Background: While significant efforts have been made to understand surgical disparities for procedures that are performed in either the elective or unplanned settings, far less is known about procedures performed in both settings. Methods: Cross-sectional study of 1,135,743 Medicare beneficiaries undergoing incisional hernia repair, colectomy, or abdominal aortic aneurysm repair between 2014 and 2018. Risk-adjusted outcomes were assessed using multivariable logistic regression. Results: Compared to White beneficiaries, unplanned surgery rates were higher for Black (44.0%vs38.8%, OR = 1.29,p < 0.001) and Asian beneficiaries(40.4%vs38.8%,OR = 1.09,p < 0.001). While there were minimal differences in 30-day mortality for elective procedures, unplanned procedures demonstrated wider disparities (Black vs White 12.4%vs11.3%,OR = 1.11,p < 0.001; Asian vs White 13.2%vs11.3%,OR = 1.18,p < 0.001). Similar patterns were observed for readmissions. Conclusions: Unplanned procedures are more common and demonstrate wider disparities in outcomes among minority Medicare beneficiaries. Reducing unplanned surgery rates among these groups may be an effective strategy to limit overall disparities in postoperative outcomes.

BACKGROUND: Racial differences in pulse oximeter accuracy increasingly have become recognized. However, previously published literature has not examined the extent to which underlying racial differences in levels of hypoxemia, such as those arising from differential testing, disease recognition, and treatment, may confound previously observed differences in pulse oximetry measurement. RESEARCH QUESTION: The presented study examined the extent to which underlying differences in arterial oxygen saturation (SaO(2)) drive previously observed racial differences in pulse oximetry occult hypoxemia measurement. STUDY DESIGN AND METHODS: Analysis was completed as a secondary data analysis of two existing databases. Data were reanalyzed from the previously published Veterans Affairs (VA) Patient Database (2013-2019) and the Extracorporeal Life Support Organization (ELSO) registry (2019-2020). Patients included general ward and critically ill patients. We compared the measured burden of occult hypoxemia (ie, SaO(2) < 88%, with peripheral capillary oxygen saturation >= 92%) when standardizing for population-level distributions of SaO(2) vs when standardizing the sensitivity at each SaO(2). RESULTS: Black patients showed a higher likelihood of occult hypoxemia when compared with White patients in both data sources (Veterans Affairs Patient Database, 18.8% vs 14.9%; Extracorporeal Life Support Organization registry, 14.6% vs 7.0%). The distribution of SaO(2), to an extent, does change the measured occult hypoxemia rates; however, large racial differences were persistent after standardizing based on underlying SaO(2 )distributions. INTERPRETATION: Underlying differences in SaO(2) distributions were observed in the analyzed data. Such differences point to ongoing differentials in care; however, even when accounting for SaO(2) distributions, differential detection of hypoxemia by race persisted in pulse oximeters in contemporary use.

Objective:The aim of this study was to evaluate changes in 30-day postoperative outcomes and individual hospital variation in outcomes from 2012 to 2019 in a collaborative quality improvement network. Summary Background Data:Collaborative quality improvement efforts have been shown to improve postoperative outcomes overall; however, heterogeneity in improvement between participating hospitals remains unclear. Understanding the distribution of individual hospital-level changes is necessary to inform resource allocation and policy design. Methods:We performed a retrospective cohort study of 51 hospitals in the Michigan Surgical Quality Collaborative (MSQC) from 2012 to 2019. Risk-and reliability-adjusted hospital rates of 30-day mortality, complications, serious complications, emergency department (ED) visits, readmissions, and reoperations were calculated for each year and compared between the last 2 years and the first 2 years of the study period. Results:There was a significant decrease in the rates of all 5 adverse outcomes across MSQC hospitals from 2012 to 2019. Of the 51 individual hospitals, 31 (61%) hospitals achieved a decrease in mortality (range -1.3 percentage points to +0.6 percentage points), 40 (78%) achieved a decrease in complications (range -8.5 percentage points to +2.9 percentage points), 26 (51%) achieved a decrease in serious complications (range -3.2 percentage points to +3.0 percentage points), 29 (57%) achieved a decrease in ED visits (range 5.0 percentage points to +2.2 percentage points), 46 (90%) achieved a decrease in readmissions (range -3.1 percentage points to +0.4 percentage points) and 39 (76%) achieved a decrease in reoperations (range 3.3 percentage points to +1.0 percentage points). Conclusions:Despite overall improvement in surgical outcomes across hospitals participating in a quality improvement collaborative, there was substantial variation in improvement between hospitals, highlighting opportunities to better understand hospital-level barriers and facilitators to surgical quality improvement.

