Social Determinants of Health and Surgical Care

Decision to operate on hepatocellular cancer patients is not driven by comorbidities in Louisiana

BACKGROUND

The mortality rate of Hepatocellular cancer (HCC) in Louisiana is second worst in the United States. This has been linked to underutilization of curative treatment (CT). This study aimed to identify risk factors associated with underutilization of CT in Louisiana.

METHODS

Patients with AJCC T1 HCC diagnosed from 2011 to 2020 were identified from the Louisiana Tumor Registry (LTR) using site and histology codes. Patients who underwent CT (ablation, resection, and transplantation) were compared to those who did not undergo CT. Logistic regression was performed and results reported as adjusted odds ratios.

RESULTS

CT was utilized in 462 (37 %) of 1247 patients with T1 HCC. There were no significant differences observed in age, race, BMI, poverty, or rurality between CT and non-CT patients. The percentage of cirrhosis was similar in both groups (35.3 % vs. 37.7 %, NS). On multivariant analysis, lack of CT was independently associated with low socioeconomic status (SES; p = 0.040), treatment outside a COC center (p < 0.001), and lack commercial/private insurance (p < 0.001).

CONCLUSION

Utilization of CT is driven not by comorbidities, but by insurance type, low SES, and treatment facility indicating the profound effect that care disparities have on HCC treatment.

Association of transplant recipient status with clinical and financial outcomes among patients undergoing major surgery

BACKGROUND

Transplant recipients undergoing surgery may represent a vulnerable population because of transplant-related comorbidities as well as reliance on immunosuppressive medications. We sought to characterize the association of prior transplant status on postoperative outcomes among patients undergoing major non-transplant-related surgical procedures.

METHODS

Data on patients who underwent a major surgical procedure (pneumonectomy, coronary artery bypass graft, abdominal aortic aneurysm repair, Whipple, colectomy) between 2016 and 2020 were obtained from the Nationwide Readmission Database. After balancing the 2 cohorts using entropy balancing, multivariable regression models were used to assess the relationship between post-transplant status and patient outcomes.

RESULTS

Among 1,818,973 patients, 0.45% (n = 8,212) had a history of solid organ transplantation (liver: n = 1,773, 21.6%; heart/lung: n = 1,087, 13.2%; kidney/pancreas: n = 4,891, 59.6%; and multiple: n = 461, 5.6%). In the unmatched cohort, patients who had a history of organ transplant were more likely to be male (64.1% vs 57.7%) and have Medicare insurance (71.7% vs 59.3%) (both P < .001). On multivariable analysis, prior transplant recipient status was associated with higher odds of postoperative complications (odds ratio 1.30, 95% confidence interval 1.22-1.38), 30-day readmission (odds ratio 1.42, 95% confidence interval 1.31-1.54), and in-hospital mortality (odds ratio 1.20, 95% confidence interval 1.03-1.40) (all P < .05). Moreover, organ transplantation was associated with higher index hospitalization costs (14.4% difference, 95% confidence interval 14.1%-14.6%) and 30-day postdischarge costs (16.2% difference, 95% confidence interval 15.3%-17.0%) (both P < .001).

CONCLUSIONS

Prior transplant recipient status was associated with adverse clinical and financial outcomes following subsequent major surgery. Prior history of transplant may be an important factor to incorporate into risk stratification of patients undergoing subsequent major surgical procedures.

Achieving Health Equity: Advancing Colorectal Surgery among Racial and Ethnic Minorities in America

Racial inequities in short and long-term outcomes following colorectal surgery continue to persist. Using inflammatory bowel disease and colorectal cancer as disease foci, we review existing racial inequities in surgical outcomes and complications, discuss how social determinants of health and biopsychosocial factors can contribute to these inequities, and highlight potential mechanisms for building interventions to achieve health equity following colorectal surgery for minority populations.

Social Determinants of Health in Diverticulitis: A Systematic Review

BACKGROUND

There is growing interest in social determinants of health for surgical populations. Within diverticulitis, no systematic collation of available evidence has been performed.

OBJECTIVE

To assess frequency, variety, and association directions for social determinants of health in colonic diverticular disease.

DATA SOURCES

Four electronic databases were queried: PubMed, Embase, Cochrane, and Web of Science.

STUDY SELECTION

Included studies reported symptomatic left-sided colonic diverticular disease with respect to a social determinant of health according to the Healthy People 2030 initiative or applicable proxy variable. Studies with non-English full text, cohort size less than 50, pediatric cohorts, and exclusively non-left-sided disease were excluded.

MAIN OUTCOME MEASURES

Quality assessment using the modified Newcastle-Ottawa Scale, frequency of variables reported, and effect size trends for common comparisons.

