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Katayama ES, Woldesenbet S, Tsilimigras D, Munir MM, Endo Y, Huang E, Cunningham L, Harzman A, Gasior A, Husain S, Arnold M, Kalady M, Pawlik TM. Inflammatory bowel disease-associated colorectal cancer negatively affects surgery outcomes and health care costs. Surgery 2024; 176:32-37. [PMID: 38582731 DOI: 10.1016/j.surg.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/30/2024] [Accepted: 03/05/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Inflammatory bowel disease may affect the pathogenesis and clinicopathologic course of colorectal cancer. We sought to characterize the impact of inflammatory bowel disease on outcomes after colectomy and/or proctectomy for a malignant indication. METHODS Patients diagnosed with colorectal cancer as well as a pre-existing comorbid diagnosis of Crohn's disease or ulcerative colitis between 2018 and 2021 were identified from Medicare claims data. The postoperative textbook outcome was defined as the absence of complications, as well as no extended hospital stay, 90-day readmission, or mortality. Postdischarge disposition and expenditures were also examined. RESULTS Among 191,684 patients with colorectal cancer, 4,770 (2.5%) had a pre-existing diagnosis of inflammatory bowel disease. Patients with inflammatory bowel disease-associated colorectal cancer were less likely to undergo surgical resection (no inflammatory bowel disease: 47.6% vs inflammatory bowel disease: 42.1%; P < .001). Among patients who did undergo colorectal surgery, individuals with inflammatory bowel disease were less likely to achieve a textbook outcome (odds ratio 0.64 [95% confidence interval 0.58-0.70]). In particular, patients with inflammatory bowel disease had higher odds of postoperative complications (odds ratio 1.24 [1.12-1.38]), extended hospital stay (odds ratio 1.41 [1.27-1.58]), and readmission within 90 days (odds ratio 1.56 [1.42-1.72]) (all P < .05). Patients with inflammatory bowel disease-associated colorectal cancer were less likely to be discharged to their home under independent care (odds ratio 0.77 [0.68-0.87]) and had 12.2% higher expenditures, which correlated with whether the patient had a postoperative textbook outcome. CONCLUSION One in 40 patients with colorectal cancer had concomitant inflammatory bowel disease. Inflammatory bowel disease was associated with a lower probability of achieving ideal postoperative outcomes, higher postdischarge expenditure, as well as worse long-term survival after colorectal cancer resection.
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Affiliation(s)
- Erryk S Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH; The Ohio State University College of Medicine, Columbus, OH. https://twitter.com/errykkatayama
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Diamantis Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Emily Huang
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Lisa Cunningham
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Alan Harzman
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Alessandra Gasior
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Syed Husain
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Mark Arnold
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Matthew Kalady
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Fei-Zhang DJ, Park AC, Chelius DC, Smith SS, Samant S, Patel UA, Sheyn AM, Rastatter JC. Influence of Social Vulnerability in Treatment and Prognosis of Squamous Cell Carcinoma of the Tongue. Otolaryngol Head Neck Surg 2024; 170:1338-1348. [PMID: 38353303 DOI: 10.1002/ohn.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/20/2023] [Accepted: 12/23/2023] [Indexed: 04/30/2024]
Abstract
OBJECTIVE To investigate the association of social determinants of health (SDoH) in squamous cell carcinoma of the tongue in the United States and to evaluate the real-world contribution of specific disparities. STUDY DESIGN Retrospective cohort study. SETTING United States. METHODS The Centers for Disease Control and Prevention-Social Vulnerability Index (SVI) and National Cancer Institute-Surveillance, Epidemiology, and End Results Program database were used to study 62,103 adult tongue squamous cell carcinoma patients from 1975 to 2017. Regression analysis assessed trends in months of follow-up and survival across social vulnerability and 4 subcategories of social vulnerability. RESULTS As overall SVI score increases (increased social vulnerability), there is a significant decrease in the average length of follow-up (22.95% decrease from 63.99 to 49.31 months; P < .001) across patients from the lowest and highest social vulnerability groups. As overall SVI score increases, there is a significant decrease in the average months of survival (28.00% decrease from 49.20 to 35.43 months; P < .001). There is also a significantly greater odds ratio (OR = 1.05; P < .001) of advanced cancer staging upon presentation at higher SVI scores. Patients with higher SVI scores have a lower OR (0.93; P < .001) of receiving surgery as their primary treatment when compared to patients with lower SVI scores. Patients with higher SVI scores also have a significantly greater OR (OR = 1.05; P < .001) of receiving chemotherapy as their primary treatment when compared to patients with lower SVI scores. CONCLUSION Increased social vulnerability is shown to have a detrimental impact on the treatment and prognosis of patients with squamous cell carcinoma of the tongue.
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Affiliation(s)
- David J Fei-Zhang
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Asher C Park
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniel C Chelius
- Department of Otolaryngology-Head and Neck Surgery, Pediatric Thyroid Tumor Program and Pediatric Head and Neck Tumor Program, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Stephanie S Smith
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sandeep Samant
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Urjeet A Patel
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anthony M Sheyn
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Pediatric Otolaryngology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jeffrey C Rastatter
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Rajasingh CM, Wren SM. Socioeconomic Status and Postoperative Emergency Department Visits-Reply. JAMA Surg 2024; 159:590-591. [PMID: 38381441 DOI: 10.1001/jamasurg.2023.8010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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4
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Mensah JA, Fei-Zhang DJ, Rossen JL, Rahmani B, Bentrem DJ, Stein JD, French DD. Assessment of Social Vulnerabilities of Care and Prognosis in Adult Ocular Melanomas in the US. Ann Surg Oncol 2024; 31:3302-3313. [PMID: 38418655 PMCID: PMC11003832 DOI: 10.1245/s10434-024-15038-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/25/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Prior works have studied the impact of social determinants on various cancers but there is limited analysis on eye-orbit cancers. Current literature tends to focus on socioeconomic status and race, with sparse analysis of interdisciplinary contributions. We examined social determinants as measured by the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), quantifying eye and orbit melanoma disparities across the United States. METHODS A retrospective review of 15,157 patients diagnosed with eye-orbit cancers in the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2017 was performed, extracting 6139 ocular melanomas. SVI scores were abstracted and matched to SEER patient data, with scores generated by weighted averages per population density of county's census tracts. Primary outcome was months survived, while secondary outcomes were advanced staging, high grading, and primary surgery receipt. RESULTS With increased total SVI score, indicating more vulnerability, we observed significant decreases of 23.1% in months survival for melanoma histology (p < 0.001) and 19.6-39.7% by primary site. Increasing total SVI showed increased odds of higher grading (odds ratio [OR] 1.20, 95% confidence interval [CI] 1.02-1.43) and decreased odds of surgical intervention (OR 0.94, 95% CI 0.92-0.96). Of the four themes, higher magnitude contributions were observed with socioeconomic status (26.0%) and housing transportation (14.4%), while lesser magnitude contributions were observed with minority language status (13.5%) and household composition (9.0%). CONCLUSIONS Increasing social vulnerability, as measured by the CDC SVI and its subscores, displayed significant detrimental trends in prognostic and treatment factors for adult eye-orbit melanoma. Subscores quantified which social determinants contributed most to disparities. This lays groundwork for providers to target the highest-impact social determinant for non-clinical factors in patient care.
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Affiliation(s)
- Joshua A Mensah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - David J Fei-Zhang
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jennifer L Rossen
- Division of Pediatric Ophthalmology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Bahram Rahmani
- Division of Pediatric Ophthalmology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David J Bentrem
- Division of Surgical Oncology and Medical Social Sciences, Department of Surgery, Chicago, IL, USA
| | - Joshua D Stein
- Division of Ophthalmology and Visual Sciences, University of Michigan Kellogg Eye Center, Ann Arbor, MI, USA
| | - Dustin D French
- Departments of Ophthalmology and Medical Social Sciences, Feinberg School of Medicine, Chicago, IL, USA
- Health Services Research and Development Service, Veteran Health Administration, Edward Hines Jr. VA Hospital, Hines, IL, USA
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Katayama ES, Stecko H, Woldesenbet S, Khalil M, Munir MM, Endo Y, Tsilimigras D, Pawlik TM. The Role of Delirium on Short- and Long-Term Postoperative Outcomes Following Major Gastrointestinal Surgery for Cancer. Ann Surg Oncol 2024:10.1245/s10434-024-15358-x. [PMID: 38683304 DOI: 10.1245/s10434-024-15358-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/09/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION The growing burden of an aging population has raised concerns about demands on healthcare systems and resources, particularly in the context of surgical and cancer care. Delirium can affect treatment outcomes and patient recovery. We sought to determine the prevalence of postoperative delirium among patients undergoing digestive tract surgery for malignant indications and to analyze the role of delirium on surgical outcomes. METHODS Medicare claims data were queried to identify patients diagnosed with esophageal, gastric, hepatobiliary, pancreatic, and colorectal cancers between 2018 and 2021. Postoperative delirium, occurring within 30 days of operation, was identified via International Classification of Diseases, 10th edition codes. Clinical outcomes of interested included "ideal" textbook outcome (TO), characterized as the absence of complications, an extended hospital stay, readmission within 90 days, or mortality within 90 days. Discharge disposition, intensive care unit (ICU) utilization, and expenditures also were examined. RESULTS Among 115,654 cancer patients (esophageal: n = 1854, 1.6%; gastric: n = 4690, 4.1%; hepatobiliary: n = 6873, 5.9%; pancreatic: n = 8912, 7.7%; colorectal: n = 93,325, 90.7%), 2831 (2.4%) were diagnosed with delirium within 30 days after surgery. On multivariable analysis, patients with delirium were less likely to achieve TO (OR 0.27 [95% CI 0.25-0.30]). In particular, patients who experienced delirium had higher odds of complications (OR 3.00 [2.76-3.25]), prolonged length of stay (OR 3.46 [3.18-3.76]), 90-day readmission (OR 1.96 [1.81-2.12]), and 90-day mortality (OR 2.78 [2.51-3.08]). Furthermore, patients with delirium had higher ICU utilization (OR 2.85 [2.62-3.11]). Upon discharge, patients with delirium had a decreased likelihood of being sent home (OR 0.40 [0.36-0.46]) and instead were more likely to be transferred to a skilled nursing facility (OR 2.17 [1.94-2.44]). Due to increased utilization of hospital resources, patients with delirium incurred in-hospital expenditures that were 55.4% higher (no delirium: $16,284 vs. delirium: $28,742) and 90-day expenditures that were 100.7% higher (no delirium: $2564 vs. delirium: $8226) (both p < 0.001). Notably, 3-year postoperative survival was adversely affected by delirium (no delirium: 55.5% vs. delirium: 37.3%), even after adjusting risk for confounding factors (HR 1.79 [1.70-1.90]; p < 0.001). CONCLUSIONS Postoperative delirium occurred in one in 50 patients undergoing surgical resection of a digestive tract cancer. Delirium was linked to a reduced likelihood of achieving an optimal postoperative outcome, increased ICU utilization, higher expenditures, and a worse long-term prognosis. Initiatives to prevent delirium are vital to improve postoperative outcomes among cancer surgery patients.
