QS100 - How Do Surgical Quality Collaboratives Impact Equity in Colorectal Surgery?

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Purpose/Background: Collaborative quality initiatives (CQIs), such as the Michigan Surgical Quality Collaborative (MSQC) funded by Blue Cross Blue Shield of Michigan, have improved surgical outcomes overall. How these improvements impact disparities in outcomes must be assessed. The objective of this study was to stratify surgical outcomes by patient race and insurance type to characterize trends in colorectal surgical disparities in the MSQC.

Methods/Interventions: We performed a retrospective observational study of patients who underwent an elective colectomy (2014-23) for any diagnosis at one of the 70 MSQC hospitals. The primary exposures were race (White versus Black) and insurance payer (private versus public [Medicare, Medicaid, or dual eligible]), as these reflect known patient-level disparities due to structural inequities. Outcomes included 30-day complications, emergency department (ED) visits, and readmissions. We estimated a logistic regression model for each exposure adjusting for patient age, comorbidities, procedure, hospital, and year, with an interaction term for the exposure and year to allow the trend over time for each cohort to vary independently. Margins were estimated with the 95% confidence interval (CI) for statistical comparison of groups at each time point.

Results/Outcomes: Among 41,110 patients, the mean age (SD) was 61 (14) years and 53.2% were female. From 2014 to 2023, 30-day complications decreased for both White (19.3% to 11.5%, p< 0.001) and Black (20.2% to 13.7%, p< 0.001) patients. There were no disparities between groups at the beginning or end of the study period. ED visits did not change over the study period for White patients but decreased significantly for Black patients (12.8% to 8.8%, p< 0.001), eliminating the disparity between groups (Figure 1). Readmissions decreased for both White (11.1% to 8.5%, p< 0.001) and Black (9.7% to 9.5%, p< 0.001) patients; there were no significant disparities. Stratified by insurance, complications decreased for patients with private (16.9% to 11.6%, p< 0.001) and public (22.3% to 11.6%, p< 0.001) insurance, and the disparity between payers disappeared (Figure 2). ED visits were similar for private insurance patients but decreased for public insurance patients (9.9% to 8.6%, p< 0.001), eliminating the disparity between groups. Readmissions decreased for patients with both private (8.6% to 8.2%, p=0.04) and public (12.7% to 8.9%, p< 0.001) insurance, and the disparity also disappeared.

Conclusion/Discussion: Amongst patients undergoing elective colorectal operations in a statewide quality collaborative, baseline disparities in complications, ED visits, and readmissions between White and Black patients or patients with private versus public insurance were eliminated over time. When no baseline disparity existed both groups experienced similar improvements. This suggests statewide quality collaborative initiatives have the potential to equitably improve outcomes in elective colorectal surgery.