Patients undergoing colorectal surgery at a Veterans Affairs Hospital do not experience racial disparity in length of stay either before or after implementing an enhanced recovery pathway

Abstract

Background Enhanced Recovery Pathways (ERP) have been shown to reduce racial disparities following surgery. The objective of this study is to determine whether ERP implementation mitigates racial disparities at a Veterans Affairs Hospital. Methods A retrospective cohort study was conducted using data obtained from the Veterans Affairs Surgical Quality Improvement Program. All patients undergoing elective colorectal surgery following ERP implementation were included. Current procedural terminology (CPT) codes were used to identify patients who underwent similar procedures prior to ERP implementation. Results Our study included 417 patients (314 pre-ERP vs. 103 ERP), 97.1% of which were male, with an average age of 62.32 (interquartile range (IQR): 25–90). ERP patients overall had a significantly shorter post-operative length of stay (pLOS) vs. pre-ERP patients (median 4 days (IQR: 3–6.5) vs. 6 days (IQR: 4–9) days (p < 0.001)). Within the pre-ERP group, median pLOS for both races was 6 days (IQR: 4–6; p < 0.976) and both groups experienced a decrease in median pLOS (4 vs. 6 days; p < 0.009 and p < 0.001) following ERP implementation. Conclusions Racial disparities did not exist in patients undergoing elective surgery at a single VA Medical Center. Implementation of an ERP significantly reduced pLOS for black and white patients.

Serving Those Who Served: Enhancing Colorectal Surgery Care for Veterans

“…The population of veterans includes many vulnerable groups such as individuals of low socioeconomic status, those who identify as lesbian, gay, bisexual, transgender, and questioning (LGBTQ), racial minorities, and those suffering from severe mental health illness. 12,13 Compared with the civilian population, veterans receiving care within the VA health care system are more likely to suffer from multiple comorbidities, including cardiovascular disease, diabetes, psychiatric illnesses, and substance use disorders. 6,10,11 Additional differences include the VA patient population being predominantly men (90%).…”

“…Notwithstanding, as within the private sector, health disparities within the VA have been documented across a variety of sociodemographic factors that include race, ethnicity, sex, LGBTQ identity, psychiatric illness, housing instability, and distance from VA medical centers. 12,13 In response, the VA has developed strategic plans (e.g., VHA Health Equity Plan and the Blueprint for Excellence) with specific goals to help address and mitigate health disparities. 13…”

“…22 In contrast, numerous VA studies examining disparities among racial and ethnic minorities have found no clear evidence of differences in receipt of guideline-concordant colorectal cancer care; however, there have been certain areas in which disparities have been detected. 12,24 For example, in a retrospective study evaluating underuse of recommended therapies for colorectal cancer in the VA, Landrum et al found no racial disparities in either access or recommendations related to either colon or rectal surgery but did find that African Americans veterans were more likely than white veterans to decline curative surgery for rectal cancer (14.6% vs. 4.8%). 38 In a single-institution study by Sabounchi et al, use of chemotherapy but not radiotherapy was noted be significantly lower in African American veterans as compared with white veterans, but despite this difference, colorectal cancer outcomes remained similar.…”

“…11 For elective colorectal procedures, ERAS programs have been associated with reduced lengths of stay, overall perioperative morbidity, and health care costs without increasing complications or hospital readmissions. 12,41,42 In 2018, the VA ESP published their findings from a systemic review of ERP's for elective colorectal surgery and identified there was reduced length of stay and perioperative morbidity compared with standard protocols. 40 Recently, Rentas et al performed a study aimed at determining whether implementation of an ERP in elective colorectal surgery mitigates racial disparities at the VA.…”

“…The principal findings in this study included a reduction in median postoperative length of stay by 2 days without significant increases in postoperative readmissions or complications and an absence of racial disparities. 12…”