Review: An Ecological Framework for Racial and Ethnic Disparities in Surgery

Racial/ethnic minority groups in the U.S. have substantially higher mortality rates after surgical procedures than white individuals. Much of the research into these disparities has focused on social determinants of health, but nonpatient-related factors are also important influences.

Quoc-Dien Trinh, MD, MBA, director of ambulatory clinical operations in the Division of Urology at Brigham and Women’s Hospital, Nicola Frego, MD, formerly in the Division, Vincent D’Andrea, MD, resident physician in the Division, and Muhieddine Labban, MD, intern in the Division, recently developed an analytic model of four interconnected sets of macro-level factors that influence access to high-quality, evidence-based surgical care. Their review appears in Current Problems in Surgery.


The team identified 1,924 papers published between January 2000 and June 2022 that reported primary research into U.S. racial disparities in receipt of surgery and/or surgical outcomes via Pubmed. The outcomes reviewed were surgical complications and mortality.

Patient-level Factors

Besides socioeconomic status, patient-level factors include minority groups’ greater burden of comorbidities and greater presence of advanced disease at diagnosis, as well as preferences for providers who share their cultural backgrounds.

The higher burden of comorbidity probably increases the surgical risk profile, leading surgeons to opt for more conservative approaches, which could partly explain poorer outcomes. Patients diagnosed at an advanced stage may no longer be surgical candidates at all.

Hospital-level Factors

Black and Latino/a/x patients are less likely than white patients to be treated in high-volume hospitals and more likely to seek treatment in minority-serving hospitals and safety-net hospitals (those serving the largest proportion of underinsured patients).

A newer term in the literature is “hospital systems serving health disparity populations” (HSDPs). These can be minority-serving hospitals, high-burden safety-net hospitals, or both.

Patients who undergo surgery at HSDPs typically have poorer outcomes, but benefits include increased diversity in healthcare staff, reduced language barriers, reduced financial barriers, and a history of treating minority populations, which may make them more trusted by their communities. Explicit identification of HSDPs may facilitate the allocation of funds and increase the volume and expertise at these sites.

The review showed people of racial/ethnic minority groups are less likely to be recommended for surgery, less likely to be treated with minimally invasive techniques, and face disparities in the receipt, timing, and quality of postoperative care, post-discharge rehabilitation, and palliative care.

Community Factors

Residential segregation has been shown to correlate with differential access to healthcare. For example, a study published in BJU International found each percentage point increase in a county’s Black or Latino/a/x population is associated with a statistically significant decrease in outpatient surgery volume, ambulatory surgical facilities, and the number of general surgeons.

Lack of reliable public transportation or a dearth of options exacerbates the problem because it’s a barrier to seeking care before a disease becomes advanced.

Structural Factors

In 2011, the U.S. Department of Health and Human Services launched a significant action plan to improve healthcare equality for all people of races and ethnicities. However, the evidence reviewed here implies it has failed to mitigate racial disparities in access to care.

The same appears to be true of the Affordable Care Act and the hospital value-based purchasing program implemented by the Center for Medicare & Medicaid Services (the transition from pay-for-service to pay-for-performance). In fact, as reported in Annals of Surgery, the latter program disproportionally penalizes minority-serving and safety-net hospitals, taking funds away from facilities that were already resource-constrained.


The intersection of race/ethnicity with medicine in the U.S. is incredibly complex, and many unidentified factors probably confound this analysis. Still, the interconnections between these factors represent an ecological framework that can help clinicians and researchers conceptualize and evaluate surgical disparities.

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