In a number of papers dating back to the 1990s, Moul and colleagues clearly demonstrated that simply being African American places men with prostate cancer at greater risk for biochemical progression after surgical treatment than men of white race — even in an equal access health care system like that of the US military.
A new paper by Barocas et al. has now demonstrated (yet again) that in the “real world” of community medicine in the USA, there are major quality-of-care “gaps” between the outcomes of black and white males undergoing radical prostatectomy for localized prostate cancer.
Barocas and his colleagues were able to utilize databases encompassing all non-federal hospitals in the states of Florida, Maryland, and New York to identify data for men older than 18 years who underwent a radical prostatectomy between 1996 and 2007. They limited their analysis to data from institutions and surgeons in the top 25 percent (quartile) of the total sample for annual volume so as to ensure that they were assessing only those institutions and surgeons within this data set that were arguably “best” at the conduct of radical prostatectomy itself, at minimizing the need for inpatient blood transfusion associated with surgery, at limiting risk for complications of surgery, at limiting risk for inpatient mortality post-surgery, and for minimizing postoperative time of hospitalization (length of stay).
Here are the core findings of the study:
- The total database included 105,972 patients, of whom
- 81,112 (76.5 percent) were white
- 14,006 (13.2 percent) were black
- 6,999 (6.6 percent) were hispanic
- 3,855 (3.6 percent) were of “all other” races
- Compared to white patients, the black patients exhibited
- Much lower use of high-volume institutions (odds ratio [OR] = 0.73)
- Much lower use of high-volume surgeons (OR = 0.67)
- Higher risk for blood transfusions (OR = 1.08)
- Higher risk for inpatient mortality (OR = 1.73)
- Longer lengths of stay post-surgery (OR = 1.07)
Now it is also worth noting that “high-volume” institutions and “high-volume” surgeons in this analysis are hardly what most regular readers of this blog would consider to be “high volume” at all:
- The 75th percentile of high-volume institutions ranged between an annual volume of 21 and 35 radical prostatectomies per year.
- The 75th percentile of high-volume surgeons ranged between 5 and 12 radical prostatectomies per year.
The fundamental conclusion of this paper by Barocas et al. is that (in non-federal hospitals, in the three states specified, during the period from 1996 to 2007, regardless of type of insurance coverage) black males electing to undergo radical prostatectomy for localized prostate cancer had substantially lower access to “high-volume” surgeons and “high-volume” institutions than did white males. Furthermore, their outcomes with regard to inpatient care were also less satisfactory than those of white males.
Given that (as Moul and his colleagues have clearly shown previously) black males undergoing surgery are already at greater risk for progressive disease than whites for reasons that have nothing to do with their quality of care, it is very saddening to see that the quality of care provided to members of the African American community is also only adding to risk of poorer outcomes for black males with localized prostate cancer after treatment at many non-federal hospitals.