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Affiliation(s)
- Erryk S Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Hunter Stecko
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Graboyes EM, Cagle JL, Ramadan S, Prasad K, Yan F, Pearce J, Mazul AL, Anoma JS, Hill EG, Chera BS, Puram SV, Jackson R, Sandulache VC, Tam S, Topf MC, Kahmke R, Osazuwa-Peters N, Nussenbaum B, Alberg AJ, Sterba KR, Halbert CH. Neighborhood-Level Disadvantage and Delayed Adjuvant Therapy in Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2024:2818081. [PMID: 38662392 PMCID: PMC11046410 DOI: 10.1001/jamaoto.2024.0424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/07/2024] [Indexed: 04/26/2024]
Abstract
Importance For patients with head and neck squamous cell carcinoma (HNSCC), initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery is recommended by the National Comprehensive Cancer Network Guidelines and the Commission on Cancer. Although individual-level measures of socioeconomic status are associated with receipt of timely, guideline-adherent PORT, the role of neighborhood-level disadvantage has not been examined. Objective To characterize the association of neighborhood-level disadvantage with delays in receiving PORT. Design, Setting, and Participants This retrospective cohort study included 681 adult patients with HNSCC undergoing curative-intent surgery and PORT from 2018 to 2020 at 4 US academic medical centers. The data were analyzed between June 21, 2023, and March 5, 2024. Main Outcome Measures and Measures The primary outcome was delay in initiating guideline-adherent PORT (ie, >6 weeks after surgery). Time-to-PORT (TTP) was a secondary outcome. Census block-level Area Deprivation Index (ADI) scores were calculated and reported as national percentiles (0-100); higher scores indicate greater deprivation. The association of ADI scores with PORT delay was assessed using multivariable logistic regression adjusted for demographic, clinical, and institutional characteristics. PORT initiation across ADI score population quartiles was evaluated with cumulative incidence plots and Cox models. Results Among 681 patients with HNSCC undergoing surgery and PORT (mean [SD] age, 61.5 [11.2] years; 487 [71.5%] men, 194 [29.5%] women) the PORT delay rate was 60.8% (414/681) and median (IQR) TTP was 46 (40-56) days. The median (IQR) ADI score was 62.0 (44.0-83.0). Each 25-point increase in ADI score was associated with a corresponding 32% increase in the adjusted odds ratio (aOR) of PORT delay (aOR, 1.32; 95% CI, 1.07-1.63) on multivariable regression adjusted for institution, age, race and ethnicity, insurance, comorbidity, cancer subsite, stage, postoperative complications, care fragmentation, travel distance, and rurality. Increasing ADI score population quartiles were associated with increasing TTP (hazard ratio of PORT initiation, 0.71; 95% CI, 0.53-0.96; 0.59; 95% CI, 0.44-0.77; and 0.54; 95% CI, 0.41-0.72; for ADI quartiles 2, 3, and 4 vs ADI quartile 1, respectively). Conclusions and Relevance Increasing neighborhood-level disadvantage was independently associated with a greater likelihood of PORT delay and longer TTP in a dose-dependent manner. These findings indicate a critical need for the development of multilevel strategies to improve the equitable delivery of timely, guideline-adherent PORT.
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Affiliation(s)
- Evan M. Graboyes
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Joshua Lee Cagle
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Salma Ramadan
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Kavita Prasad
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Flora Yan
- Department of Otolaryngology–Head and Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - John Pearce
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Angela L. Mazul
- Department of Otolaryngology–Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jean-Sebastien Anoma
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Elizabeth G. Hill
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Bhisham S. Chera
- Hollings Cancer Center, Department of Radiation Oncology, Medical University of South Carolina, Charleston
| | - Sidharth V. Puram
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Ryan Jackson
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Vlad C. Sandulache
- Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
- ENT Section, Operative CareLine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Samantha Tam
- Department of Otolaryngology–Head and Neck Surgery, Henry Ford Health, Detroit, Michigan
| | - Michael C. Topf
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Russel Kahmke
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina
- Deputy Editor, Diversity, Equity, and Inclusion, JAMA Otolaryngology–Head & Neck Surgery
| | - Brian Nussenbaum
- American Board of Otolaryngology–Head and Neck Surgery, Houston, Texas
| | - Anthony J. Alberg
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia
| | - Katherine R. Sterba
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Chanita Hughes Halbert
- Department of Population and Public Health Sciences and Norris Comprehensive Cancer Center, University of Southern California, Los Angeles
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Bindra GS, Fei-Zhang DJ, Desai A, Maddalozzo J, Smith SS, Patel UA, Chelius DC, D'Souza JN, Rastatter JC, Gillespie MB, Sheyn AM. Assessing social vulnerabilities of salivary gland cancer care, prognosis, and treatment in the United States. Head Neck 2024. [PMID: 38651501 DOI: 10.1002/hed.27783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/01/2024] [Accepted: 04/11/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Salivary gland cancers (SGC)-social determinants of health (SDoH) investigations are limited by narrow scopes of SGC-types and SDoH. This Social Vulnerability Index (SVI)-study hypothesized that socioeconomic status (SES) most contributed to SDoH-associated SGC-disparities. METHODS Retrospective cohort of 24 775 SGCs assessed SES, minority-language status (ML), household composition (HH), housing-transportation (HT), and composite-SDoH measured by the SVI via regressions with surveillance and survival length, late-staging presentation, and treatment (surgery, radio-, chemotherapy) receipt. RESULTS Increasing social vulnerability showed decreases in surveillance/survival; increased odds of advanced-presenting-stage (OR: 1.12, 95% CI: 1.07, 1.17), chemotherapy receipt (OR: 1.13, 95% CI: 1.03, 1.23); decreased odds of primary surgery (0.89, 0.84, 0.94), radiotherapy (0.91, 0.85, 0.97, p = 0.003) for SGCs. Trends were differentially correlated with SES, ML, HH, and HT-vulnerabilities. CONCLUSIONS Through quantifying SDoH-derived SGC-disparities, the SVI can guide targeted initiatives against SDoH that elicit the most detrimental associations for specific sociodemographics.
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Affiliation(s)
- Govind S Bindra
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - David J Fei-Zhang
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Atharva Desai
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - John Maddalozzo
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Stephanie S Smith
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Urjeet A Patel
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniel C Chelius
- Department of Otolaryngology-Head and Neck Surgery, Pediatric Thyroid Tumor Program and Pediatric Head and Neck Tumor Program, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Jill N D'Souza
- Division of Pediatric Otolaryngology, Children's Hospital of New Orleans and Louisiana State University, New Orleans, Louisiana, USA
| | - Jeffrey C Rastatter
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - M Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Anthony M Sheyn
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- Department of Pediatric Otolaryngology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Masoud SJ, Seo JE, Singh E, Woody RL, Muhammed M, Webster W, Mantyh CR. Social Vulnerability Index and Survivorship after Colorectal Cancer Resection. J Am Coll Surg 2024; 238:693-706. [PMID: 38441160 DOI: 10.1097/xcs.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Abstract
BACKGROUND Race and socioeconomic status incompletely identify patients with colorectal cancer (CRC) at the highest risk for screening, treatment, and mortality disparities. Social vulnerability index (SVI) was designed to delineate neighborhoods requiring greater support after external health stressors, summarizing socioeconomic, household, and transportation barriers by census tract. SVI is implicated in lower cancer center use and increased complications after colectomy, but its influence on long-term prognosis is unknown. Herein, we characterized relationships between SVI and CRC survival. STUDY DESIGN Patients undergoing resection of stage I to IV CRC from January 2010 to May 2023 within an academic health system were identified. Clinicopathologic characteristics were abstracted using institutional National Cancer Database and NSQIP. Addresses from electronic health records were geocoded to SVI. Overall survival and cancer-specific survival were compared using Kaplan-Meier and Cox proportional hazards methods. RESULTS A total of 872 patients were identified, comprising 573 (66%) patients with colon tumor and 299 (34%) with rectal tumor. Patients in the top SVI quartile (32%) were more likely to be Black (41% vs 13%, p < 0.001), carry less private insurance (39% vs 48%, p = 0.02), and experience greater comorbidity (American Society of Anesthesiologists physical status III: 86% vs 71%, p < 0.001), without significant differences by acuity, stage, or CRC therapy. In multivariable analysis, high SVI remained associated with higher all-cause (hazard ratio 1.48, 95% CI 1.12 to 1.96, p < 0.01) and cancer-specific survival mortality (hazard ratio 1.71, 95% CI 1.10 to 2.67, p = 0.02). CONCLUSIONS High SVI was independently associated with poorer prognosis after CRC resection beyond the perioperative period. Acknowledging needs for multi-institutional evaluation and elaborating causal mechanisms, neighborhood-level vulnerability may inform targeted outreach in CRC care.
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Affiliation(s)
- Sabran J Masoud
- From the Department of Surgery, Duke University Medical Center, Durham, NC (Masoud, Mantyh)
| | - Jein E Seo
- Duke University School of Medicine, Durham, NC (Seo, Singh)
| | - Eden Singh
- Duke University School of Medicine, Durham, NC (Seo, Singh)
| | | | | | | | - Christopher R Mantyh
- From the Department of Surgery, Duke University Medical Center, Durham, NC (Masoud, Mantyh)
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Azap L, Woldesenbet S, Akpunonu CC, Alaimo L, Endo Y, Lima HA, Yang J, Munir MM, Moazzam Z, Huang ES, Kalady MF, Pawlik TM. The Association of Food Insecurity and Surgical Outcomes Among Patients Undergoing Surgery for Colorectal Cancer. Dis Colon Rectum 2024; 67:577-586. [PMID: 38100574 DOI: 10.1097/dcr.0000000000003073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
BACKGROUND Food insecurity predisposes individuals to suboptimal nutrition, leading to chronic disease and poor outcomes. OBJECTIVE We sought to assess the impact of county-level food insecurity on colorectal surgical outcomes. DESIGN Retrospective cohort study. SETTING Data from the Surveillance, Epidemiology, and End Results-Medicare database was merged with county-level food insecurity obtained from the Feeding America: Mapping the Meal Gap report. Multiple logistic and Cox regression adjusted for patient-level covariates were implemented to assess outcomes. PATIENTS Medicare beneficiaries diagnosed with colorectal cancer between 2010 and 2015. MAIN OUTCOME MEASURES Surgical admission type (nonelective and elective admission), any complication, extended length of stay, discharge disposition (discharged to home and nonhome discharge), 90-day readmission, 90-day mortality, and textbook outcome. Textbook outcome was defined as no extended length of stay, postoperative complications, 90-day readmission, and 90-day mortality. RESULTS Among 72,354 patients with colorectal cancer, 46,296 underwent resection. Within the surgical cohort, 9091 (19.3%) were in low, 27,716 (59.9%) were in moderate, and 9,489 (20.5%) were in high food insecurity counties. High food insecurity patients had greater odds of nonelective surgery (OR: 1.17; 95% CI, 1.09-1.26; p < 0.001), 90-day readmission (OR: 1.11; 95% CI, 1.04-1.19; p = 0.002), extended length of stay (OR: 1.32; 95% CI, 1.21-1.44; p < 0.001), and complications (OR: 1.11; 95% CI, 1.03-1.19; p = 0.002). High food insecurity patients also had decreased odds of home discharge (OR: 0.85; 95% CI, 0.79-0.91; p < 0.001) and textbook outcomes (OR: 0.81; 95% CI, 0.75-0.87; p < 0.001). High food insecurity minority patients had increased odds of complications (OR 1.59; 95% CI, 1.43-1.78) and extended length of stay (OR 1.89; 95% CI, 1.69-2.12) compared with low food insecurity white patients (all, p < 0.001). Notably, high food insecurity minority patients had 31% lower odds of textbook outcomes (OR: 0.69; 95% CI, 0.62-0.76; p < 0.001) compared with low food insecurity White patients ( p < 0.001). LIMITATIONS This study was limited to Medicare beneficiaries aged 65 years or older; hence, it may not be generalizable to younger populations or those without insurance or with private insurance. CONCLUSIONS County-level food insecurity was associated with suboptimal outcomes, demonstrating the importance of interventions to mitigate these inequities. See Video Abstract. LA ASOCIACIN DE INSEGURIDAD ALIMENTARIA Y RESULTADOS QUIRRGICOS ENTRE PACIENTES SOMETIDOS A CIRUGA DE CNCER COLORRECTAL ANTECEDENTES:La inseguridad alimentaria predispone a las personas a una nutrición subóptima, lo que conduce a enfermedades crónicas y malos resultados.OBJETIVO:Intentamos evaluar el impacto de la inseguridad alimentaria a nivel de condado en resultados de la cirugía colorrectal.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:La base de datos SEER-Medicare fusionada con la inseguridad alimentaria a nivel de condado obtenida del informe Feeding America: Mapping the Meal Gap. Para evaluar los resultados se implementaron regresiones logísticas múltiples y de Cox ajustadas según las covariables a nivel de paciente.PACIENTES:Beneficiarios de Medicare diagnosticados con cáncer colorrectal entre 2010 y 2015.PRINCIPALES MEDIDAS DE RESULTADO:Tipo de ingreso quirúrgico (ingreso no electivo y electivo), cualquier complicación, duración prolongada de la estancia hospitalaria, disposición del alta (alta al domicilio y alta no domiciliaria), reingreso a los 90 días, mortalidad a los 90 días y resultado del libro de texto. El resultado de los libros de texto se definió como ausencia de estancia hospitalaria prolongada, complicaciones postoperatorias, reingreso a los 90 días y mortalidad a los 90 días.RESULTADOS:Entre 72.354 pacientes con cáncer colorrectal, 46.296 se sometieron a resección. Dentro de la cohorte quirúrgica, 9.091 (19,3%) tenían inseguridad alimentaria baja, 27.716 (59,9%) eran moderadas y 9.489 (20,5%) tenían inseguridad alimentaria alta. Los pacientes con alta inseguridad alimentaria tuvieron mayores probabilidades de cirugía no electiva (OR: 1,17, IC 95%: 1,09-1,26, p <0,001), reingreso a los 90 días (OR: 1,11, IC95%: 1,04-1,19, p = 0,002), duración prolongada de la estancia hospitalaria (OR: 1,32; IC95%: 1,21-1,44, p < 0,001) y complicaciones (OR: 1,11; IC95%: 1,03-1,19, p = 0,002). Los pacientes con alta inseguridad alimentaria también tuvieron menores probabilidades de ser dados de alta a domicilio (OR: 0,85, IC del 95%: 0,79-0,91, p <0,001) y resultados de los libros de texto (OR: 0,81, IC del 95%: 0,75-0,87, p <0,001). Los pacientes minoritarios con alta inseguridad alimentaria tuvieron mayores probabilidades de complicaciones (OR 1,59, IC 95%, 1,43-1,78) y duración prolongada de la estadía (OR 1,89, IC 95%, 1,69-2,12) en comparación con los individuos blancos con baja inseguridad alimentaria (todos, p < 0,001). En particular, los pacientes minoritarios con alta inseguridad alimentaria tenían un 31% menos de probabilidades de obtener resultados según los libros de texto (OR: 0,69, IC del 95%, 0,62-0,76, p <0,001) en comparación con los pacientes blancos con baja inseguridad alimentaria ( p <0,001).LIMITACIONES:Limitado a beneficiarios de Medicare mayores de 65 años, por lo tanto, puede no ser generalizable a poblaciones más jóvenes o a aquellos sin seguro o con seguro privado.CONCLUSIONES:La inseguridad alimentaria a nivel de condado se asoció con resultados subóptimos, lo que demuestra la importancia de las intervenciones para mitigar estas desigualdades. (Dr. Francisco M. Abarca-Rendon ).