Mcdyer JF, et al. The effect of HIV infection on longitudinal lung function decline among IDUs: a prospective cohort. AIDS 2013;27: 1303–1311. 3 Drummond MB, Kunisaki KM, Huang L. Obstructive lung diseases in HIV: a clinical review and identification of key future research needs. Semin Respir Crit Care Med 2016;37:277–288. 4 Presti RM, Flores SC, Palmer BE, Atkinson JJ, Lesko CR, Lau B, et al. Mechanisms underlying HIV-associated noninfectious lung disease. Chest 2017;152:1053–1060. 5 Martinez CH, Diaz AA, Meldrum C, Curtis JL, Cooper CB, Pirozzi C, et al.; SPIROMICS Investigators. Age and small airway imaging abnormalities in subjects with and without airflow obstruction in SPIROMICS. Am J Respir Crit Care Med 2017;195:464–472. 6 Labaki WW, Martinez CH, Martinez FJ, Galb an CJ, Ross BD, Washko GR, et al. The role of chest computed tomography in the evaluation and management of the patient with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2017;196:1372–1379. 7 Vasilescu DM, Martinez FJ, Marchetti N, Galb an CJ, Hatt C, Meldrum CA, et al. Noninvasive imaging biomarker identifies small airway damage in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2019;200:575–581. 8 Maselli DJ, Yen A, Wang W, Okajima Y, Dolliver WR, Mercugliano C, et al. Small airway disease and emphysema are associated with future exacerbations in smokers with CT-derived bronchiectasis and COPD: results from the COPDGene cohort. Radiology 2021;300:706–714. 9 Lambert AA, Kirk GD, Astemborski J, Mehta SH, Wise RA, Drummond MB. HIV infection is associated with increased risk for acute exacerbation of COPD. J Acquir Immune Defic Syndr 2015;69: 68–74. 10 Raju S, Astemborski J, Drummond MB, Ramamurthi HC, Sun J, Brown RH, et al. Brief report: HIV is associated with impaired pulmonary diffusing capacity independent of emphysema. J Acquir Immune Defic Syndr 2022;89:64–68. 11 Drummond MB, Lambert AA, Hussien AF, Lin CT, Merlo CA, Wise RA, et al. HIV infection is independently associated with increased CT scan lung density. Acad Radiol 2017;24:137–145. 12 Quanjer PH, Stanojevic S, Cole TJ, Baur X, Hall GL, Culver BH, et al. Multi-ethnic reference values for spirometry for the 3–95 year age range: the global lung function 2012 equations. Eur Respir J 2012;40: 1324–1343. 13 Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, et al.; ATS/ERS Task Force. Standardisation of spirometry. Eur Respir J 2005;26:319–338. 14 Checkley W, Foreman MG, Bhatt SP, Dransfield MT, Han M, Hanania NA, et al.; COPDGene Study Investigators. Differences between absolute and predicted values of forced expiratory volumes to classify ventilatory impairment in chronic obstructive pulmonary disease. Respir Med 2016;111:30–38. 15 King GG, Brown NJ, Diba C, Thorpe CW, Mu~ noz P, Marks GB, et al. The effects of body weight on airway calibre. Eur Respir J 2005;25: 896–901. 16 Morris A, Sciurba FC, Norris KA. Pneumocystis: a novel pathogen in chronic obstructive pulmonary disease? COPD 2008;5:43–51. 17 Bhatt SP, Bodduluri S, Hoffman EA, Newell JD Jr, Sieren JC, Dransfield MT, et al.; COPDGene Investigators. Computed tomography measure of lung at risk and lung function decline in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2017;196:569–576. 18 Verleden SE, Kirby M, Everaerts S, Vanstapel A, McDonough JE, Verbeken EK, et al. Small airway loss in the physiologically ageing lung: a cross-sectional study in unused donor lungs. Lancet Respir Med 2021;9:167–174. 19 Hern andez Cordero AI, Yang CX, Yang J, Horvath S, Shaipanich T, MacIsaac J, et al. Airway aging and methylation disruptions in HIVassociated chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2022;206:150–160. 20 Popescu I, Drummond MB, Gama L, Lambert A, Hoji A, Coon T, et al. HIV suppression restores the lung mucosal CD4 T-cell viral immune response and resolves CD81 T-cell alveolitis in patients at risk for HIVassociated chronic obstructive pulmonary disease. J Infect Dis 2016; 214:1520–1530. 21 Popescu I, Drummond MB, Gama L, Coon T, Merlo CA, Wise RA, et al. Activation-induced cell death drives profound lung CD4(1) T-cell depletion in HIV-associated chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2014;190:744–755.