RESULTS

Among 50 included studies, 40 were good and 10 were fair in quality. Social determinants of health in diverticulitis were identified across economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context domains. The 2 most common variables were self-reported race and ethnicity (n = 33) and insurance (n = 22). Among 18 unique studies reporting comparisons of White versus any other self-reported race and ethnicity, 12 identified a disparity disadvantaging non-White groups with effect sizes (95% CI ranging from 1.23 [1.10-1.37] to 5.35 [1.32-21.61]). Among 15 unique studies reporting a nonprivate versus private insurance comparison, 9 identified nonprivate insurance as a risk factor with effect sizes (95% CIs) ranging from 1.15 (1.02-1.29) to 3.83 (3.01-4.87).

LIMITATIONS

Retrospective studies, heterogeneity across cohorts, and variable definitions.

CONCLUSIONS

Social determinants of health domains are associated with a variety of diverticulitis outcomes. Additional studies are needed to address infrequently reported domains and identify optimal strategies for intervening in clinical settings.

PROSPERO ID

CRD42023422606.

Association of Race and Postoperative Outcomes in Ventral Hernia Repair With Component Separation

INTRODUCTION

Hernia repairs are the most common surgical procedures in the United States, with a significant financial burden primarily attributed to emergent presentations and postsurgery complications. This study aimed to examine race differences on postoperative outcomes.

METHODS

American College of Surgeons National Surgical Quality Improvement Program database was queried to identify ventral hernia repair (VHR) cases from 2016 to 2021, with a subgroup of patients undergoing component separation (CS). Statistical analysis utilized multinomial regression to compare outcomes across racial groups, generating weighted cohorts with balanced covariates to assess differences between groups.

RESULTS

288,515 patients were initially identified. Of these, 120,017 underwent VHR and 8732 VHR with CS. After weighting for the different groups, there were no differences in demographics or comorbidities between the racial groups for both cohorts. When evaluating postoperative complications after VHR, others (American Indian or Alaskan Native, Asian, Native Hawaiian, or Pacific Islander) had the highest rate of organ or space surgical site infection (SSI) (P < 0.001). Hospitalization >30 d was the lowest in Whites (0%), compared to Blacks (1%, P = 0.003) and others (1%, P < 0.001). For patients in the VHR with CS group, significant differences were noted in organ or space SSI (others 8%, P = 0.005), return to the operating room (others 13%, P = 0.015), hospitalizations >30 d (others 4% P = 0.002), and total LOS (others 5 [IQR 3,8], P = 0.004).

CONCLUSIONS

Despite advancements in surgical techniques, racial differences in VHR outcomes persist. These include higher rates of complications such as SSIs, higher rates of return to the operating room, and extended hospital stays among racial groups.

Open versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database

BACKGROUND

It is generally perceived that minimally invasive nephroureterectomy (MINU), especially in the form of robotic-assisted laparoscopy, is gaining an increasing role in many institutions.

OBJECTIVE

The aim of our study was to investigate contemporary trends in the adoption of MINU in the United States compared with open nephroureterectomy (ONU).

METHODS

Patients who underwent ONU or MINU between 2011 and 2021 were retrospectively analyzed using PearlDiver Mariner, an all-payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patients' characteristics, social determinants of health (SDOH), and perioperative complications. The primary objective assessed different trends and costs in NU adoption, while secondary objectives analyzed factors influencing the postoperative complications, including SDOH. Outcomes were compared using multivariable regression models.

RESULTS

Overall, 15,240 patients underwent ONU (n = 7675) and MINU (n = 7565). Utilization of ONU declined over the study period, whereas that of MINU increased from 29 to 72% (p = 0.01). The 60-day postoperative complication rate was 23% for ONU and 19% for MINU (p < 0.001). At multivariable analysis, ONU showed a significantly higher risk of postoperative complications (odds ratio 1.33, 95% CI 1.20-1.48). Approximately 5% and 9% of patients reported at least one SDOH at baseline for both ONU and MINU (p < 0.001).

CONCLUSIONS

Contemporary trend analysis of a large national dataset confirms that there has been a significant shift towards MINU, which is gradually replacing ONU. A minimally invasive approach is associated with lower risk of complications. SDOH are non-clinical factors that currently do not have an impact on the outcomes of nephroureterectomy.

Social Determinants of Health and Surgical Desirability of Outcome Ranking in Older Veterans

Importance

Evaluating how social determinants of health (SDOH) influence veteran outcomes is crucial, particularly for quality improvement.

Objective

To measure associations between SDOH, care fragmentation, and surgical outcomes using a Desirability of Outcome Ranking (DOOR).