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Affiliation(s)
- Lovette Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Chinaemelum C Akpunonu
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Henrique Araujo Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Jason Yang
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Emily S Huang
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Matthew F Kalady
- Division of Colorectal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
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Rashid Z, Munir MM, Woldesenbet S, Khan MMM, Khalil M, Endo Y, Tsilimigras DI, Dillhoff M, Ejaz A, Pawlik TM. Association between social determinants of health and delayed postoperative adjuvant therapy among patients undergoing resection of pancreatic cancer. J Surg Oncol 2024; 129:850-859. [PMID: 38151795 DOI: 10.1002/jso.27571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Pancreatic cancer (PDAC) requires a multimodality approach. We sought to define the association between social determinants of health (SDOH) and delayed or nonreceipt of adjuvant chemotherapy (aCT) among patients undergoing PDAC resection. METHODS Data on patients who underwent PDAC resection between 2014 and 2020 were identified from Medicare Standard Analytic Files and merged with the county-level social vulnerability index (SVI). Mediation analysis defined the association between SVI subthemes and aCT receipt. RESULTS Among 24 078 patients, 47.7% received timely aCT, 17.7% received delayed aCT, and 34.6% did not receive any aCT. High SVI was associated with delay (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.10-1.34) and nonreceipt of aCT (OR 1.30, 95% CI 1.20-1.41) (both p < 0.05). 73.1% of the variation in timely aCT receipt was directly attributable to SVI, whereas 26.9% of the effect was due to indirect mediators including hospital volume (6.4%), length-of-stay (7.9%) and postoperative complications (12.6%). Socioeconomic status (delayed aCT: OR 1.25, 95% CI 1.13-1.38; nonreceipt aCT: OR 1.25, 95% CI 1.15-1.36) and household composition and disability (delayed aCT: OR 1.30, 95% CI 1.17-1.43; nonreceipt aCT: OR 1.19, 95% CI 1.09-1.29) were associated with receipt of aCT (both p < 0.001). CONCLUSIONS Most of the disparities in receipt of aCT after PDAC surgery are driven by underlying SDOH such as SVI.
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Affiliation(s)
- Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad M Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad M M Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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Abla H, Collins RA, Dhanasekara CS, Shrestha K, Dissanaike S. Using the Social Vulnerability Index to Analyze Statewide Health Disparities in Cholecystectomy. J Surg Res 2024; 296:135-141. [PMID: 38277949 DOI: 10.1016/j.jss.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/27/2023] [Accepted: 12/25/2023] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Addressing the effects of social determinants of health in surgery has become a national priority. We evaluated the utility of the Social Vulnerability Index (SVI) in determining the likelihood of receiving cholecystectomy for cholecystitis in Texas. METHODS A retrospective study of adults with cholecystitis in the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Data Public Use Data File from 2016 to 2019. Patients were stratified into SVI quartiles, with the lowest quartile as low vulnerability, the middle two as average vulnerability, and the highest as high vulnerability. The relative risk (RR) of undergoing surgery was calculated using average vulnerability as the reference category and subgroup sensitivity analyses. RESULTS A total of 67,548 cases were assessed, of which 48,603 (72.0%) had surgery. Compared with the average SVI groups, the low vulnerability groups were 21% more likely to undergo cholecystectomy (RR = 1.21, 95% confidence interval [CI] 1.18-1.24), whereas the high vulnerability groups were 9% less likely to undergo cholecystectomy (RR = 0.91, 95% CI 0.88-0.93). The adjusted model showed similar results (RR = 1.05, 95% CI 1.04-1.06 and RR = 0.97, 95% CI 0.96-0.99, for low and high vulnerability groups, respectively). These results remained significant after stratifying for age, sex, ethnicity, and insurance status. However, the differences between low, average, and high vulnerability groups diminished in rural settings, with lower surgery rates in all groups. CONCLUSIONS Patients with higher SVI were less likely to receive an elective cholecystectomy. SVI is an effective method of identifying social determinants impacting access to and receipt of surgical care.
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Affiliation(s)
- Habib Abla
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | - Reagan A Collins
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, Texas.
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Smith BP, Katta MH, Hollis RH, Shao CC, Jones BA, McLeod MC, Tan TW, Chu DI. Understanding the Impact of Enhanced Recovery Programs on Social Vulnerability, Race, and Colorectal Surgery Outcomes. Dis Colon Rectum 2024; 67:566-576. [PMID: 38084910 DOI: 10.1097/dcr.0000000000003159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2024]
Abstract
BACKGROUND Increasing social vulnerability, measured by the Social Vulnerability Index, has been associated with worse surgical outcomes. However, less is known about the impact of social vulnerability on patients who underwent colorectal surgery under enhanced recovery programs. OBJECTIVE We hypothesized that increasing social vulnerability is associated with worse outcomes before enhanced recovery implementation, but that after implementation, disparities in outcomes would be reduced. DESIGN Retrospective cohort study using multivariable logistic regression to identify associations of social vulnerability and enhanced recovery with outcomes. SETTINGS Institutional American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS Patients undergoing elective colorectal surgery (2010-2020). Enhanced recovery programs were implemented in 2015. Those adhering to 70% or more of enhanced recovery program components were defined as enhanced recovery and all others as nonenhanced recovery. OUTCOMES Length of stay, complications, and readmissions. RESULTS Of 1523 patients, 589 (38.7%) were in the enhanced recovery group, with 625 patients (41%) in the lowest third of the Social Vulnerability Index, 411 (27%) in the highest third. There were no differences in Social Vulnerability Index distribution by the enhanced recovery group. On multivariable modeling, social vulnerability was not associated with increased length of stay, complications, or readmissions in the enhanced recovery group. Black race was associated with increased length of stay in both the nonenhanced recovery (OR 1.2; 95% CI, 1.1-1.3) and enhanced recovery groups (OR 1.2; 95% CI, 1.1-1.4). Enhanced recovery adherence was associated with reductions in racial disparities in complications as the Black race was associated with increased odds of complications in the nonenhanced recovery group (OR 1.9; 95% CI, 1.2-3.0) but not in the enhanced recovery group (OR 0.8; 95% CI, 0.4-1.6). LIMITATIONS Details of potential factors affecting enhanced recovery program adherence were not assessed and are the subject of current work by this team. CONCLUSION High social vulnerability was not associated with worse outcomes among both enhanced recovery and nonenhanced recovery colorectal patients. Enhanced recovery program adherence was associated with reductions in racial disparities in complication rates. However, disparities in length of stay remain, and work is needed to understand the underlying mechanisms driving these disparities. See Video Abstract . COMPRENDIENDO EL IMPACTO DE LOS PROGRAMAS DE RECUPERACIN MEJORADA EN LA VULNERABILIDAD SOCIAL, LA RAZA Y LOS RESULTADOS DE LA CIRUGA COLORRECTAL ANTECEDENTES:El aumento de la vulnerabilidad social medida por el índice de vulnerabilidad social se ha asociado con peores resultados quirúrgicos. Sin embargo, se sabe menos sobre el impacto de la vulnerabilidad social en los pacientes de cirugía colorrectal bajo programas de recuperación mejorados.OBJETIVO:Planteamos la hipótesis de que el aumento de la vulnerabilidad social se asocia con peores resultados antes de la implementación de la recuperación mejorada, pero después de la implementación, las disparidades en los resultados se reducirían.DISEÑO:Estudio de cohorte retrospectivo que utilizó regresión logística multivariable para identificar asociaciones de vulnerabilidad social y recuperación mejorada con los resultados.ESCENARIO:Base de datos institucional del Programa de Mejora Nacional de la Calidad de la Cirugía del American College of Surgeons.PACIENTES:Pacientes sometidos a cirugía colorrectal electiva (2010-2020). Programas de recuperación mejorada implementados en 2015. Aquellos que se adhieren a ≥70% de los componentes del programa de recuperación mejorada definidos como recuperación mejorada y todos los demás como recuperación no mejorada.MEDIDAS DE RESULTADO:Duración de la estancia hospitalaria, complicaciones y reingresos.RESULTADOS:De 1.523 pacientes, 589 (38,7%) estaban en el grupo de recuperación mejorada, con 732 (40,3%) pacientes en el tercio más bajo del índice de vulnerabilidad social, 498 (27,4%) en el tercio más alto, y no hubo diferencias en la distribución del índice vulnerabilidad social por grupo de recuperación mejorada. En el modelo multivariable, la vulnerabilidad social no se asoció con una mayor duración de la estancia hospitalaria, complicaciones o reingresos en ninguno de los grupos de recuperación mejorada. La raza negra se asoció con una mayor duración de la estadía tanto en el grupo de recuperación no mejorada (OR1,2, IC95% 1,1-1,3) como en el grupo de recuperación mejorada (OR1,2, IC95% 1,1-1,4). La adherencia a la recuperación mejorada se asoció con reducciones en las disparidades raciales en las complicaciones, ya que la raza negra se asoció con mayores probabilidades de complicaciones en el grupo de recuperación no mejorada (OR1,9, IC95% 1,2-3,0), pero no en el grupo de recuperación mejorada (OR0,8, IC95% 0,4-1,6).LIMITACIONES:No se evaluaron los detalles de los factores potenciales que afectan la adherencia al programa de recuperación mejorada y son el tema del trabajo actual de este equipo.CONCLUSIÓN:La alta vulnerabilidad social no se asoció con peores resultados entre los pacientes colorrectales con recuperación mejorada y sin recuperación mejorada. Una mayor adherencia al programa de recuperación se asoció con reducciones en las disparidades raciales en las tasas de complicaciones. Sin embargo, persisten disparidades en la duración de la estadía y es necesario trabajar para comprender los mecanismos subyacentes que impulsan estas disparidades. (Traducción-Dr. Felipe Bellolio ).
