Disparities Across Race, Ethnicity, and Rurality Among Surgical Patients

Objective: Our study seeks to assess the interplay between race and ethnicity and rurality on surgical outcomes. Background: Disparities in surgical care for rural Americans are well-documented, but little research takes into account the growing racial and ethnic heterogeneity of rural America. Prior studies defining difficulties in access to surgical care have primarily studied “race” and “place” separately. Methods: We performed a retrospective study of rural and urban Medicare beneficiaries who underwent common general surgical procedures between 2016 and 2020. Rurality was defined based on beneficiary residential ZIP codes and corresponding Rural-Urban Commuting Area score 4–10. We used patient and hospital factors for risk adjustment in multivariable logistic regression models to determine rates of postoperative 30-day mortality, complications, serious complications, and unplanned procedures. Results: We identified 325,183 rural and 1,278,405 urban beneficiaries who underwent surgery. After risk adjustment, nonwhite rural patients had higher rates of 30-day mortality [odds ratio (OR): 1.11, 95% confidence interval (CI): 1.04–1.18, P = 0.003], complications (OR: 1.15, 95% CI: 1.10–1.19, p < 0.001), and serious complications (OR: 1.25, 95% CI: 1.19–1.32, P < 0.001). Rural adjusted rates for 30-day mortality were 6.99% for Nonwhite versus 6.55% for white patients ( P < 0.001), compared to 5.98% for urban Nonwhite versus 5.75% for urban white patients ( P < 0.001). The difference in difference of 0.43% (95% CI: 0.07–0.80) indicated the additive disparity of nonwhite race and rural residence. Conclusions: Nonwhite rural beneficiaries were significantly more likely to experience a postoperative complication and experienced higher rates of 30-day mortality when compared with their white rural counterparts. When compared with urban patients stratified by race or ethnicity, nonwhite rural patients experienced significantly greater mortality disparity.