Inequity in Telemedicine Use Among Patients with Cancer in the Deep South During the COVID-19 Pandemic.

BACKGROUND: Telemedicine use has increased significantly during the COVID-19 pandemic. It remains unclear if its rapid growth exacerbates disparities in healthcare access. We aimed to characterize telemedicine use among a large oncology population in the Deep South during the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective cohort study was performed at the only National Cancer Institute designated-cancer center in Alabama March 2020 to December 2020. With a diverse (26.5% Black, 61% rural) population, this southeastern demographic uniquely reflects historically vulnerable populations. All non-procedural visits at the cancer center from March to December 2020 were included in this study excluding those with a department that had fewer than 100 visits during this time period. Patient and clinic level characteristics were analyzed using t-test and Chi-square to compare characteristics between visit types (in-person versus telemedicine, and video versus audio within telemedicine). Generalized estimating equations were used to identify independent factors associated with telemedicine use and type of telemedicine use. RESULTS: There were 50 519 visits and most were in-person (81.3%). Among telemedicine visits, most were phone based (58.3%). Black race and male sex predicted in-person visits. Telemedicine visits were less likely to have video among patients who were Black, older, male, publicly insured, and from lower income areas. CONCLUSIONS: Telemedicine use, specifically with video, is significantly lower among historically vulnerable populations. Understanding barriers to telemedicine use and preferred modalities of communication among different populations will help inform insurance reimbursement and interventions at different socioecological levels to ensure the continued evolution of telemedicine is equitable.

Understanding the Surgical Experience for African-Americans and Caucasians With Enhanced Recovery.

INTRODUCTION: Racial/ethnic disparities in surgical outcomes exist. Enhanced recovery programs (ERPs) have reduced some racial/ethnic disparities, but it remains unclear if disparities in experiences are also reduced. The purpose of this study was to use qualitative methods to better understand the surgical experience for African-American and Caucasian patients in the setting of an ERP. METHODS: Using purposeful sampling at a minority-serving institution, we recruited African-American and Caucasian patients who had undergone colorectal surgery under an ERP to six focus groups. Participants identified barriers and facilitators to a positive, or negative, surgical experience. Audio recordings were transcribed and analyzed using an indicative thematic approach with NVivo 10 software (QSR International). RESULTS: Forty-three patients (15 African-Americans and 28 Caucasians) participated in six focus groups. Six themes were identified by patients to be important in surgery: 1) knowledge about colorectal surgery, 2) obtaining information, 3) quality of information, 4) setting expectations about surgery, 5) following preoperative and postoperative instructions, and 6) confidence in surgery outcomes. For both racial/ethnic groups, patients felt that more information could have been provided, information should be given at their level of understanding, and trust in the physician made them feel confident in a positive outcome. African-American patients described experiences of having incorrect or no expectations on surgical outcomes, being provided inconsistent information, and feeling misled. African-Americans also described following instructions from family members and valued the importance of diet and exercise in recovery. CONCLUSIONS: African-American and Caucasian surgical patients have varied surgical experiences even under an ERP. All patients, however, valued the ability to obtain, process, and understand health information during the surgical process. These elements define "health literacy" and suggest the importance of providing health literacy-sensitive care in surgery.

Understanding the surgical experience for Black and White patients with inflammatory bowel disease (IBD): The importance of health literacy.

BACKGROUND: Racial/ethnic disparities in outcomes exist for patients with inflammatory bowel disease (IBD) undergoing surgery. The underlying mechanism(s) remain unclear and patient perspectives are needed. We therefore aimed to characterize the surgical experience for Black and White IBD patients using qualitative methods. METHODS: Patients with IBD who had undergone surgery were recruited to same-race qualitative interviews. Semi-structured interviews explored barriers and facilitators to a positive or negative surgical experience. Transcripts were analyzed with NVivo 12 software. RESULTS: Six focus groups were conducted that included 10 Black and 17 White IBD participants. The mean age was 44.8 years (SD 13.2), 52% were male and 65% had Crohn's disease. Four themes emerged that most defined the surgical experience: the impact of the IBD diagnosis, the quality of provided information, disease management and the surgery itself. Within these themes, barriers to a positive surgical experience included inadequate personal knowledge of IBD, ineffective written and verbal communication, lack of a support system and complications after surgery. Both groups reported that information was provided inconsistently which led to unclear expectations of surgical outcomes. CONCLUSIONS: Black and White patients with IBD have varied surgical experiences but all stressed the importance of accurate, trustworthy and understandable health information. These findings highlight the value of providing health literacy-sensitive care in surgery.