Design, Setting, And Participants

This was a cohort study of US veterans using data from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP; 2013-2019) limited to patients aged 65 years or older with inpatient stays between 2 and 30 days, merged with multiple data sources, including Medicare. Race and ethnicity data were retrieved from VASQIP, Medicare and Medicaid beneficiary summary files, the Veterans Health Administration Corporate Data Warehouse, and the United States Veterans Eligibility Trends and Statistics file. Data were analyzed between September 2023 and February 2024.

Exposure

Living in a highly deprived neighborhood (Area Deprivation Index >85), race and ethnicity used as a social construct, rurality, and care fragmentation (percentage of non-VA care days).

Main Outcomes and Measures

DOOR is a composite, patient-centered ranking of 26 outcomes ranging from no complication (1, best) to 90-day mortality or near-death complications (6, worst). A series of proportional odds regressions was used to assess the impact of SDOH and care fragmentation adjusted for clinical risk factors, including presentation acuity (presenting with preoperative acute serious conditions and urgent or emergent surgical procedures).

Results

The cohort had 93 644 patients (mean [SD] age, 72.3 [6.2] years; 91 443 [97.6%] male; 74 624 [79.7%] White). Veterans who identified as Black (adjusted odds ratio [aOR], 1.06; 95% CI, 1.02-1.10; P = .048) vs White and veterans with higher care fragmentation (per 20% increase in VA care days relative to all care days: aOR, 1.01; 95% CI, 1.01-1.02; P < .001) were associated with worse (higher) DOOR scores until adjusting for presentation acuity. Living in rural geographic areas was associated with better DOOR scores than living in urban areas (aOR, 0.93; 95% CI, 0.91-0.96; P < .001), and rurality was associated with lower presentation acuity (preoperative acute serious conditions: aOR, 0.88; 95% CI, 0.81-0.95; P = .001). Presentation acuity was higher in veterans identifying as Black, living in deprived neighborhoods, and with increased care fragmentation.

Conclusions and Relevance

Veterans identifying as Black and veterans with greater proportions of non-VA care had worse surgical outcomes. VA programs should direct resources to reduce presentation acuity among Black veterans, incentivize veterans to receive care within the VA where possible, and better coordinate veterans' treatment and records between care sources.

Open versus Minimally Invasive Partial Nephrectomy: Trends and Outcomes from a Wide National Population-Based Database

Objectives: To investigate temporal trends and overall complication rates among open partial nephrectomy (OPN) and minimally invasive partial nephrectomy (MIPN), including the impact of social determinants of health (SDOH) on postoperative outcomes. Methods: Patients who underwent OPN or MIPN between 2011 and 2021 were retrospectively analyzed by using PearlDiver-Mariner, an all-payer insurance claims database. The International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical operation, patient's characteristics (age, sex, region, insurance plan), postoperative complications and SDOH, categorized in education, healthcare, environmental, social, and economic domains. Outcomes were compared using multivariable regression models. Results: Overall, 65,325 patients underwent OPN (n = 23,377) or MIPN (n = 41,948). OPN adoption declined over the study period, whereas that of MIPN increased from 24% to 34% (p = 0.001). The 60-day postoperative complication rate was 15% for the open and 9% for the minimally invasive approach. Approximately 16% and 11% of patients reported at least one SDOH at baseline for OPN and MIPN, respectively. SDOH were associated with higher odds of postoperative complications (OPN = OR: 1.11, 95% CI: 1.01-1.25; MIPN = OR: 1.31, 95% CI: 1.18-1.46). The open approach showed a significantly higher risk of postoperative complications (OR: 1.62, 95% CI: 1.54-1.70) compared to the minimally invasive one. Conclusions: Our findings confirm that MIPN is gradually replacing OPN, which carries a higher risk of complications. SDOH are significant predictors of postoperative complications following PN, regardless of the approach.

Association of socioeconomic vulnerability with clinical and financial outcomes following emergent hernia repair

BACKGROUND

While race and insurance have been linked with greater likelihood of hernia incarceration and emergent presentation, the association of broader social determinants of health (SDOH) with outcomes following urgent repair remains to be elucidated.

STUDY DESIGN

All adult hospitalizations entailing emergent repair for strangulated inguinal, femoral, and ventral hernias were identified in the 2016-2020 Nationwide Readmissions Database. Socioeconomic vulnerability was ascertained using relevant diagnosis codes. Multivariable models were developed to consider the independent associations between socioeconomic vulnerability and study outcomes.

RESULTS

Of ∼236,215 patients, 20,306 (8.6 ​%) were Vulnerable. Following risk-adjustment, socioeconomic vulnerability remained associated with greater odds of in-hospital mortality, any perioperative complication, increased hospitalization expenditures and higher risk of non-elective readmission.

CONCLUSIONS

Among patients undergoing emergent hernia repair, socioeconomic vulnerability was linked with greater morbidity, expenditures, and readmission. As part of patient-centered care, novel screening, postoperative management, and SDOH-informed discharge planning programs are needed to mitigate disparities in outcomes.