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Affiliation(s)
- Burkely P Smith
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Meghna H Katta
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert H Hollis
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Connie C Shao
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bayley A Jones
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marshall C McLeod
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tze-Woei Tan
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Daniel I Chu
- Division of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Salafian K, Mazimba C, Volodin L, Varadarajan I, Pilehvari A, You W, Knio ZO, Ballen K. The impact of social vulnerability index on survival following autologous stem cell transplant for multiple myeloma. Bone Marrow Transplant 2024; 59:459-465. [PMID: 38238453 PMCID: PMC10994832 DOI: 10.1038/s41409-024-02200-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 04/06/2024]
Abstract
Autologous hematopoietic stem cell transplantation (ASCT) is the standard of care for eligible patients with multiple myeloma (MM) to prolong progression-free survival (PFS). While several factors affect survival following ASCT, the impact of social determinants of health such as the CDC Social Vulnerability Index (SVI) is not well documented. This single-center retrospective analysis evaluated the impact of SVI on PFS following ASCT in MM patients. 225 patients with MM who underwent ASCT participated, with 51% transplanted in the last 5 years. At 5 years post-transplant, 55 (50%) achieved PFS and 66 (60%) remained alive. Higher SVI values were significantly associated with lower odds of PFS (OR = 0.521, p < 0.01, 95% CI [0.41, 0.66]) and OS (OR = 0.592, p < 0.01, 95% CI [0.46, 0.76]) post-transplant. Greater vulnerability scores in the socioeconomic status (OR = 0.890; 95% CI: [0.82, 0.96]), household characteristics (OR = 0.912; 95% CI: [0.87, 0.95]), and racial and ethnic minority status (OR = 0.854; 95% CI: [0.81, 0.90]) themes significantly worsened the odds of PFS. These results suggest high SVI areas may need more resources to achieve optimal PFS and OS. Future studies will focus on addressing factors within the socioeconomic status, household characteristics, and racial and ethnic minority subthemes, as these have a more pronounced effect on PFS.
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Affiliation(s)
- Kiarash Salafian
- Department of Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Christine Mazimba
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA
| | - Leonid Volodin
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA
| | - Indumathy Varadarajan
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA
| | - Asal Pilehvari
- Department of Public Health Sciences, University of Virginia, and University of Virginia Comprehensive Cancer Center, Charlottesville, VA, USA
| | - Wen You
- Department of Public Health Sciences, University of Virginia, and University of Virginia Comprehensive Cancer Center, Charlottesville, VA, USA
| | - Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Karen Ballen
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA.
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Baxter SN, Johnson AH, Brennan JC, MacDonald JH, Turcotte JJ, King PJ. Social vulnerability adversely affects emergency-department utilization but not patient-reported outcomes after total joint arthroplasty. Arch Orthop Trauma Surg 2024; 144:1803-1811. [PMID: 38206446 DOI: 10.1007/s00402-023-05186-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Multiple studies demonstrate social deprivation is associated with inferior outcomes after total hip (THA) and total knee (TKA) arthroplasty; its effect on patient-reported outcomes is debated. The primary objective of this study evaluated the relationship between social vulnerability and the PROMIS-PF measure in patients undergoing THA and TKA. A secondary aim compared social vulnerability between patients who required increased resource utilization or experienced complications and those who didn't. MATERIALS AND METHODS A retrospective review of 537 patients from March 2020 to February 2022 was performed. The Centers for Disease Control Social Vulnerability Index (SVI) were used to quantify socioeconomic disadvantage. The cohort was split into THA and TKA populations; univariate and multivariate analyses were performed to evaluate primary and secondary outcomes. Statistical significance was assessed at p < 0.05. RESULTS 48.6% of patients achieved PROMIS-PF MCID at 1-year postoperatively. Higher levels of overall social vulnerability (0.40 vs. 0.28, p = 0.03) were observed in TKA patients returning to the ED within 90-days of discharge. Increased overall SVI (OR = 9.18, p = 0.027) and household characteristics SVI (OR = 9.57, p = 0.015) were independent risk factors for 90-day ED returns after TKA. In THA patients, increased vulnerability in the household type and transportation dimension was observed in patients requiring 90-day ED returns (0.51 vs. 0.37, p = 0.04). CONCLUSION Despite an increased risk for 90-day ED returns, patients with increased social vulnerability still obtain good 1-year functional outcomes. Initiatives seeking to mitigate the effect of social deprivation on TJA outcomes should aim to provide safe alternatives to ED care during early recovery.
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Affiliation(s)
- Samantha N Baxter
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Andrea H Johnson
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Jane C Brennan
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - James H MacDonald
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA
| | - Justin J Turcotte
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA.
| | - Paul J King
- Anne Arundel Medical Center Inc, 2000 Medical Parkway, Annapolis, MD, 21401, USA
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Katayama ES, Woldesenbet S, Munir MM, Endo Y, Rawicz-Pruszyński K, Khan MMM, Tsilimigras D, Dillhoff M, Cloyd J, Pawlik TM. Effect of Behavioral Health Disorders on Surgical Outcomes in Cancer Patients. J Am Coll Surg 2024; 238:625-633. [PMID: 38420963 DOI: 10.1097/xcs.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND Behavioral health disorders (BHDs) can often be exacerbated in the setting of cancer. We sought to define the prevalence of BHD among cancer patients and characterize the association of BHD with surgical outcomes. STUDY DESIGN Patients diagnosed with lung, esophageal, gastric, liver, pancreatic, and colorectal cancer between 2018 and 2021 were identified within Medicare Standard Analytic Files. Data on BHD defined as substance abuse, eating disorder, or sleep disorder were obtained. Postoperative textbook outcomes (ie no complications, prolonged length of stay, 90-day readmission, or 90-day mortality), as well as in-hospital expenditures and overall survival were assessed. RESULTS Among 694,836 cancer patients, 46,719 (6.7%) patients had at least 1 BHD. Patients with BHD were less likely to undergo resection (no BHD: 23.4% vs BHD: 20.3%; p < 0.001). Among surgical patients, individuals with BHD had higher odds of a complication (odds ratio [OR] 1.32 [1.26 to 1.39]), prolonged length of stay (OR 1.36 [1.29 to 1.43]), and 90-day readmission (OR 1.57 [1.50 to 1.65]) independent of social vulnerability or hospital-volume status resulting in lower odds to achieve a TO (OR 0.66 [0.63 to 0.69]). Surgical patients with BHD also had higher in-hospital expenditures (no BHD: $16,159 vs BHD: $17,432; p < 0.001). Of note, patients with BHD had worse long-term postoperative survival (median, no BHD: 46.6 [45.9 to 46.7] vs BHD: 37.1 [35.6 to 38.7] months) even after controlling for other clinical factors (hazard ratio 1.26 [1.22 to 1.31], p < 0.001). CONCLUSIONS BHD was associated with lower likelihood to achieve a postoperative textbook outcome, higher expenditures, as well as worse prognosis. Initiatives to target BHD are needed to improve outcomes of cancer patients undergoing surgery.
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Affiliation(s)
- Erryk S Katayama
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
- Division of Surgical Oncology, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH (Katayama)
| | - Selamawit Woldesenbet
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Muhammad Musaab Munir
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Yutaka Endo
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Karol Rawicz-Pruszyński
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
- Department of Surgical Oncology, Medical University of Lublin, Poland (Rawicz-Pruszyński)
| | - Muhammad Muntazir Mehdi Khan
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Diamantis Tsilimigras
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Mary Dillhoff
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Jordan Cloyd
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
| | - Timothy M Pawlik
- From the Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Katayama, Woldesenbet, Munir, Endo, Rawicz-Pruszyński, Khan, Tsilimigras, Dillhoff, Cloyd, Pawlik)
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16
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Schmidt S, Jacobs MA, Kim J, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. Presentation Acuity and Surgical Outcomes for Patients With Health Insurance Living in Highly Deprived Neighborhoods. JAMA Surg 2024; 159:411-419. [PMID: 38324306 PMCID: PMC10851138 DOI: 10.1001/jamasurg.2023.7468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/14/2023] [Indexed: 02/08/2024]
Abstract
Importance Insurance coverage expansion has been proposed as a solution to improving health disparities, but insurance expansion alone may be insufficient to alleviate care access barriers. Objective To assess the association of Area Deprivation Index (ADI) with postsurgical textbook outcomes (TO) and presentation acuity for individuals with private insurance or Medicare. Design, Setting, and Participants This cohort study used data from the National Surgical Quality Improvement Program (2013-2019) merged with electronic health record data from 3 academic health care systems. Data were analyzed from June 2022 to August 2023. Exposure Living in a neighborhood with an ADI greater than 85. Main Outcomes and Measures TO, defined as absence of unplanned reoperations, Clavien-Dindo grade 4 complications, mortality, emergency department visits/observation stays, and readmissions, and presentation acuity, defined as having preoperative acute serious conditions (PASC) and urgent or emergent cases. Results Among a cohort of 29 924 patients, the mean (SD) age was 60.6 (15.6) years; 16 424 (54.9%) were female, and 13 500 (45.1) were male. A total of 14 306 patients had private insurance and 15 618 had Medicare. Patients in highly deprived neighborhoods (5536 patients [18.5%]), with an ADI greater than 85, had lower/worse odds of TO in both the private insurance group (adjusted odds ratio [aOR], 0.87; 95% CI, 0.76-0.99; P = .04) and Medicare group (aOR, 0.90; 95% CI, 0.82-1.00; P = .04) and higher odds of PASC and urgent or emergent cases. The association of ADIs greater than 85 with TO lost significance after adjusting for PASC and urgent/emergent cases. Differences in the probability of TO between the lowest-risk (ADI ≤85, no PASC, and elective surgery) and highest-risk (ADI >85, PASC, and urgent/emergent surgery) scenarios stratified by frailty were highest for very frail patients (Risk Analysis Index ≥40) with differences of 40.2% and 43.1% for those with private insurance and Medicare, respectively. Conclusions and Relevance This study found that patients living in highly deprived neighborhoods had lower/worse odds of TO and higher presentation acuity despite having private insurance or Medicare. These findings suggest that insurance coverage expansion alone is insufficient to overcome health care disparities, possibly due to persistent barriers to preventive care and other complex causes of health inequities.
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Affiliation(s)
- Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan C. Silverstein
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio
- University Health, San Antonio, Texas
- Department of Primary Care and Rural Medicine, School of Medicine, Texas A&M University, Bryan
- Department of Medical Physiology, School of Medicine, Texas A&M University, Bryan
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17
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Dyas AR, Carmichael H, Bronsert MR, Stuart CM, Garofalo DM, Henderson WG, Colborn KL, Schulick RD, Meguid RA, Velopulos CG. Social vulnerability is associated with higher risk-adjusted rates of postoperative complications in a broad surgical population. Am J Surg 2024; 229:26-33. [PMID: 37775458 DOI: 10.1016/j.amjsurg.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/08/2023] [Accepted: 09/22/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE The purpose of this study was to determine if an association between Social Vulnerability Index (SVI) and risk-adjusted complications exists in a broad spectrum of surgical patients. SUMMARY BACKGROUND DATA Growing evidence supports the impact of social circumstances on surgical outcomes. SVI is a neighborhood-based measure accounting for sociodemographic factors putting communities at risk. METHODS This was a multi-hospital, retrospective cohort study including a sample of patients within one healthcare system (2012-2017). Patient addresses were geocoded to determine census tract of residence and estimate SVI. Patients were grouped into low SVI (score<75) and high SVI (score≥75) cohorts. Perioperative variables and postoperative outcomes were tracked and compared using local ACS-NSQIP data. Multivariable logistic regression was performed to generate risk-adjusted odds ratios of postoperative complications in the high SVI cohort. RESULTS Overall, 31,224 patients from five hospitals were included. Patients with high SVI were more likely to be racial minorities, have 12/18 medical comorbidities, have high ASA class, be functionally dependent, be treated at academic hospitals, and undergo emergency operations (all p < 0.05). Patients with high SVI had significantly higher rates of 30-day mortality, overall morbidity, respiratory, cardiac and infectious complications, urinary tract infections, postoperative bleeding, non-home discharge, and unplanned readmissions (all p < 0.05). After risk-adjustment, only the associations between high SVI and mortality and unplanned readmission became non-significant. CONCLUSIONS High SVI was associated with multiple adverse outcomes even after risk adjustment for preoperative clinical factors. Targeted preventative interventions to mitigate risk of these specific complications should be considered in this high-risk population.
