US study finds less access to important surgeries in people with HIV or hepatitis C virus and in racialized groups

• Researchers analysed data from over 500,000 people for whom surgery was recommended
• People with HIV or hepatitis C and racialized populations were less likely to undergo such surgery
• The researchers recommended a range of interventions to improve access to life-saving surgery

A team of researchers at Harvard University and other academic centres in the United States has analysed health-related information from more than 500,000 people. The researchers focused on people for whom emergency surgery (for relatively common issues) was recommended and whether or not they underwent such surgery. In particular, researchers were interested in access to surgery by people with chronic viral infections such as HIV or HCV.

The researchers found that compared to people without chronic viral infections, people with HIV or HCV were less likely to undergo several relatively common emergency surgeries (details about these appear later in this CATIE News bulletin). They also found that people with chronic viral infections were more likely to be Black or Hispanic than people without these infections. As a result, these racialized groups were less likely to have surgery than White people.

The researchers suggested several interventions to help make life-saving surgery more accessible to minority populations and people with chronic viral infections. However, studies are needed to assess if such interventions can lead to more equitable access to needed surgeries.

Study details

Researchers analysed health-related information collected between 2016 and 2019 about people admitted to hospitals. The data were collected from the U.S. National Inpatient Sample. According to the researchers, this is the largest publicly available inpatient care database in the U.S. It has a representative sample of patients and has data on about 20% of people who had surgery at community hospitals.

Due to the onset of the COVID-19 pandemic in 2020, the researchers did not analyse data in 2020 or beyond, as the pandemic may have affected the surgeries that patients underwent.

The researchers focused on seven procedures that they said are responsible for more than 80% of emergency general surgeries, related complications and deaths, and hospital costs. The seven procedures were as follows:

• partial removal of the colon
• partial removal of the small bowel
• removal of the gallbladder
• surgery for peptic ulcer disease
• removal of scar tissue that injured the intestine
• removal of the appendix
• opening the abdomen to examine organs

Of the 507,458 people whose data were analysed, 2,094 had HIV and 7,227 had HCV.

According to the researchers, people with HIV were likely to have the following attributes compared to people without HIV:

• younger age (51 vs. 59 years)
• more likely to be male (56% vs. 32%)
• more likely to be Black (44% vs. 12%) or Hispanic (17% vs. 15%)
• more likely to have a low income

People with HIV in this study were concentrated in the northeast and southern regions of the U.S.

People with HCV were likely to have the following attributes compared to people without HCV:

• younger age (56 vs. 59 years)
• more likely to be male (56% vs. 39%)
• more likely to be Black (21% vs. 12%)
• more likely to have a low income
• more likely to have liver disease (in addition to HCV infection)

People with HCV in this study were concentrated in the western and southern regions of the U.S.

Results

The researchers found that people with chronic viral infections were less likely to undergo needed surgery than people without chronic viral infections. Specifically, among people with HIV, 43% underwent one of the surgeries listed compared to 48% of people without HIV.

Among people with HCV, 34% underwent one of the surgeries listed compared to 48% of people without HCV.

These differences in surgical access persisted even when researchers considered personal factors such as age, region of residency, gender, and other pre-existing health issues. The differences also persisted when researchers explored hospital characteristics.

In general, people of colour were more likely to have HIV or HCV in this study than White people. Not surprisingly, the researchers found that people with HIV or HCV who were Black or Hispanic or who had a very low income (on Medicaid) were less likely to undergo recommended surgery compared to White people or people who had higher levels of insurance coverage. The researchers stated that this finding was aligned with other studies that have also found a disparity in levels of surgical care among people of colour in the U.S.

The researchers also stated that previous studies have found that people with HIV were less likely to undergo surgery in the U.S. even when such procedures were recommended for the following:

• heart attack
• emergency general surgery
• spinal surgery

Why do gaps in surgical care occur?

The researchers explored several possible reasons for the disparities in surgical access found in the present study. However, they dismissed some of them (such as more severe illness among people with chronic viral infections, seeking care late in the course of illness), stating that they were “unlikely to fully account for our findings.”

The researchers suspected that issues such as stigma and discrimination were relevant to their findings. They stated that “stigma may be attached to patients’ social characteristics that are not fully captured in our data, such as occupation, education level, sexual orientation or gender identity.”

The researchers noted that “due to the structural factors that predispose people to acquiring HIV or HCV, people living with HIV and HCV are more likely to hold multiple marginalized identities. If HIV and/or HCV infection is interpreted by healthcare providers as a marker for these identities, discrimination on the basis of these social characteristics could explain [the disparities] observed in our study.”

Another possible explanation advanced by the researchers is that some surgical teams may have stigma arising from “fear of occupational exposure to HIV or HCV.” The researchers stated that such stigma may cause some “surgeons and/or anesthesiologists to less frequently recommend [surgery]”, even when patients have been referred by emergency room physicians.

Improving access to needed surgery

As mentioned by the researchers, people with chronic viral infections may have multiple identities that cause them to be marginalized by larger society. The researchers suggested that the following steps be taken “to address racism and insurance status–based discrimination”:

• monitor data to reveal who does and who does not get access to surgical care
• redesign the health insurance system to ensure equitable reimbursement
• ensure greater transparency and accountability of health systems to community organizations
• expand efforts to dismantle structural racism

In addition to the above steps, the researchers suggested that education be made available to healthcare providers to explain “low rates of occupational HIV/HCV transmission, universal precautions, and ready availability of post-exposure prophylaxis for HIV”. They note that educating providers about these topics “may decrease healthcare worker stigma and discrimination”.

The researchers called for studies to test these and other potential strategies to improve access to life-saving healthcare for people with chronic viral infections, many of whom are from minority populations.

By Sean R. Hosein

REFERENCES:

1. Himmelstein KEW, Afif IN, Beard JH, et al. HIV and hepatitis C virus-related disparities in undergoing emergency general surgical procedures in the United States, 2016-2019. Annals of Surgery. 2023; in press.
2. Resneck JS Jr. Medicare Physician Payment in Need of Major Repair. JAMA. 2023; in press.