Independent Associations of Neighborhood Deprivation and Patient-Level Social Determinants of Health With Textbook Outcomes After Inpatient Surgery

• Published in: Annals of surgery open Vol. 4; no. 1; p. e237
• Main Authors: Schmidt, Susanne, Kim, Jeongsoo, Jacobs, Michael A., Hall, Daniel E., Stitzenberg, Karyn B., Kao, Lillian S., Brimhall, Bradley B., Wang, Chen-Pin, Manuel, Laura S., Su, Hoah-Der, Silverstein, Jonathan C., Shireman, Paula K.
• Format: Journal Article
• Language: English
• Published: Wolters Kluwer Health 01-03-2023
• ISSN: 2691-3593; 2691-3593
• DOI: 10.1097/AS9.0000000000000237

ObjectiveAssess associations of Social Determinants of Health (SDoH) using Area Deprivation Index (ADI), race/ethnicity and insurance type with Textbook Outcomes (TO). Summary Background DataIndividual- and contextual-level SDoH affect health outcomes, but only one SDoH level is usually included. MethodsThree healthcare system cohort study using National Surgical Quality Improvement Program (2013-2019) linked with ADI risk-adjusted for frailty, case status and operative stress examining TO/TO components (unplanned reoperations, complications, mortality, Emergency Department/Observation Stays and readmissions). ResultsCohort (34,251 cases) mean age 58.3 [SD=16.0], 54.8% females, 14.1% Hispanics, 11.6% Non-Hispanic Blacks, 21.6% with ADI>85, and 81.8% TO. Racial and ethnic minorities, non-Private insurance, and ADI>85 patients had increased odds of urgent/emergent surgeries (aORs range: 1.17-2.83, all P<.001). Non-Hispanic Black patients, ADI>85 and non-Private insurances had lower TO odds (aORs range: 0.55-0.93, all P<.04), but ADI>85 lost significance after including case status. Urgent/emergent versus elective had lower TO odds (aOR=0.51, P<.001). ADI>85 patients had higher complication and mortality odds. Estimated reduction in TO probability was 9.9% (CI=7.2%-12.6%) for urgent/emergent cases, 7.0% (CI=4.6%-9.3%) for Medicaid, and 1.6% (CI=0.2%-3.0%) for non-Hispanic Black patients. TO probability difference for lowest-risk (White-Private-ADI≤85-elective) to highest-risk (Black-Medicaid-ADI>85-urgent/emergent) was 29.8% for very frail patients. ConclusionMulti-level SDoH had independent effects on TO, predominately affecting outcomes through increased rates/odds of urgent/emergent surgeries driving complications and worse outcomes. Lowest-risk versus highest-risk scenarios demonstrated the magnitude of intersecting SDoH variables. Combination of insurance type and ADI should be used to identify high-risk patients to redesign care pathways to improve outcomes. Risk adjustment including contextual neighborhood deprivation and patient-level SDoH could reduce unintended consequences of value-based programs.