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RACIAL DISPARITIES IN PATIENT EXPERIENCE UNDER AN ENHANCED RECOVERY AFTER SURGERY (ERAS) PATHWAY: A ROLE FOR HEALTH LITERACY?
Robert H. Hollis*, Ivan Herbey, Lauren Goss, Jamie A. Cannon, Gregory D. Kennedy, Melanie Morris, Sara J. Knight, Daniel I. Chu
Surgery, University of Alabama at Birmingham, Birmingham, AL

Introduction:
Racial disparities in surgical outcomes exist. Standardizing care with pathways such as ERAS may reduce some of these disparities, but the underlying mechanism(s) remain unclear. Part of this ambiguity stems from the lack of understanding of the surgical experience for patients of different racial/ethnic identities. To address this gap in knowledge, we used qualitative methods to explore the surgical experience for African-American and Caucasian-American patients under an ERAS pathway.

Methods
Purposively selected patients who had undergone colorectal surgery under an ERAS protocol in 2016 from a minority-serving single-institution were recruited to participate in same-race focus groups. We developed a semi-structured interview guide that addressed the patient's experience in the entire perioperative period. Focus groups were audio-recorded and transcribed verbatim. Interview transcripts were coded and then organized into larger categories using thematic analysis with NVivo 10 software.

Results
Three focus groups were conducted including 16 African-American and 8 Caucasian-American patients. Six common themes emerged from the analysis: 1) variations in knowledge about surgery and the recovery process, 2) differences in the methods for obtaining information about surgery, 3) varying quality of surgical information, 4) different expectations for surgical outcomes, 5) compliance with perioperative surgery instructions when given, and 6) importance of confidence in surgical outcomes including trust in the physician. For both groups, patients felt that more information could have been provided, information should be given at their level of understanding, and that trust in the physician made them feel confident in a positive outcome. Compared to Caucasians, African-American patients described more cases of no or wrong expectations on surgical outcomes, being provided inconsistent information, and even feeling misled on the surgical process. African-Americans also described following instructions more from family members, valuing the importance of diet and exercise in recovery, and using the Internet to gain information.

Conclusions
African-American and Caucasian-American patients have varied surgical experiences even under ERAS. Patients value the ability to obtain, process and understand health information during the surgical process. These domains are the very definition of health literacy and suggest the importance of providing literacy-sensitive care in surgery.


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