INTRODUCTION:While there is a broad understanding that patient factors, hospital characteristics, and an individual's neighborhoods all contribute to the observed disparities, the relationship between these factors remains unclear. The purpose of this study was to evaluate the association of neighborhood deprivation improve postoperative outcomes for White and Black Medicare beneficiaries equally.METHODS:We performed a cross-sectional Retrospective cohort study from 2014 to 2018 of 1372,487 White and Black Medicare beneficiaries aged 65 and older who underwent an inpatient colon resection, coronary artery bypass, cholecystectomy, appendectomy, or incisional hernia repair. We compared postoperative complications, readmission, and mortality by race across neighborhood deprivation. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods Area Deprivation Index; a modern-day measure of neighborhood disadvantage that includes education, employment, housing quality, and poverty measures.RESULTS:Overall, 1372,487 Medicare beneficiaries with mean age 72.1 years, 50.3% female, 91.2% White, residing in 1107,051 unique neighborhoods underwent 1 of 5 operations. The proportion of Black beneficiaries was 6.5% within the lowest deprivation neighborhoods and increased to 16.9% within the highest deprivation neighborhoods ( P <0.001). The interaction between beneficiary neighborhood and race demonstrated that the association of neighborhood on outcomes varied by race. Specifically, White beneficiaries had 1.5% absolute mortality decrease from the highest to lowest deprivation neighborhoods [odds ratio (OR):1.32, 95% confidence interval (CI): 1.27-1.38; P <0.001], whereas Black beneficiaries had a 0.72% absolute mortality decrease from the highest to lowest deprivation neighborhoods (OR: 1.13, 95% CI: 1.02-1.24; P =0.018). Similarly, White beneficiaries had 3.6% absolute decrease in complication rate from the highest to lowest deprivation neighborhoods (OR: 1.23, 95% CI: 1.21-1.28; P <0.001) while Black beneficiaries had a 1.2%% absolute decrease in complication rate from the highest to lowest deprivation neighborhoods (OR: 1.07, 95% CI: 1.01-1.13; P =0.017). For 30-day readmission rates, White beneficiaries realized a 2.3% absolute decrease from the highest to lowest deprivation neighborhoods (OR: 1.19, 95% CI: 1.02-1.24; P <0.001), whereas Black beneficiaries saw no change (OR: 1.03, 95% CI: 0.97-1.10; P =0.269).CONCLUSIONS AND RELEVANCE:Lower neighborhood deprivation is associated with improved outcomes across both White and Black Medicare beneficiaries; however, improvement in neighborhood deprivation disproportionately favored White beneficiaries. These findings provide a cautionary example of the misperception of the protective effect of higher social class for Black patients and provide a cautionary example that improvements in neighborhoods may have disparate health impact on its members.

Organ transplantation utilizes a shared and scarce resource. In order to best utilize this resource, a network of organ procurement organizations, hospitals and individuals must work together. National societies make recommendations for policies that govern organ transplantation recoveries, however at each tier of the network there is room for variability. Donation after circulatory death (DCD) policies are one example of organ transplantation policies that are not standardized. The American Society of Transplantation Surgeons defines death in DCD recoveries as "irreversible cessation of cardiac and respiratory function." However, many individual hospitals have policies that may differ from this practice of observing pulseless electrical activity (PEA) for the ASTS recommended wait time of 2 minutes. In this study, we examined the DCD protocols of 50 adult hospitals representing a single OPO within Michigan. We hypothesized there would be institutional variance in the definition of death, the provider who can declare death and maximum wait time for the donor to expire after extubation until organ recovery is no longer pursued. We found that there was substantial variation in how each hospital defined death, with the most common definition being asystole. Most hospitals require a physician to declare death in DCD and the minutes to expire range from 60 to 120 minutes. Given that the difference between PEA and asystole may result in time lost and organs to become nonviable, we recommend that standard policies are created and there is increased education to physicians and designees that declare death in DCD recoveries.

