors and reduce inequities in surgical outcomes.

"Further research is needed to understand better the preoperative, intraoperative, and postoperative factors contributing to this higher mortality rate among Black men after elective surgery, " they conclude.