County-level Social Vulnerability is Associated With Worse Surgical Outcomes Especially Among Minority Patients

Abstract

Objective: We sought to characterize the association between patient county-level vulnerability with postoperative outcomes.

Summary background data: Although the impact of demographic-, clinical- and hospital-level factors on outcomes following surgery have been examined, little is known about the effect of a patient's community of residence on surgical outcomes.

Methods: Individuals who underwent colon resection, coronary artery bypass graft (CABG), lung resection, or lower extremity joint replacement (LEJR) were identified in the 2016 to 2017 Medicare database, which was merged with Center for Disease Control social vulnerability index (SVI) dataset at the beneficiary level of residence. Logistic regression models were utilized to estimate the probability of postoperative complications, mortality, readmission, and expenditures.

Results: Among 299,583 Medicare beneficiary beneficiaries who underwent a colectomy (n = 88,778, 29.6%), CABG (n = 109,564, 36.6%), lung resection (n = 30,401, 10.1%), or LEJR (n = 70,840, 23.6%).Mean SVI score was 50.2 (standard deviation: (25.2); minority patients were more likely to reside in highly vulnerable communities (low SVI: n = 3531, 5.8% vs high SVI: n = 7895, 13.3%; P < 0.001). After controlling for competing risk factors, the risk-adjusted probability of a serious complication among patients from a high versus low SVI county was 10% to 20% higher following colectomy [odds ratio (OR) 1.1 95% confidence intervals (CI) 1.1-1.2] or CABG (OR 1.2 95%CI 1.1-1.3), yet there no association of SVI with risk of serious complications following lung resection (OR 1.2 95%CI 1.0-1.3) or LEJR (OR 1.0 95%CI 0.93-1.2). The risk-adjusted probability of 30-day mortality was incrementally higher among patients from high SVI counties following colectomy (OR 1.1 95%CI 1.1-1.3), CABG (OR 1.4, 95%CI 1.2-1.5), and lung resection (OR 1.4 (95%CI 1.1-1.8), yet not LEJR (OR 0.95 95%CI 0.72-1.2). Black/minority patients undergoing a colectomy, CABG, or lung resection who lived in highly socially vulnerable counties had an estimate 28% to 68% increased odds of a serious complication and a 58% to 60% increased odds of 30-day mortality compared with a Black/minority patient from a low socially vulnerable county, as well as a markedly higher risk than White patients (all P > 0.05).

Conclusions: Patients residing in vulnerable communities characterized by a high SVI generally had worse postoperative outcomes. The impact of social vulnerability was most pronounced among Black/minority patients, rather than White individuals. Efforts to ensure equitable surgical outcomes need to focus on both patient-level, as well as community-specific factors.