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RACIAL DISPARITIES IN TIME TO STOMA REVERSAL PERSIST EVEN AFTER ADJUSTMENT FOR PATIENT, SOCIAL AND STOMA-LEVEL CHARACTERISTICS
Drew J. Gunnells*1, Allison A. Gullick2, Melanie Morris2, Gregory D. Kennedy2, Jamie A. Cannon2, Daniel I. Chu2
1General Surgery, University of Alabama at Birmingham, Birmingham, AL; 2Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, AL
PURPOSE: To investigate racial disparities in stoma reversal rates and time to reversal.
Introduction: Previous studies have observed racial disparities in stoma reversal (SR) rates. These studies were limited by claims-based covariates and could not adjust for factors such as social determinants of health (SDOH) or include time to stoma reversals. Our aim was to investigate the role of race in SR rates and time to reversal at a minority-serving hospital with adjustment for these factors. We hypothesized that racial disparities would persist.
METHODS: All adult patients (>18yrs) who received an ileostomy or colostomy from 2006-2014 at a minority-serving, tertiary-care academic medical center were identified. Patients with permanent stomas were excluded. Patients were stratified by race. Covariates included SDOH, indication for operation and stoma characteristics. Primary outcomes were SR rates and time to reversal. Using stepwise logistic regression, adjusted predictors of SR reversal were determined. A multivariate Cox proportional hazards analysis was performed to examine predictive factors of time to SR.
RESULTS: Of 673 patients who underwent a stoma construction, 446 (66.3%) underwent SR. Of those reversed, 78.9% were white and 21.1% black. Compared to white patients, black patients had less ileostomies (72.3 vs. 85.2 %), more colostomies (27.7 vs 14.8%), less loop configurations (66.0 vs 72.4 %), and more end configurations (34 vs. 27.6%). Indications for index operations included colorectal cancer (35%), inflammatory bowel disease (34.5%), benign disease (19.7%), and diverticular disease (10.8%). Black patients were nearly twice as likely to have diverticular disease (17.0 vs 9.1%, p<0.05). Black patients were significantly more disadvantaged than white patients with neighborhood summary scores of -3.0 vs 2.31, respectively (p<0.05). Overall, black patients had lower SR rates (58.8 vs 68.6%). Compared with white patients, black patients also had significantly longer median and mean time to reversal, 135 vs 126 days and 253 vs 183 days, respectively (p<0.05). On adjusted analysis for covariate differences, race did not predict overall SR rates. Instead, major predictors for SR included having a loop ileostomy, IBD or diverticular disease, and private insurance. For time to reversal, black race (HR= 0.784) was associated with longer time to SR. Additional predictors for delays included having an end ostomy (0.502), colorectal cancer (HR= 0.705), and being socially disadvantaged.
CONCLUSIONS: While overall SR rates are similar, black patients were significantly at risk for delay to SR even after adjustment for patient, social and stoma-level characteristics. Future work is necessary to understand the mechanisms for these observed disparities.
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