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Affiliation(s)
- Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Heather Carmichael
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christina M Stuart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Denise M Garofalo
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - William G Henderson
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kathryn L Colborn
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA; Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Catherine G Velopulos
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
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18
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Diaz A, Azap L, Moazzam Z, Knight-Davis J, Pawlik TM. Association of social determinants of health International Classification of Disease, Tenth Edition clinical modification codes with outcomes for emergency general surgery and trauma admissions. Surgery 2024; 175:899-906. [PMID: 37863693 DOI: 10.1016/j.surg.2023.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/22/2023] [Accepted: 08/08/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Patients with Acute Care Surgery needs (ie, emergency general surgery diagnosis or trauma admission) are at particularly high risk for nonmedical patient-related factors that can be important drivers of healthcare outcomes. These social determinants of health are typically ascertained at the geographic area level (ie, county or neighborhood) rather than at the individual patient level. Recently, the International Classification of Diseases Tenth Revision, Tenth Edition created codes to capture health hazards related to patient socioeconomic and psychosocial circumstances. We sought to characterize the impact of these social determinants of health-related codes on perioperative outcomes among patients with acute care surgery needs. METHODS Patients diagnosed between 2017 and 2020 with acute care surgery needs (ie, emergency general surgery diagnosis or a trauma admission) were identified in the California Department of Healthcare Access and information Patient Discharge database. Data on concomitant social determinants of health-related codes (International Classification of Diseases Tenth Revision, Tenth Edition Z55-Z65), which designated health hazards related to socioeconomic and psychosocial (socioeconomic and psychosocial, respectively) circumstances, were obtained. After controlling for patient factors, including age, sex, race, payer type, and admitting hospital, the association of socioeconomic and psychosocial codes with perioperative outcomes and hospital disposition was analyzed. RESULTS Among 483,280 with an acute care surgery admission (emergency general surgery: n = 289,530, 59.9%; trauma: n = 193,705, 40.1%) mean age was 56.5 years (standard deviation: 21.5) and 271,911 (56.3%) individuals were male. Overall, 16,263 (3.4%) patients had a concomitant socioeconomic and psychosocial diagnosis code. The percentage of patients with a concurrent social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis increased throughout the study period from 2.6% in 2017 to 4.4% in 2020. Patients that were male (odds ratio 1.89; 95% confidence interval 1.82, 1.96), insured by Medicaid (odds ratio 5.43; 95% confidence interval 5.15, 5.72) or self-pay (odds ratio 3.04; 95% confidence interval 2.75, 3.36) all had higher odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. Black race did not have a significant association with an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis (odds ratio 0.99; 95% confidence interval 0.94, 1.04); however, Hispanic (odds ratio 0.44; 95% confidence interval 0.43, 0.46) and Asian (odds ratio 0.40; 95% confidence interval 0.36, 0.44) race/ethnicity was associated with a lower odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. After controlling for competing risk factors on multivariable analyses, the risk-adjusted probability of hospital postoperative death was 3.1% (95% confidence interval 2.8, 3.4) among patients with a social determinants of health diagnosis versus 5.9% (95% confidence interval 5.9, 6.0) (odds ratio 0.48; 95% confidence interval 0.44, 0.54) among patients without a social determinants of health diagnosis. Risk-adjusted complications were 26.7% (95% confidence interval 26.1, 37.3) among patients with a social determinants of health diagnosis compared with 31.9% (95% confidence interval 31.7, 32.0) (odds ratio 0.74; 95% confidence interval 0.71, 0.77) among patients without a social determinants of health diagnosis. CONCLUSION International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code use was low, with only 3.4% of patients having documentation of a socioeconomic and psychosocial circumstance. The presence of an International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code was not associated with greater odds of complications or death; however, it was associated with longer length of stay and higher odds of being discharged to a skilled nursing facility.
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Affiliation(s)
- Adrian Diaz
- The Ohio State University, Department of Surgery, Columbus, OH.
| | - Lovette Azap
- The Ohio State University, Department of Surgery, Columbus, OH
| | - Zorays Moazzam
- The Ohio State University, Department of Surgery, Columbus, OH
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19
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Ledenko M, Antwi SO, Patel T. Geospatial analysis of cyanobacterial exposure and liver cancer in the contiguous United States. Hepatology 2024; 79:575-588. [PMID: 37607728 DOI: 10.1097/hep.0000000000000573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/09/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND AND AIMS Cyanobacteria are commonly found in water bodies and their production of hepatotoxins can contribute to liver damage. However, the population health effects of cyanobacteria exposure (CE) are unknown. Our objectives were to determine the effect of chronic exposure to cyanobacteria through proximity to water bodies with high cyanobacteria counts on the incidence and mortality of liver cancers, as well as to identify location-based risk factors. APPROACH AND RESULTS Across the contiguous United States, regions with high cyanobacteria counts in water bodies were identified using satellite remote sensing data. The data were geospatially mapped to county boundaries, and disease mortality and incidence rates were analyzed. Distinctive spatial clusters of CE and mortality related to liver diseases or cancer were identified. There was a highly significant spatial association between CE, liver disease, and liver cancer but not between CE and all cancers. Hot spots of CE and mortality were identified along the Gulf of Mexico, eastern Texas, Louisiana, and Florida, and cold spots across the Appalachians. The social vulnerability index was identified as a major location-based determinant by logistic regression, with counties in the fourth or fifth quintiles having the highest prevalence of hot spots of CE and mortality from liver cancer. CONCLUSIONS These findings emphasize the importance of environmental exposure to cyanobacteria as a location-based determinant of mortality from liver cancer. Public health initiatives addressing CE may be considered to reduce mortality, particularly in areas of high social vulnerability.
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Affiliation(s)
- Matthew Ledenko
- Department of Transplantation, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Samuel O Antwi
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Tushar Patel
- Department of Transplantation, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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20
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Olecki EJ, Perez Holguin RA, Mayhew MM, Wong WG, Vining CC, Peng JS, Shen C, Dixon MEB. Disparities in Surgical Treatment of Resectable Pancreatic Adenocarcinoma at Minority Serving Hospitals. J Surg Res 2024; 294:160-168. [PMID: 37897875 DOI: 10.1016/j.jss.2023.09.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/02/2023] [Accepted: 09/24/2023] [Indexed: 10/30/2023]
Abstract
INTRODUCTION Minority serving hospitals (MSH) are those serving a disproportionally high number of minority patients. Previous research has demonstrated that treatment at MSH is associated with worse outcomes. We hypothesize that patients treated at MSH are less likely to undergo surgical resection of pancreatic adenocarcinoma compared to patients treated at non-MSH. METHODS Patients with resectable pancreatic cancer were identified using the National Cancer Database. Institutions treating Black and Hispanic patients in the top decile were categorized as an MSH. Factors associated with the primary outcome of definitive surgical resection were evaluated using multivariable logistic regression. Univariate and multivariable survival analysis was performed. RESULTS Of the 75,513 patients included in this study, 7.2% were treated at MSH. Patients treated at MSH were younger, more likely to be uninsured, and higher stage compared to those treated at non-MSH (P < 0.001). Patients treated at MSH underwent surgical resection at lower rates (MSH 40% versus non-MSH 44.5%, P < 0.001). On multivariable logistic regression, treatment at MSH was associated with decreased likelihood of undergoing definitive surgery (odds ratio 0.91, P = 0.006). Of those who underwent surgical resection, multivariable survival analysis revealed that treatment at an MSH was associated with increased morality (hazard ratio 1.12, P < 0.001). CONCLUSIONS Patients with resectable pancreatic adenocarcinoma treated at MSH are less likely to undergo surgical resection compared to those treated at non-MSH. Targeted interventions are needed to address the unique barriers facing MSH facilities in providing care to patients with pancreatic adenocarcinoma.
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Affiliation(s)
- Elizabeth J Olecki
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania.
| | - Rolfy A Perez Holguin
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Mackenzie M Mayhew
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - William G Wong
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Charles C Vining
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; Program for Liver, Pancreas & Foregut Tumors, Division of Surgical Oncology, Penn State Milton S Hershey Medical Center, Hershey, Pennsylvania
| | - June S Peng
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania; Program for Liver, Pancreas & Foregut Tumors, Division of Surgical Oncology, Penn State Milton S Hershey Medical Center, Hershey, Pennsylvania
| | - Chan Shen
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Matthew E B Dixon
- Department of Surgery, Rush University Medical College, Chicago, Illinois; Section of Hepatopancreatobiliary Surgery, Division of Surgical Oncology, Rush University Medical Center, Chicago, Illinois
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21
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Avila A, Lao OB, Neville HL, Yorkgitis BK, Chang HL, Thatch K, Plumley D, Larson SD, Fitzwater JW, Markley M, Pedroso F, Fischer A, Armstrong LB, Petroze RT, Snyder CW. Social determinants of health in pediatric trauma: Associations with injury mechanisms and outcomes in the context of the COVID-19 pandemic. Am J Surg 2024; 228:107-112. [PMID: 37661530 DOI: 10.1016/j.amjsurg.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/17/2023] [Accepted: 08/19/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Relationships between social determinants of health and pediatric trauma mechanisms and outcomes are unclear in context of COVID-19. METHODS Children <16 years old injured between 2016 and 2021 from ten pediatric trauma centers in Florida were included. Patients were stratified by high vs. low Social Vulnerability Index (SVI). Injury mechanisms studied were child abuse, ATV/golf carts, and firearms. Mechanism incidence trends and mortality were evaluated by interrupted time series and multivariable logistic regression. RESULTS Of 19,319 children, 68% and 32% had high and low SVI, respectively. Child abuse increased across SVI strata and did not change with COVID. ATV/golf cart injuries increased after COVID among children with low SVI. Firearm injuries increased after COVID among children with high SVI. Mortality was predicted by injury mechanism, but was not independently associated with SVI, race, or COVID. CONCLUSION Social vulnerability influences pediatric trauma mechanisms and COVID effects. Child abuse and firearm injuries should be targeted for prevention.
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Affiliation(s)
- Azalia Avila
- Joe DiMaggio Children's Hospital, Memorial Health, Hollywood, FL, 1005 Joe DiMaggio Dr, Hollywood, FL, 33021, USA.
| | - Oliver B Lao
- Joe DiMaggio Children's Hospital, Memorial Health, Hollywood, FL, 1005 Joe DiMaggio Dr, Hollywood, FL, 33021, USA.
| | - Holly L Neville
- Joe DiMaggio Children's Hospital, Memorial Health, Hollywood, FL, 1005 Joe DiMaggio Dr, Hollywood, FL, 33021, USA.
| | - Brian K Yorkgitis
- University of Florida, College of Medicine-Jacksonville, Department of Surgery, 655 8th St W, Jacksonville, FL, 32209, USA.
| | - Henry L Chang
- Tampa General Hospital - Children's Hospital, Tampa, FL, 1 Tampa General Cir, Tampa, FL, 33606, USA; Johns Hopkins All Children's Hospital, St Petersburg, FL, 501 6th Ave S, St. Petersburg, FL, 33701, USA.
| | - Keith Thatch
- Tampa General Hospital - Children's Hospital, Tampa, FL, 1 Tampa General Cir, Tampa, FL, 33606, USA; Johns Hopkins All Children's Hospital, St Petersburg, FL, 501 6th Ave S, St. Petersburg, FL, 33701, USA.
| | - Donald Plumley
- Arnold Palmer Hospital for Children, Orlando Health, Orlando, FL, 92 W Miller St, Orlando, FL, 32806, USA.
| | - Shawn D Larson
- University of Florida, College of Medicine-Jacksonville, Department of Surgery, 655 8th St W, Jacksonville, FL, 32209, USA.
| | - John W Fitzwater
- Baylor Scott & White McLane Children's Medical Center, Temple, TX, 1901 SW H K Dodgen Loop, Temple, TX, 76502, USA.
| | - Michele Markley
- Salah Foundation Children's Hospital, Broward Health, Ft. Lauderdale, Florida, 1600 S Andrews Ave, Fort Lauderdale, FL, 33316, USA.
| | - Felipe Pedroso
- Nicklaus Children's Hospital, Miami, FL, 3100 SW 62nd Ave, Miami, FL, 33155, USA.
| | - Anne Fischer
- Palm Beach Children's Hospital, West Palm Beach, FL, 901 45th St, West Palm Beach, FL, 33407, USA.
| | - Lindsey B Armstrong
- Johns Hopkins All Children's Hospital, St Petersburg, FL, 501 6th Ave S, St. Petersburg, FL, 33701, USA.
| | - Robin T Petroze
- University of Florida, College of Medicine-Jacksonville, Department of Surgery, 655 8th St W, Jacksonville, FL, 32209, USA.
| | - Christopher W Snyder
- Johns Hopkins All Children's Hospital, St Petersburg, FL, 501 6th Ave S, St. Petersburg, FL, 33701, USA.