Cost-benefit analysis of a patient engagement technology (PET) in cardiac, thoracic, and colorectal surgery.

BACKGROUND: Patient engagement technologies (PETs) guide patients through perioperative care, but little is known about their costs-benefits. METHODS: Retrospective cohort study of patients undergoing elective colorectal, cardiac, thoracic surgery 2015-2020. PET was implemented 2018. Patients were propensity-matched in pre-PET, PET, non-PET groups. Costs of surgical encounter and 30 days post-discharge, mortality, length-of-stay, readmissions, complications, satisfaction were compared. RESULTS: Overall, 4,373 patients underwent surgery and 607 (13.9%) patients enrolled in the PET. PET patients did not have increased costs in any specialty. Colorectal PET patients' variable costs of surgical encounter were $102 lower than non-PET, $1495 lower than pre-PET (p = 0.03). Thoracic PET patients' total costs of surgical encounter were $9224 lower than non-PET, $2187 lower than pre-PET (p = 0.03). Thoracic PET patients had lower mean LOS (2.4 days, 5.1 non-PET, 3.1 pre-PET, p = 0.03). PET patient satisfaction ranged 86.0%-97.8%. CONCLUSIONS: Use of a PET did not increase costs and was associated with benefits for patients undergoing elective surgery.

Increased Risk of Postoperative Mortality Associated With Prior COVID-19 Infection.

INTRODUCTION: The impact of COVID-19 infection on surgical patients is largely described by small-cohort studies. This study characterized the risk factors for postoperative mortality among patients with preoperative COVID-19 infection. METHODS: Data were abstracted from the electronic medical record for patients who tested positive for COVID-19 before surgery, excluding procedures related to extracorporeal membrane oxygenation (case, March 2020-April 2021). Mortality was compared with that for patients from the American College of Surgeons National Surgical Quality Improvement Program database (control, January 2018‒February 2020) with chi-square, t test, and multivariable regression. RESULTS: There were 5,209 patients in the control cohort. Among 1,072 patients with positive COVID-19 testing before surgery, 589 had surgeries with specialties tracked by the American College of Surgeons National Surgical Quality Improvement Program (General Surgery, Gynecology, Neurosurgery, Orthopedics, Thoracic, Vascular). Patients with previous COVID-19 infection were younger (age 48 vs 59 years, p<0.001), were more likely to be Black (42% vs 28%, p<0.001), and underwent fewer elective surgeries (55% vs 83%, p<0.001). Postoperative mortality was greater among the case cohort (4.4% vs 1%, p<0.001). On multivariable logistic regression, postoperative mortality increased with age (OR=1.02), emergent surgeries (OR=2.6), and previous COVID-19 infection (OR=3.8). Among patients with previous COVID-19 infection, postoperative mortality was associated with male sex (OR=2.7), higher American Society of Anesthesiologists Physical Status Classification Score (OR=4.8), and smoking history (OR=3.7). CONCLUSIONS: Although data abstraction was limited by the electronic medical record, postoperative mortality is nearly 6 times higher for patients infected with COVID-19 within 2 weeks before surgery when adjusting for patient- and procedure-level factors. Among those with previous COVID-19 infection, postoperative mortality is associated with male sex, American Society of Anesthesiologists Physical Status Classification Score, and smoking history.

Improving surgical patient education materials using informational design with visual elements.

Patient education materials (PEMs) serve as a foundation for educating patients and families across all surgical fields but are often not understandable. The National Institute of Health (NIH) recommends that PEMs be written at a grade 6-7 reading level; however, most current materials exceed that measure.3 Lack of understandable and appropriate surgical PEMs compounds the difficulties that low health literacy patients face with resultant poor surgical outcomes.2,3 The challenge for surgeons is to adequately educate patients pre-operatively and post-operatively on the complexities of surgery. Another challenge is to compact decades of education and training into an easy-to-understand medium for patients. To address this challenge, many physicians have utilized visual aids to improve PEM efficacy. While visual aids are a critical piece of education materials, they must be designed intentionally to be effective. The most important consideration is that the PEM communicates the information clearly to users. With this in mind, we created a framework for productive utilization of visual aids by integrating the C.A.R.P. graphic design technique into an existing surgical PEM to enhance communication and understandability.

Racial disparities exist in surgical outcomes for patients with inflammatory bowel disease.