Social determinants of health and disparities in spine surgery: a 10-year analysis of 8,565 cases using ensemble machine learning and multilayer perceptron

BACKGROUND CONTEXT

The influence of SDOH on spine surgery is poorly understood. Historically, researchers commonly focused on the isolated influences of race, insurance status, or income on healthcare outcomes. However, analysis of SDOH is becoming increasingly more nuanced as viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDOH on healthcare delivery.

PURPOSE

The aim of this study was to evaluate the effects of patient social history on length of stay (LOS) and readmission within 90 days following spine surgery using ensemble machine learning and multilayer perceptron.

STUDY DESIGN

Retrospective chart review.

PATIENT SAMPLE

8,565 elective and emergency spine surgery cases performed from 2013 to 2023 using our institution's database of longitudinally collected electronic medical record information.

OUTCOMES MEASURES

Patient LOS, discharge disposition, and rate of 90-day readmission.

METHODS

Ensemble machine learning and multilayer perceptron were employed to predict LOS and readmission within 90 days following spine surgery. All other subsequent statistical analysis was performed using SPSS version 28. To further assess correlations among variables, Pearson's correlation tests and multivariate linear regression models were constructed. Independent sample t-tests, paired sample t-tests, one-way analysis of variance (ANOVA) with post-hoc Bonferroni and Tukey corrections, and Pearson's chi-squared test were applied where appropriate for analysis of continuous and categorical variables.

RESULTS

Black patients demonstrated a greater LOS compared to white patients, but race and ethnicity were not significantly associated with 90-day readmission rates. Insured patients had a shorter LOS and lower readmission rates compared to non-insured patients, as did privately insured patients compared to publicly insured patients. Patients discharged home had lower LOS and lower readmission rates, compared to patients discharged to other facilities. Marriage decreased both LOS and readmission rates, underweight patients showcased increased LOS and readmission rates, and religion was shown to impact LOS and readmission rates. When utilizing patient social history, lab values, and medical history, machine learning determined the top 5 most-important variables for prediction of LOS -along with their respective feature importances-to be insurance status (0.166), religion (0.100), ICU status (0.093), antibiotic use (0.061), and case status: elective or urgent (0.055). The top 5 most-important variables for prediction of 90-day readmission-along with their respective feature importances-were insurance status (0.177), religion (0.123), discharge location (0.096), emergency case status (0.064), and history of diabetes (0.041).

CONCLUSIONS

This study highlights that SDOH is influential in determining patient length of stay, discharge disposition, and likelihood of readmission following spine surgery. Machine learning was utilized to accurately predict LOS and 90-day readmission with patient medical history, lab values, and social history, as well as social history alone.

Social Determinants of Health Associated With the Need for Urgent Versus Elective Cholecystectomy at an Urban, Safety-Net Hospital

Background: Benign gallstone disease is the most frequent indication for cholecystectomy in the United States. Many patients present with complicated disease requiring urgent interventions, which increases morbidity and mortality. We investigated the association between individual and population-level social determinants of health (SDoH) with urgent versus elective cholecystectomy. Patients and Methods: All patients undergoing cholecystectomy (2014-2021) for benign gallstone disease were included. Demographic and clinical data were linked to population-level SDoH characteristics using census tracts. Data were analyzed using descriptive and inferential statistics. Results: A total of 3,197 patients met inclusion criteria; 1,913 (59.84%) underwent urgent cholecystectomy, 1,204 (37.66%) underwent emergent cholecystectomy, and 80 (2.5%) underwent interval cholecystectomy. On multinomial logistic regression, patients who were older (relative risk [RR], 1.010; p < 0.001), black (RR, 1.634; p = 0.008), and living in census tracts with a higher percent of poverty (RR, 0.017; p = 0.021) had a higher relative risk of presenting for urgent cholecystectomy. Patients who were female (RR, 0.462; p < 0.001), had a primary care provider (PCP; RR, 0.821; p = 0.018), and lived in census tracts with low supermarket access (RR, 0.764; p = 0.038) had a lower relative risk of presenting for urgent cholecystectomy. Only age (RR, 1.066; p < 0.001), female gender (RR, 0.227; p < 0.001), and having a PCP (RR, 1.984; p = 0.034) were associated with presentation for interval cholecystectomy. Conclusions: Patients who were older, black, and living in census tracts with high poverty levels had a higher relative risk of presenting for urgent cholecystectomy at our institution, whereas females and patients with PCPs were more likely to undergo elective cholecystectomy. Improved access to primary care and surgical clinics for all patients at safety-net hospitals may result in improved outcomes in the management of benign gallstone disease by increasing diagnosis and treatment in the elective setting.