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22
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Moazzam Z, Woldesenbet S, Munir MM, Lima HA, Alaimo L, Endo Y, Cloyd J, Dillhoff M, Ejaz A, Pawlik TM. Mediators of racial disparities in postoperative outcomes among patients undergoing complex surgery. Am J Surg 2024; 228:165-172. [PMID: 37743217 DOI: 10.1016/j.amjsurg.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/07/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND This study sought to quantify the direct and indirect effects of race on postoperative outcomes after complex surgery. METHODS Medicare patients who underwent abdominal aortic aneurysm (AAA) repair, coronary artery bypass grafting (CABG), lung resection or colectomy were identified (2014-2018). Generalized structural equation modelling was utilized to quantify the direct and indirect effects of race on Textbook outcome (TO). RESULTS Among 930,033 patients, 46.8% of patients achieved a TO, with Black patients less likely to achieve a TO (referent: White; Black: OR 0.72, 95% CI 0.70-0.73). Notably, 32.3% of the disparities in TO were attributable to race itself, while 67.7% was explained by other factors. Specifically, residential segregation accounted for 39.4% of the lower TO rates among Black patients, while 21.0% was attributable to a high comorbidity burden. CONCLUSIONS These data highlight the need to target structural racism as a policy priority to promote a more equitable healthcare system.
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Affiliation(s)
- Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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23
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Diaz A, Pawlik T. Association of ICD-10 Clinical Modification Codes for Social Determinants of Health with Surgical Outcomes and Hospital Charges Among Cancer Patients. Ann Surg Oncol 2024; 31:1171-1177. [PMID: 38006529 DOI: 10.1245/s10434-023-14501-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 10/11/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION We sought to characterize the impact of social determinants of health (SDOH)-related codes on outcomes among patients with a cancer diagnosis. METHODS Patients diagnosed with lung, pancreas, colon, or rectal cancer between 2017 and 2020 were identified in the California Department of Healthcare Access and Information Patient Discharge Database. Data on concomitant SDOH-related codes (International Classification of Diseases, Tenth Revision [ICD-10] Z55-Z65) designating health hazards related to socioeconomic and psychosocial circumstances were obtained. The association of these SDOH codes with postoperative outcomes was evaluated. RESULTS Among 10,421 patients who underwent an operation from 2017 to 2020, median age was 66 years (interquartile range [IQR] 56-75) and nearly half of the cohort was male (n = 551,252.9%). In total, 102 (1%) patients had a concurrent ICD-10 SDOH diagnosis. After controlling for competing risk factors, the risk-adjusted probability of in-hospital death was 4.1% (95% confidence interval [CI] 1.0-7.2) among patients with an SDOH diagnosis compared with 2.9% (95% CI 2.5-3.2) among patients without an SDOH diagnosis (odds ratio [OR] 1.52, 95% CI 0.63-3.66; p = 0.258); postoperative complications were 27.0% (95% CI 20.0-34.1) compared with 24.9% (95% CI 24.1-25.6) among patients without an SDOH diagnosis (OR 1.15, 95% CI 0.73-1.82; p = 0.141), and length of stay was 10.6 days (95% CI 10.0-11.2) compared with 9.4 days (95% CI 9.3-9.5) among patients without an SDOH diagnosis. Patients with an SDOH diagnosis had a 5.19 (95% CI 3.23-8.34; p < 0.005) higher odds of being discharged to a skilled nursing facility versus patients without an SDOH diagnosis. CONCLUSION Uptake and utilization of ICD-10 SDOH was 1% among California patients with lung, pancreas, colon, or rectal cancer. Patients with a concomitant ICD-10 SDOH code had longer length of stay and had higher odds of being discharged to a skilled nursing facility.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University, Columbus, OH, USA.
| | - Timothy Pawlik
- Department of Surgery, The Ohio State University, Columbus, OH, USA
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Diaz A, Pawlik T. ASO Author Reflections: International Classification of Diseases Codes for Social Determinants of Health: Still Not Ready for Prime Time. Ann Surg Oncol 2024; 31:1200-1201. [PMID: 37962744 DOI: 10.1245/s10434-023-14539-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 11/15/2023]
Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University, Columbus, OH, USA.
| | - Timothy Pawlik
- Department of Surgery, The Ohio State University, Columbus, OH, USA
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Stuart CM, Dyas AR, Bronsert MR, Velopulos CG, Randhawa SK, David EA, Mitchell JD, Meguid RA. The Effect of Social Vulnerability on Initial Stage and Treatment for Non-Small Cell Lung Cancer. Lung Cancer 2024; 188:107452. [PMID: 38176296 PMCID: PMC10872251 DOI: 10.1016/j.lungcan.2023.107452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/12/2023] [Accepted: 12/22/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE The Social Vulnerability Index (SVI) is a composite metric for social determinants of health. The objective of this study was to determine if SVI influences stage at presentation for non-small cell lung cancer (NSCLC) patients and subsequent therapies. MATERIALS AND METHODS NSCLC patients from our local contribution to the National Cancer Database (2011-2021) were grouped into low SVI (<75 %ile) and high SVI (>75 %ile) cohorts. Demographics, cancer-related variables, and treatment modalities were compared. Multivariable logistic regression was performed to control for the impact of demographics on cancer presentation and for the impact of oncologic variables on treatment outcomes. RESULTS Of 1,662 NSCLC patients, 435 (26 %) were defined as high SVI. Compared to the 1,227 (74 %) low SVI patients, highly vulnerable patients were more likely to be male (53.3 % vs 46.0 %, p = 0.009), non-White (17.2 % vs 9.7 %, p < 0.0001), have comorbidities (29.4 % vs 23.1 %, p = 0.009) and present at a higher AJCC clinical T, M and overall stage (all p < 0.05). These findings persisted on multivariable analysis, with highly vulnerable patients having 1.5x the odds (95 %CI: 1.23-1.86, p < 0.001) of presenting at more advanced stage. Patients with high SVI were less likely to be recommended for and receive surgery (40.9 % vs 53.2 %, p < 0.001), and this finding persisted after controlling for stage at presentation (OR 1.37, 95 %CI 1.04-1.80). CONCLUSIONS Highly vulnerable patients present at a more advanced clinical stage and are less likely to be recommended and receive surgery, even after controlling for stage at presentation. Further investigation into these findings is warranted to achieve more equitable oncologic care.
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Affiliation(s)
- Christina M Stuart
- Department of Surgery, The University of Colorado, Anschutz Medical Campus, Aurora CO, USA.
| | - Adam R Dyas
- Department of Surgery, The University of Colorado, Anschutz Medical Campus, Aurora CO, USA
| | - Michael R Bronsert
- Adult and Child Center for Outcomes Research and Delivery Science, The University of Colorado, Anschutz Medical Campus, Aurora CO, USA
| | - Catherine G Velopulos
- Department of Surgery, The University of Colorado, Anschutz Medical Campus, Aurora CO, USA
| | - Simran K Randhawa
- Department of Surgery, The University of Colorado, Anschutz Medical Campus, Aurora CO, USA
| | - Elizabeth A David
- Department of Surgery, The University of Colorado, Anschutz Medical Campus, Aurora CO, USA
| | - John D Mitchell
- Department of Surgery, The University of Colorado, Anschutz Medical Campus, Aurora CO, USA
| | - Robert A Meguid
- Department of Surgery, The University of Colorado, Anschutz Medical Campus, Aurora CO, USA
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Nieri CA, Davies C, Luttrell JB, Sheyn A. Associations Between Social Vulnerability Indicators and Pediatric Tonsillectomy Outcomes. Laryngoscope 2024; 134:954-962. [PMID: 38050924 DOI: 10.1002/lary.30836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/25/2023] [Accepted: 05/24/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVE To investigate the impact of neighborhood-level social vulnerability on pediatric tonsillectomy outcomes. METHODS This single-center retrospective cohort study included tonsillectomies performed on children aged 1 to 18 between August 2019 and August 2020. Geographic information systems were used to geocode addresses, and spatial overlays were used to assign census-tract level social vulnerability index (SVI) scores to each patient. For categorical variables, two-sided Pearson chi-square tests were used, whereas for continuous variables, paired t-tests, means, and standard deviations were calculated. SVI and its four subthemes were investigated using binomial logistic regressions to determine their impact on post-T&A complications and readmissions. RESULTS The study included 397 patients, with 52 having complications (13.1%) and 33 (8.3%) requiring readmissions due to their complications. Controlling for age, gender, race, insurance status, surgical indication, comorbidities, obesity, and obstructive sleep apnea, postoperative complications were associated with high overall SVI (odds ratio [OR] 5.086, 95% confidence interval [CI] 1.128-22.938), high socioeconomic vulnerability (SVI theme 1, OR 6.003, 95% CI 1.270-28.385), and high house composition vulnerability (SVI theme 2, OR 6.340, 95% CI 1.275-31.525). Readmissions were also associated with high overall SVI (10.149, 95% CI 1.293-79.647) and high housing/transportation vulnerability (SVI theme 4, OR 5.657, 95% CI 1.089-29.396). CONCLUSION Social vulnerability at the neighborhood level is linked to poorer surgical outcomes in otherwise healthy children, suggesting a target for community-based interventions. Because of the increased risk, it may have implications for preoperative decision-making, treatment plans, and clinic follow-ups. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:954-962, 2024.
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Affiliation(s)
- Chad A Nieri
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Camron Davies
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A
| | - Jordan B Luttrell
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A
| | - Anthony Sheyn
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A
- Division of Otolaryngology, LeBonheur Children's Hospital, Memphis, Tennessee, U.S.A
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Katayama ES, Woldesenbet S, Munir MM, Endo Y, Moazzam Z, Lima HA, Shaikh CF, Pawlik TM. Poor Access to Mental Healthcare is Associated with Worse Postoperative Outcomes Among Patients with Gastrointestinal Cancer. Ann Surg Oncol 2024; 31:49-57. [PMID: 37814182 DOI: 10.1245/s10434-023-14374-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/17/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Mental health has an important role in the care of cancer patients, and access to mental health services may be associated with improved outcomes. Thus, poor access to psychiatric services may contribute to suboptimal cancer treatment. We conducted a geospatial analysis to characterize psychiatrist distribution and assess the impact of mental healthcare shortages with surgical outcomes among patients with gastrointestinal cancer. METHODS Medicare beneficiaries with mental illness diagnosed with complex gastrointestinal cancers between 2004 and 2016 were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry. National Provider Identifier-registered psychiatrist locations were mapped and linked to SEER-Medicare records. Regional access to psychiatric services was assessed relative to textbook outcome, a composite assessment of postoperative complications, prolonged length of stay, 90-day readmission and mortality. RESULTS Among 15,714 patients with mental illness and gastrointestinal cancer, 3937 were classified as having high access to psychiatric services while 3910 had low access. On multivariable logistic regression, areas with low access had higher risk of worse postoperative outcomes. Specifically, individuals residing in areas with low access had increased odds of prolonged length of stay (OR 1.11, 95%CI 1.01-1.22; p = 0.028) and 90-day readmission (OR 1.19, 95%CI 1.08-1.31; p < 0.001), as well as decreased odds of textbook outcome (OR 0.85, 95%CI 0.77-0.93; p < 0.001) and discharge to home (OR 0.89, 95%CI 0.80-0.99; p = 0.028). CONCLUSION Patients with mental illness and lower access to psychiatric services had worse postoperative outcomes. Policymakers and providers should prioritize incorporating mental health screening and access to psychiatric services to address disparities among patients undergoing gastrointestinal surgery.