BACKGROUND: Reducing racial disparities in lung transplant outcomes is a current priority of providers, policymakers, and lung transplant centers. It is unknown how the combined effect of race and ethnicity, gender, and diagnosis group is associated with differences in 1-year mortality and 5-year survival.METHODS: This is a longitudinal cohort study using Standard Transplant Analysis Research files from the United Network for organ sharing. A total of 25,444 patients undergoing first time lung transplanta-tion between 2006 and 2019 in the United States. The primary exposures were lung transplant recipient race and ethnicity, gender, and primary diagnosis group at listing. Multivariable regression models and cox-proportional hazards models were used to determine adjusted 1-year mortality and 5-year survival.RESULTS: Overall, 25,444 lung transplant patients were included in the cohort including 15,160 (59.6%) men, 21,345 (83.9%) White, 2,318 (9.1%), Black and Hispanic/Latino (7.0%). Overall, men had a significant higher 1-year mortality than women (11.87%; 95% CI 11.07-12.67 vs 12.82%; 95% CI 12.20%-13.44%). Black women had the highest mortality of all race and gender combinations (14.51%; 95% CI 12.15%-16.87%). Black patients with pulmonary vascular disease had the highest 1-year mortality (19.77%; 95% CI 12.46%-27.08%) while Hispanic/Latino patients with obstructive lung disease had the lowest (7.42%; 95% CI 2.8%-12.05%). 5-year adjusted survival was highest among Hispanic/Latino patients (62.32%) compared to Black (57.59%) and White patients (57.82%).CONCLUSIONS: There are significant differences in 1-year and 5-year mortality between and within racial and ethnic groups depending on gender and primary diagnosis. This demonstrates the impact of social and clinical factors on lung transplant outcomes. J Heart Lung Transplant 2023;42:985-992 & COPY; 2023 International Society for Heart and Lung Transplantation. All rights reserved.

Abstract Objectives To evaluate measurement discrepancies by race between pulse oximetry and arterial oxygen saturation (as measured in arterial blood gas) among inpatients not in intensive care. Design Multicenter, retrospective cohort study using electronic medical records from general care medical and surgical inpatients. Setting Veteran Health Administration, a national and racially diverse integrated health system in the United States, from 2013 to 2019. Participants Adult inpatients in general care (medical and surgical), in Veteran Health Administration medical centers. Main outcomes measures Occult hypoxemia (defined as arterial blood oxygen saturation (SaO2) of <88% despite a pulse oximetry (SpO2) reading of ≥92%), and whether rates of occult hypoxemia varied by race and ethnic origin. Results A total of 30 039 pairs of SpO2-SaO2 readings made within 10 minutes of each other were identified during the study. These pairs were predominantly among non-Hispanic white (21 918 (73.0%)) patients; non-Hispanic black patients and Hispanic or Latino patients accounted for 6498 (21.6%) and 1623 (5.4%) pairs in the sample, respectively. Among SpO2 values greater or equal to 92%, unadjusted probabilities of occult hypoxemia were 15.6% (95% confidence interval 15.0% to 16.1%) in white patients, 19.6% (18.6% to 20.6%) in black patients (P<0.001 v white patients, with similar P values in adjusted models), and 16.2% (14.4% to 18.1%) in Hispanic or Latino patients (P=0.53 v white patients, P<0.05 in adjusted models). This result was consistent in SpO2-SaO2 pairs restricted to occur within 5 minutes and 2 minutes. In white patients, an initial SpO2-SaO2 pair with little difference in saturation was associated with a 2.7% (95% confidence interval −0.1% to 5.5%) probability of SaO2 <88% on a later paired SpO2-SaO2 reading showing an SpO2 of 92%, but black patients had a higher probability (12.9% (−3.3% to 29.0%)). Conclusions In general care inpatient settings across the Veterans Health Administration where paired readings of arterial blood gas (SaO2) and pulse oximetry (SpO2) were obtained, black patients had higher odds than white patients of having occult hypoxemia noted on arterial blood gas but not detected by pulse oximetry. This difference could limit access to supplemental oxygen and other more intensive support and treatments for black patients.