BACKGROUND: Racial disparities in surgical outcomes exist for Black patients with IBD compared to White patients. However, previous studies fail to include other racial/ethnic populations. We hypothesized these disparities exist for Hispanic and Asian patients. METHODS: This is a retrospective cohort study of patients undergoing surgery for IBD using the American College of Surgeons National Surgical Quality Improvement Program (ACS- NSQIP) database (2005-2017). Bivariate comparisons and adjusted multivariable regressions were performed to evaluate associations between race and outcomes. RESULTS: Of 23,901 patients with IBD, the racial/ethnic makeup were: 88.7% White, 7.6% Black, 2.4% Hispanic and 1.4% Asian. Overall mean LOS was 8 days (SD 8.2) and significantly varied between groups (8d for White, 10d for Black, 8.5d for Hispanic, and 11.1d for Asian; p < 0.001). Hispanic patients had the highest odds of readmission (OR: 1.4; 95% CI 1.1-1.8). Black patients had increased odds of renal insufficiency (OR: 1.8; 95% CI 1.1-2.9), bleeding requiring transfusions (OR: 1.7; 95% CI 1.4-1.9), and sepsis (OR: 1.7; 95% CI 1.4-2.02) compared to White patients. CONCLUSIONS: Racial disparities exist among IBD patients undergoing surgery. Black, Hispanic and Asian IBD patients experience major disparities in post-operative complications, readmissions and LOS, respectively, when compared to White patients with IBD. Future research is needed to better understand the mechanisms of these disparities including evaluation of social determinants of health.

Low Health Literacy Exists in the Inflammatory Bowel Disease (IBD) Population and Is Disproportionately Prevalent in Older African Americans.

BACKGROUND: Low health literacy is common in general populations, but its prevalence in the inflammatory bowel disease (IBD) population is unclear. The objective of this study was to assess the prevalence of low health literacy in a diverse IBD population and to identify risk factors for low health literacy. METHODS: Adult patients with IBD at a single institution from November 2017 to May 2018 were assessed for health literacy using the Newest Vital Sign (NVS). Demographic and socioeconomic data were also collected. Primary outcome was the prevalence of low health literacy. Secondary outcomes were length-of-stay (LOS) and 30-day readmissions after surgical encounters. Bivariate comparisons and multivariable regression were used for analyses. RESULTS: Of 175 IBD patients, 59% were women, 23% were African Americans, 91% had Crohn disease, and mean age was 46 years (SD = 16.7). The overall prevalence of low health literacy was 24%. Compared to white IBD patients, African Americans had significantly higher prevalence of low health literacy (47.5% vs 17.0%, P < 0.05). On multivariable analysis, low health literacy was associated with older age and African American race (P < 0.05). Of 83 IBD patients undergoing abdominal surgery, mean postoperative LOS was 5.5 days and readmission rate was 28.9%. There was no significant difference between LOS and readmissions rates by health literacy levels. CONCLUSIONS: Low health literacy is present in IBD populations and more common among older African Americans. Opportunities exist for providing more health literacy-sensitive care in IBD to address disparities and to benefit those with low health literacy.

Health Literacy in Surgery.

BACKGROUND: Low health literacy is associated with poor health outcomes in many chronic diseases and may have an important role in determining surgical outcomes. This study aims to comprehensively review the current state of science on adult health literacy in surgery and to identify knowledge gaps for future research. METHODS: Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic search was conducted to identify all studies from January 2002 through May 2018 that used validated instruments to assess health literacy among adult patients undergoing surgery. Studies were assessed for quality using the Newcastle-Ottawa scale and evaluated on findings by their focus on identifying health literacy levels, understanding associations with surgical outcomes, and/or developing interventions to address low health literacy. KEY RESULTS: There were 51 studies on health literacy with data from 22,139 patients included in this review. Low health literacy was present in more than one-third of surgical patients (34%, interquartile range 16%-50%). The most commonly used validated instrument for assessment of health literacy in the surgical population was the Newest Vital Sign. Most studies were focused on identifying the prevalence of low health literacy within a surgery population (84%, n = 43). Few studies focused on understanding the association of health literacy to surgical outcomes (12%, n = 6) and even fewer studies developed interventions to address health literacy (4%, n = 2). DISCUSSION: Low health literacy is common among surgical patients. Important opportunities exist to better understand the role of health literacy in determining surgical outcomes and to develop more health literacy-sensitive models of surgical care. [HLRP: Health Literacy Research and Practice. 2020;4(1):e45-e65.] PLAIN LANGUAGE SUMMARY: Health literacy has not been well-studied in surgery but likely plays an important role. In this article, we reviewed all current research on health literacy in surgery to help us understand where we are at and where we need to go. We found that low health literacy is common and we need more ways to address it in surgery.