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Affiliation(s)
- Erryk S Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Chanza F Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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Fei-Zhang DJ, Chelius DC, Sheyn AM, Rastatter JC. Large-data contextualizations of social determinant associations in pediatric head and neck cancers. Curr Opin Otolaryngol Head Neck Surg 2023; 31:424-429. [PMID: 37712774 DOI: 10.1097/moo.0000000000000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
PURPOSE OF REVIEW Prior investigations in social determinants of health (SDoH) and their impact on pediatric head and neck cancers are limited by the narrow scope of cancer types and SDoH being studied while lacking inquiry on the interrelational contribution of varied SDoH in real-world contexts. The purpose of this review is to discuss the current research tackling these shortcomings of SDoH-based studies in head and neck cancer and to discuss means of applying these findings in prospective initiatives and implementations. RECENT FINDINGS Through leveraging contemporary, large-data analyses measuring diverse social vulnerabilities, several studies have identified comprehensive delineations of which social disparities contribute the largest quantifiable impact on the care of head and neck cancer patients. Progressing from prior SDoH-based research of the decade, these studies contextualize the effect of social vulnerabilities and have laid the foundations to begin addressing these issues in the complex, modern-day environment of interrelatedsocial factors. SUMMARY Social determinants of health markedly affect pediatric head and neck cancer care and prognosis in complex and surprising ways. Modern-day tools and analyses derived from large-data techniques have unveiled the quantifiable underpinnings of how SDoH impact these pathologies.
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Affiliation(s)
| | - Daniel C Chelius
- Department of Otolaryngology-Head and Neck Surgery, Pediatric Thyroid Tumor Program and Pediatric Head and Neck Tumor Program, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Anthony M Sheyn
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center
- Department of Pediatric Otolaryngology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee
| | - Jeff C Rastatter
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Barry M, Gozali A, Vu L. Impact of Social Vulnerability on Long-Term Growth Outcomes in Sutureless Versus Sutured Repair of Gastroschisis. Eur J Pediatr Surg 2023; 33:477-484. [PMID: 36720245 DOI: 10.1055/s-0043-1761921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study is to describe the long-term growth and nutrition outcomes of sutureless versus sutured gastroschisis repair. We hypothesized that weight z-score at 1 year would be affected by social determinants of health measured by the U.S. Centers for Disease Control Social Vulnerability Index (SVI). MATERIALS AND METHODS We conducted a single-center retrospective review of patients who underwent gastroschisis repair (n = 97) from 2007 to 2018. Growth z-scores collected through 5 years of age and long-term clinical outcomes were compared based on the closure method and the type of gastroschisis (simple vs. complicated). Multiple regression analysis was performed to identify the impact of SVI themes and other covariates on weight for age z-score at 1 year. RESULTS In total, 46 patients underwent sutureless repair and 51 underwent sutured repair with median follow-up duration of 2.5 and 1.9 years, respectively. Weight and length z-scores decreased after birth but normalized within the first year of life. Growth and long-term clinical outcomes were similar regardless of the closure method, while patients with complicated gastroschisis had higher rates of hospitalizations, small bowel obstructions, and additional abdominal surgeries. Using multiple regression, both low discharge weight and high SVI in the "minority status and language" theme were associated with lower weight for age z-scores at 1 year (p = 0.003 and p = 0.03). CONCLUSION Sutureless and sutured gastroschisis repairs result in similar growth and long-term outcomes. Patients living in areas with greater social vulnerability may be at increased risk of poor weight gain. Patients should be followed at least through their first year to ensure appropriate growth.
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Affiliation(s)
- Mark Barry
- Department of Surgery, University of California San Francisco, San Francisco, California, United States
| | - Aileen Gozali
- School of Medicine, University of California San Francisco, San Francisco, California, United States
| | - Lan Vu
- Division of Pediatric Surgery, University of California San Francisco, San Francisco, California, United States
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Moazzam Z, Woldesenbet S, Munir MM, Alaimo L, Lima H, Ashraf A, Endo Y, Pawlik TM. Immigrant Doctors and Their Role in US Healthcare. J Gastrointest Surg 2023; 27:2724-2732. [PMID: 37950096 DOI: 10.1007/s11605-023-05878-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The composition of the US healthcare workforce relative to citizenship status remains ill-defined. We sought to characterize practice patterns among US doctors relative to citizenship status. MATERIALS AND METHODS Data were extracted from the 2008-2019 American Community Surveys, and citizenship was stratified as: citizens by birth, naturalized citizens for ≥ 10 years or < 10 years, and non-citizens. Multinomial logistic regression models and inverse probability weighting were employed. The data were reported as differences in proportions/means with 95% confidence intervals. RESULTS Among 97,775,606 respondents, 113,638 were identified as doctors (0.12%). Among the surveyed doctors, 72.4% (95% CI 72.1-72.8%) were citizens by birth, followed by naturalized citizens ≥ 10 years [14.4% (95% CI 14.1-14.6%)], non-citizens [7.2% (95% CI 7.0-7.4%)], and naturalized citizens < 10 years [6.0% (95% CI 5.8-6.1%)]. Naturalized citizens ≥ 10 and < 10 years worked 40.4 (95% CI 12.6-68.2) and 38.2 (95% CI 4.8-71.6) more hours annually compared with citizens by birth, respectively (both p < 0.05). While 22.7% of doctors who were citizens by birth worked in high socially vulnerable counties, immigrant doctors were more likely to work in these areas (difference (95% CI); naturalized citizens ≥ 10 years, 7.7% (6.1-9.4) vs. naturalized citizens < 10 years, 8.0% (5.9-10.1) vs. non-citizens, 4.1% (2.0-6.1)). Furthermore, naturalized citizens ≥ 10 years and < 10 years worked in lower physician density counties that had 29.6 (14.4-44.8) and 59.9 (42.3-77.5) more people, respectively, relative to doctors (all p < 0.001). CONCLUSIONS Immigrant doctors play a vital role in addressing US healthcare needs. Policies that encourage the increased integration and utilization of immigrant doctors and physicians-in-training may help to foster a sustainable healthcare workforce over the coming decades.
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Affiliation(s)
- Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Henrique Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Alina Ashraf
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12Th Ave., Suite 670, Columbus, OH, USA.
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Azap L, Woldesenbet S, Lima H, Munir MM, Diaz A, Endo Y, Yang J, Mokadam NA, Ganapathi A, Pawlik TM. The Association of Persistent Poverty and Outcomes Among Patients Undergoing Cardiac Surgery. J Surg Res 2023; 292:30-37. [PMID: 37572411 DOI: 10.1016/j.jss.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 08/14/2023]
Abstract
INTRODUCTION We sought to evaluate the association of county-level poverty duration and cardiac surgical outcomes. METHODS Patients who underwent coronary artery bypass graft, surgical aortic valve replacement, and mitral valve repair and replacement between 2016 and 2020 were identified using the Medicare Standard Analytical Files Database. County-level poverty data were acquired from the American Community Survey and US Department of Agriculture (1980-2015). High poverty was defined as ≥19.5% of residents in poverty. Patients were stratified into never-high poverty (NHP), intermittent low poverty, intermittent high poverty, and persistent poverty (PP). A mixed-effect hierarchical generalized linear model and Cox regression models that adjusted for patient-level covariates were used to evaluate outcomes. RESULTS Among 237,230 patients, 190,659 lived in NHP counties, while 10,273 resided in PP counties. Compared with NHP patients, PP patients were more likely to present at a younger median age (NHP: 75 y versus PP: 74 y), be non-Hispanic Black (5388, 2.9% versus PP: 1030, 10.1%), and live in the south (NHP: 66,012, 34.6% versus PP: 87,815, 76.1%) (all P < 0.001). PP patients also had more nonelective surgical operations (NHP: 58,490, 30.8% versus 3645, 35.6%, P < 0.001). Notably, PP patients had increased odds of 30-d mortality (odds ratio 1.13, 95% confidence interval [CI] 1.02-1.26), 90-d mortality (odds ratio 1.14, 95% CI 1.05-1.24), and risk of long-term mortality (hazard ratio 1.13, 95% CI 1.09-1.19) compared with patients in NHP counties (all P < 0.05). CONCLUSIONS County-level poverty was associated with a greater risk of short- and long-term mortality among cardiac surgical patients.
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Affiliation(s)
- Lovette Azap
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio; Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Selamawit Woldesenbet
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Henrique Lima
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Muhammad Musaab Munir
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Adrian Diaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Yutaka Endo
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Jason Yang
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Nahush A Mokadam
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Asvin Ganapathi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio.
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Allgood KL, Whittington B, Xie Y, Hirschtick JL, Ro A, Orellana RC, Fleischer NL. Social vulnerability and new mobility disability among adults with polymerase chain reaction (PCR)-confirmed SARS-CoV-2: Michigan COVID-19 Recovery Surveillance Study. Prev Med 2023; 177:107719. [PMID: 37788721 DOI: 10.1016/j.ypmed.2023.107719] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/22/2023] [Accepted: 09/29/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE Understanding the relationship between social factors and persistent COVID-19 health outcomes, such as onset of a disability after a SARS-CoV-2 (the virus that causes COVID-19) infection, is an increasingly important public health issue. The purpose of this paper is to examine associations between social vulnerability and new onset of a mobility disability post-COVID-19 diagnosis. METHODS We used data from the Michigan COVID-19 Recovery Surveillance Study, a population-based probability survey of adults with PCR-confirmed SARS-CoV-2 infection in Michigan between January 2020-May 2022 (n = 4295). We used the Minority Health Social Vulnerability Index (MHSVI), with high county-level social vulnerability defined at or above the 75th percentile. Mobility disability was defined as new difficulty walking or climbing stairs. We regressed mobility disability on the overall MHSVI, as well as sub-themes of the index (socioeconomic status, household composition/disability, minority and language, housing type, healthcare access, and medical vulnerability), using multivariable logistic regression, adjusting for age, race, sex, education, employment, and income. RESULTS Living in a county with high (vs. low) social vulnerability was associated with 1.38 times higher odds (95% confidence interval [CI]:1.18-1.61) of reporting a new mobility disability after a COVID-19 diagnosis after adjustment. Similar results were observed for the socioeconomic status and household composition/disability sub-themes. In contrast, residents of highly racially diverse counties had lower odds (odds ratio 0.74, 95% CI: 0.61, 0.89) of reporting a new mobility disability compared to low diversity counties. CONCLUSIONS Mitigating the effects of social vulnerabilities requires additional resources and attention to support affected individuals.
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Affiliation(s)
- Kristi L Allgood
- University of Michigan School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health. 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI 48109, USA; Texas A&M University School of Public Health, Department of Epidemiology & Biostatistics, USA.
| | - Blair Whittington
- University of Michigan School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health. 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI 48109, USA
| | - Yanmei Xie
- University of Michigan School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health. 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI 48109, USA
| | - Jana L Hirschtick
- University of Michigan School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health. 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI 48109, USA
| | - Annie Ro
- University of California - Irvine, Department of Health, Society, & Behavior. UCI Health Sciences Complex, 856 Health Sciences Quad, Suite 3600, Irvine, CA 92617, USA
| | - Robert C Orellana
- CDC Foundation, 600 Peachtree St NE #1000, Atlanta, GA 30308, USA; Bureau of Infectious Disease Prevention, Michigan Department of Health and Human Services, 333 S Grand Ave, P.O. Box 30195, Lansing, MI 48933, USA
| | - Nancy L Fleischer
- University of Michigan School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health. 1415 Washington Heights, 2649A, SPH Tower, Ann Arbor, MI 48109, USA
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Abdelhack M, Tripathi S, Chen Y, Avidan MS, King CR. Social Vulnerability and Surgery Outcomes: A Cross-sectional Analysis. RESEARCH SQUARE 2023:rs.3.rs-3580911. [PMID: 38077013 PMCID: PMC10705703 DOI: 10.21203/rs.3.rs-3580911/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
Background Post-operative complications present a challenge to the healthcare system due to the high unpredictability of their incidence. However, the socioeconomic factors that relate to postoperative complications are still unclear as they can be heterogeneous based on communities, types of surgical services, and sex and gender. Methods In this study, we conducted a large population cross-sectional analysis of social vulnerability and the odds of various post-surgical complications. We built statistical logistic regression models of postsurgical complications with social vulnerability index as the independent variable along with sex interaction. Results We found that social vulnerability was associated with abnormal heart rhythm with socioeconomic status and housing status being the main association factors. We also found associations of the interaction of social vulnerability and female sex with an increase in odds of heart attack and surgical wound infection. Conclusions Our results indicate that social vulnerability measures such as socioeconomic status and housing conditions could be related to health outcomes. This suggests that the domain of preventive medicine should place social vulnerability as a priority to achieve its goals.