BACKGROUND: Pulse oximeters may produce less accurate results in non-White patients. RESEARCH QUESTION: Do pulse oximeters detect arterial hypoxemia less effectively in Black, Hispanic, and/or Asian patients than in White patients in respiratory failure and about to undergo extracorporeal membrane oxygenation (ECMO)? STUDY DESIGN AND METHODS: Data on adult patients with respiratory failure readings 6 h before ECMO were provided by the Extracorporeal Life Support Organization registry. Data was collected from 324 centers between January 2019 and July 2020. Our primary analysis was of rates of occult hypoxemia-low arterial oxygen saturation (Sao(2) <= 88%) on arterial blood gas measurement despite a pulse oximetry reading in the range of 92% to 96%. RESULTS: The rate of pre-ECMO occult hypoxemia, that is, arterial oxygen saturation (Sao(2)) <= 88%, was 10.2% (95% CI, 6.2%-15.3%) for 186 White patients with peripheral oxygen saturation (Sao(2)) of 92% to 96%; 21.5% (95% CI, 11.3%-35.3%) for 51 Black patients (P = .031 vs White); 8.6% (95% CI, 3.2%-17.7%) for 70 Hispanic patients (P = .693 vs White); and 9.2% (95% CI, 3.5%-19.0%) for 65 Asian patients (P = .820 vs White). Black patients with respiratory failure had a statistically significantly higher risk of occult hypoxemia with an OR of 2.57 (95% CI, 1.12-5.92) compared with White patients (P = .026). The risk of occult hypoxemia for Hispanic and Asian patients was equivalent to that of White patients. In a secondary analysis of patients with Sao(2 )<= 88% despite Sao(2 )> 96%, Black patients had more than three times the risk compared with White patients (OR, 3.52; 95% CI, 1.12-11.10; P = .032). INTERPRETATION: Compared with White patients, the prevalence of occult hypoxemia was higher in Black patients than in White patients about to undergo ECMO for respiratory failure, but it was comparable in Hispanic and Asian patients compared with White patients.

Assessment of blood oxygen saturation is an important measure of health on which many diagnostic and treatment decisions are based. Blood oxygen saturation is most commonly assessed via pulse oximetry, with increasing use across the home, clinic, and hospital settings during the COVID-19 pandemic.1 However, inaccuracies in pulse oximetry measurement have come under scientific scrutiny over the past 2 years.2-6 Professional organizations, lawmakers, and the public have actively engaged with the issue.4 A known design flaw of the pulse oximeter is that patients with darker skin (compared with lighter skin) are more likely to experience occult hypoxemia—defined conceptually as substantial arterial hypoxemia (SaO2) detected on blood gas but not noted on simultaneous pulse oximetry (SpO2). Less is known about whether underdiagnosis of hypoxemia for historically marginalized racial and ethnic groups has consequences. In their article “Racial and Ethnic Discrepancy in Pulse Oximetry and Delayed Identification of Treatment Eligibility Among Patients With COVID-19,” Dr Fawzy and colleagues evaluate this measurement bias in pulse oximetry among a population of hospitalized patients diagnosed with COVID-19.7 The authors show measurement bias was associated with differences in delay in recognizing patients’ eligibility for COVID-19 treatment, with racial and ethnic minoritized groups being more affected. Although less visible, this is similar to the ways in which raceand ethnicity-based cutoffs in pulmonary function tests and estimated glomerular filtration fraction8 lead to underestimation of disease severity among patients of racial and ethnic minoritized groups, which in turn delays treatment of severe lung disease and limits access to timely kidney replacement therapy, including transplantation. The study by Dr Fawzy and colleagues was a retrospective analysis using a large database from 5 well-resourced hospitals.7 As in other investigations of pulse oximetry, the authors evaluated clinical SaO2 and SpO2 measurements within 10 minutes of each other, a design that allows for head-tohead comparison of pulse oximetry estimations of arterial oxygenation with the gold standard from blood gas analysis. Using race and ethnicity as a proxy for skin color, the authors chose to aggregate the data for Black−Hispanic patients and Black patients into a single study group. Dr Fawzy and colleagues reported higher rates of occult hypoxemia (SaO2 <88% when SpO2 was 92%-96%) for Asian, Black, and Hispanic patients compared with non-Hispanic White patients, as well as delayed or unrecognized eligibility for the US Centers for Disease Control and Prevention guidelineconcordant COVID-19 treatments (eg, steroids, remdesivir) for Black and Hispanic patients.7 Using underdetection of a treatment threshold to assess the consequences of undetected hypoxemia was a novel and key feature of this study. Remdesivir has US Food and Drug Administration approved use for patients whose SpO2 level is less than 94%, and dexamethasone is only recommended for patients with COVID-19 who are receiving supplemental oxygen. These findings suggest that underdetection of even mild hypoxemia can delay guidelineappropriate care. Increased mortality and/or differential mortality in patients of racial and ethnic minoritized groups has been demonstrated in studies of acute respiratory distress syndrome,9 a condition defined by arterial hypoxemia and for which treatment decisions frequently are based on pulse oximetry. Racial and ethnic discrepancy in the accuracy of commonly used pulse oximetry might play an important role in the outcome disparities described in the pulmonary literature. A recent investigation by Wong and colleagues3 similarly demonstrated consequences of underdetection of hypoxemia among a population of patients with respiratory disease. In this multicenter, retrospective, cross-sectional study using data from 3 publicly available databases that included 215 hospitals and 382 intensive care units, the authors associated higher odds of hospital mortality, elevated lactate, and high sequential organ failure assessment scores with a higher prevalence of occult hypoxemia among Asian, Black, and Hispanic patients compared with White patients. The outcome of interest (occult hypoxemia) was defined differently than in Dr Fawzy and colleagues’ study (ie, SaO2 < 88% when SpO2 > 88%), yet both studies showed that underdetected arterial hypoxemia was harmful and more frequently encountered in patients of racial and ethnic minoritized groups. Based on prior investigations and the most recent studies on pulse oximetry, 2 questions stand: (1) Why has this racial and ethnic discrepancy in the accuracy of commonly used pulse oximetry not been addressed? (2) How should clinicians respond given the increased awareness of the problem and some of its ramifications? Historical neglect of patients of racial and ethnic minoritized groups and a diminished concern for their health outcomes may explain in part why this phenomenon—differential pulse oximetry accuracy—has been recognized for more than 30 years10 and has not been corrected. Using White patients as the standard in biomedical design has led to both differential care and innovation inertia for optimizing the way devices and algorithms work for patients of racial and ethnic minoritized groups.11 The economics associated with ignoring the issue cannot be excluded from this discussion. Hospitals and practitioners continue to buy and use these devices despite their inaccuracy for non-White patients. The observation that designing a new deRelated article page 730 Opinion

Introduction: While there is a broad understanding that patient factors, hospital characteristics, and an individual’s neighborhoods all contribute to the observed disparities, the relationship between these factors remains unclear. The purpose of this study was to evaluate the association of neighborhood deprivation improve postoperative outcomes for White and Black Medicare beneficiaries equally. Methods: We performed a cross-sectional Retrospective cohort study from 2014 to 2018 of 1372,487 White and Black Medicare beneficiaries aged 65 and older who underwent an inpatient colon resection, coronary artery bypass, cholecystectomy, appendectomy, or incisional hernia repair. We compared postoperative complications, readmission, and mortality by race across neighborhood deprivation. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods Area Deprivation Index; a modern-day measure of neighborhood disadvantage that includes education, employment, housing quality, and poverty measures. Results: Overall, 1372,487 Medicare beneficiaries with mean age 72.1 years, 50.3% female, 91.2% White, residing in 1107,051 unique neighborhoods underwent 1 of 5 operations. The proportion of Black beneficiaries was 6.5% within the lowest deprivation neighborhoods and increased to 16.9% within the highest deprivation neighborhoods (P<0.001). The interaction between beneficiary neighborhood and race demonstrated that the association of neighborhood on outcomes varied by race. Specifically, White beneficiaries had 1.5% absolute mortality decrease from the highest to lowest deprivation neighborhoods [odds ratio (OR):1.32, 95% confidence interval (CI): 1.27–1.38; P<0.001], whereas Black beneficiaries had a 0.72% absolute mortality decrease from the highest to lowest deprivation neighborhoods (OR: 1.13, 95% CI: 1.02–1.24; P=0.018). Similarly, White beneficiaries had 3.6% absolute decrease in complication rate from the highest to lowest deprivation neighborhoods (OR: 1.23, 95% CI: 1.21–1.28; P<0.001) while Black beneficiaries had a 1.2%% absolute decrease in complication rate from the highest to lowest deprivation neighborhoods (OR: 1.07, 95% CI: 1.01–1.13; P=0.017). For 30-day readmission rates, White beneficiaries realized a 2.3% absolute decrease from the highest to lowest deprivation neighborhoods (OR: 1.19, 95% CI: 1.02–1.24; P<0.001), whereas Black beneficiaries saw no change (OR: 1.03, 95% CI: 0.97–1.10; P=0.269). Conclusions and Relevance: Lower neighborhood deprivation is associated with improved outcomes across both White and Black Medicare beneficiaries; however, improvement in neighborhood deprivation disproportionately favored White beneficiaries. These findings provide a cautionary example of the misperception of the protective effect of higher social class for Black patients and provide a cautionary example that improvements in neighborhoods may have disparate health impact on its members.

This study examined US kidney transplant center websites for readability and for inclusion of languages other than English.