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Affiliation(s)
- Mohamed Abdelhack
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
- Krembil Centre for Neuroinformatics, Centre for Addiction and Mental Health, Toronto, ON
| | - Sandhya Tripathi
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
| | - Yixin Chen
- Department of Computer Science, Washington University in St. Louis, St. Louis MO
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
| | - Christopher R King
- Department of Anesthesiology, Washington University School of Medicine, St. Louis MO
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Stuart CM, Dyas AR, Byers S, Velopulos C, Randhawa S, David EA, Pritap A, Stewart CL, Mitchell JD, McCarter MD, Meguid RA. Social vulnerability is associated with increased postoperative morbidity following esophagectomy. J Thorac Cardiovasc Surg 2023; 166:1254-1261. [PMID: 37119966 DOI: 10.1016/j.jtcvs.2023.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/28/2023] [Accepted: 04/22/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVES The effect of a patient's Social Vulnerability Index (SVI) on complication rates after esophagectomy remains unstudied. The purpose of this study was to determine how social vulnerability influences morbidity following esophagectomy. METHODS This was a retrospective review of a prospectively collected esophagectomy database at one academic institution, 2016 to 2022. Patients were grouped into low-SVI (<75%ile) and high-SVI (>75%ile) cohorts. The primary outcome was overall postoperative complication rate; secondary outcomes were rates of individual complications. Perioperative patient variables and postoperative complication rates were compared between the 2 groups. Multivariable logistic regression was used to control for covariates. RESULTS Of 149 patients identified who underwent esophagectomy, 27 (18.1%) were in the high-SVI group. Patients with high SVI were more likely to be of Hispanic ethnicity (18.5% vs 4.9%, P = .029), but there were no other differences in perioperative characteristics between groups. Patients with high SVI were significantly more likely to develop a postoperative complication (66.7% vs 36.9%, P = .005) and had greater rates of postoperative pneumonia (25.9% vs 6.6%, P = .007), jejunal feeding-tube complications (14.8% vs 3.3%, P = .036), and unplanned intensive care unit readmission (29.6% vs 12.3%, P = .037). In addition, patients with high SVI had a longer postoperative hospital length of stay (13 vs 10 days, P = .017). There were no differences in mortality rates. These findings persisted on multivariable analysis. CONCLUSIONS Patients with high SVI have greater rates of postoperative morbidity following esophagectomy. The effect of SVI on esophagectomy outcomes warrants further investigation and may prove useful in identifying populations that benefit from interventions to mitigate these complications.
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Affiliation(s)
- Christina M Stuart
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo.
| | - Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo
| | - Sara Byers
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colo
| | - Catherine Velopulos
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Simran Randhawa
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Elizabeth A David
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Akshay Pritap
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - John D Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Martin D McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colo
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Korvink M, Gunn LH, Molina G, Hackner D, Martin J. A Novel Approach to Developing Disease and Outcome-Specific Social Risk Indices. Am J Prev Med 2023; 65:727-734. [PMID: 37149108 PMCID: PMC10156642 DOI: 10.1016/j.amepre.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/08/2023]
Abstract
INTRODUCTION A variety of industry composite indices are employed within health research in risk-adjusted outcome measures and to assess health-related social needs. During the COVID-19 pandemic, the relationships among risk adjustment, clinical outcomes, and composite indices of social risk have become relevant topics for research and healthcare operations. Despite the widespread use of these indices, composite indices are often comprised of correlated variables and therefore may be affected by information duplicity of their underlying risk factors. METHODS A novel approach is proposed to assign outcome- and disease group-driven weights to social risk variables to form disease and outcome-specific social risk indices and apply the approach to the county-level Centers for Disease Control and Prevention social vulnerability factors for demonstration. The method uses a subset of principal components reweighed through Poisson rate regressions while controlling for county-level patient mix. The analyses use 6,135,302 unique patient encounters from 2021 across seven disease strata. RESULTS The reweighed index shows reduced root mean squared error in explaining county-level mortality in five of the seven disease strata and equivalent performance in the remaining strata compared with the reduced root mean squared error using the current Centers for Disease Control and Prevention Social Vulnerability Index as a benchmark. CONCLUSIONS A robust method is provided, designed to overcome challenges with current social risk indices, by accounting for redundancy and assigning more meaningful disease and outcome-specific variable weights.
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Affiliation(s)
| | - Laura H Gunn
- Department of Public Health Sciences, College of Health and Human Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina; The School of Data Science, University of North Carolina at Charlotte, Charlotte, North Carolina; Faculty of Medicine, School of Public Health, Imperial College London, London, United Kingdom
| | | | - Dani Hackner
- Medicine Care Center, Southcoast Hospitals Group, New Bedford, Massachusetts
| | - John Martin
- ITS Data Science, Premier, Inc., Charlotte, North Carolina
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Sharma RK, Patel S, Ye W, Rohde SL. Association of social vulnerability on survival, treatment, and presentation in oral cavity cancer. Head Neck 2023; 45:2185-2197. [PMID: 37415555 DOI: 10.1002/hed.27447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/14/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVE This study utilized a population database to investigate how social environments are associated with outcomes including stage at diagnosis, multimodal treatment, and disease-specific survival for oral cavity squamous cell carcinomas. METHODS Retrospective analysis of adults with oral cavity squamous cell carcinoma between 2007 and 2016 from the Surveillance, Epidemiology, End Results (SEER) registry was performed. The CDC's social vulnerability index (SVI) was used to characterize social vulnerability at the county level. Predictors of disease-specific survival, stage at diagnosis, and use of multimodal therapy were identified using Cox regression and logistic regression. RESULTS Our analysis included 17 043 patients. On adjusted models, patients in the highest SVI quartile (most social vulnerability) exhibited worse disease-specific survival compared to the lowest quartile (HR 1.24, 95% CI 1.12-1.37, p < 0.001), and were more likely to be diagnosed at later stages (OR 1.24, 95% CI 1.11-1.38, p < 0.001) and less likely to receive multimodal therapy (OR 0.84, 95% CI 0.77-0.99, p = 0.037). CONCLUSION High social vulnerability was associated with worse disease-specific survival and disease presentation in oral cavity cancer patients.
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Affiliation(s)
- Rahul K Sharma
- Department of Otolaryngology - Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Siddharth Patel
- Department of Otolaryngology - Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Meharry Medical College, Nashville, Tennessee, USA
| | - Wenda Ye
- Department of Otolaryngology - Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Department of Otolaryngology - Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Kunze KN, So MM, Padgett DE, Lyman S, MacLean CH, Fontana MA. Machine Learning on Medicare Claims Poorly Predicts the Individual Risk of 30-Day Unplanned Readmission After Total Joint Arthroplasty, Yet Uncovers Interesting Population-level Associations With Annual Procedure Volumes. Clin Orthop Relat Res 2023; 481:1745-1759. [PMID: 37256278 PMCID: PMC10427054 DOI: 10.1097/corr.0000000000002705] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/28/2023] [Accepted: 04/28/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Unplanned hospital readmissions after total joint arthroplasty (TJA) represent potentially serious adverse events and remain a critical measure of hospital quality. Predicting the risk of readmission after TJA may provide patients and clinicians with valuable information for preoperative decision-making. QUESTIONS/PURPOSES (1) Can nonlinear machine-learning models integrating preoperatively available patient, surgeon, hospital, and county-level information predict 30-day unplanned hospital readmissions in a large cohort of nationwide Medicare beneficiaries undergoing TJA? (2) Which predictors are the most important in predicting 30-day unplanned hospital readmissions? (3) What specific information regarding population-level associations can we obtain from interpreting partial dependency plots (plots describing, given our modeling choice, the potentially nonlinear shape of associations between predictors and readmissions) of the most important predictors of 30-day readmission? METHODS National Medicare claims data (chosen because this database represents a large proportion of patients undergoing TJA annually) were analyzed for patients undergoing inpatient TJA between October 2016 and September 2018. A total of 679,041 TJAs (239,391 THAs [61.3% women, 91.9% White, 52.6% between 70 and 79 years old] and 439,650 TKAs [63.3% women, 90% White, 55.2% between 70 and 79 years old]) were included. Model features included demographics, county-level social determinants of health, prior-year (365-day) hospital and surgeon TJA procedure volumes, and clinical classification software-refined diagnosis and procedure categories summarizing each patient's Medicare claims 365 days before TJA. Machine-learning models, namely generalized additive models with pairwise interactions (prediction models consisting of both univariate predictions and pairwise interaction terms that allow for nonlinear effects), were trained and evaluated for predictive performance using area under the receiver operating characteristic (AUROC; 1.0 = perfect discrimination, 0.5 = no better than random chance) and precision-recall curves (AUPRC; equivalent to the average positive predictive value, which does not give credit for guessing "no readmission" when this is true most of the time, interpretable relative to the base rate of readmissions) on two holdout samples. All admissions (except the last 2 months' worth) were collected and split randomly 80%/20%. The training cohort was formed with the random 80% sample, which was downsampled (so it included all readmissions and a random, equal number of nonreadmissions). The random 20% sample served as the first test cohort ("random holdout"). The last 2 months of admissions (originally held aside) served as the second test cohort ("2-month holdout"). Finally, feature importances (the degree to which each variable contributed to the predictions) and partial dependency plots were investigated to answer the second and third research questions. RESULTS For the random holdout sample, model performance values in terms of AUROC and AUPRC were 0.65 and 0.087, respectively, for THA and 0.66 and 0.077, respectively, for TKA. For the 2-month holdout sample, these numbers were 0.66 and 0.087 and 0.65 and 0.075. Thus, our nonlinear models incorporating a wide variety of preoperative features from Medicare claims data could not well-predict the individual likelihood of readmissions (that is, the models performed poorly and are not appropriate for clinical use). The most predictive features (in terms of mean absolute scores) and their partial dependency graphs still confer information about population-level associations with increased risk of readmission, namely with older patient age, low prior 365-day surgeon and hospital TJA procedure volumes, being a man, patient history of cardiac diagnoses and lack of oncologic diagnoses, and higher county-level rates of hospitalizations for ambulatory-care sensitive conditions. Further inspection of partial dependency plots revealed nonlinear population-level associations specifically for surgeon and hospital procedure volumes. The readmission risk for THA and TKA decreased as surgeons performed more procedures in the prior 365 days, up to approximately 75 TJAs (odds ratio [OR] = 1.2 for TKA and 1.3 for THA), but no further risk reduction was observed for higher annual surgeon procedure volumes. For THA, the readmission risk decreased as hospitals performed more procedures, up to approximately 600 TJAs (OR = 1.2), but no further risk reduction was observed for higher annual hospital procedure volumes. CONCLUSION A large dataset of Medicare claims and machine learning were inadequate to provide a clinically useful individual prediction model for 30-day unplanned readmissions after TKA or THA, suggesting that other factors that are not routinely collected in claims databases are needed for predicting readmissions. Nonlinear population-level associations between low surgeon and hospital procedure volumes and increased readmission risk were identified, including specific volume thresholds above which the readmission risk no longer decreases, which may still be indirectly clinically useful in guiding policy as well as patient decision-making when selecting a hospital or surgeon for treatment. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Kyle N. Kunze
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Miranda M. So
- Center for Analytics, Modeling, and Performance, Hospital for Special Surgery, New York, NY, USA
| | - Douglas E. Padgett
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Stephen Lyman
- Healthcare Research Institute, Hospital for Special Surgery, New York, NY, USA
- Center for the Advancement of Value in Musculoskeletal Care, Hospital for Special Surgery, New York, NY, USA
| | - Catherine H. MacLean
- Weill Cornell Medical College, New York, NY, USA
- Healthcare Research Institute, Hospital for Special Surgery, New York, NY, USA
| | - Mark Alan Fontana
- Center for Analytics, Modeling, and Performance, Hospital for Special Surgery, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
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Smithson MG, McLeod MC, Al-Obaidi M, Harmon CA, Sawant A, Hardiman KM, Chu DI, Bhatia S, Williams GR, Hollis RH. Racial Differences in Aging-Related Deficits Among Older Adults With Colorectal Cancer. Dis Colon Rectum 2023; 66:1245-1253. [PMID: 37235857 PMCID: PMC10524491 DOI: 10.1097/dcr.0000000000002672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Despite the known influences of both race- and aging-related factors in colorectal cancer outcomes and mortality, limited literature is available on the intersection between race and aging-related impairments. OBJECTIVE To explore racial differences in frailty and geriatric deficit subdomains among patients with colorectal cancer. DESIGN Retrospective study using data from the Cancer and Aging Resilience Evaluation registry. SETTINGS A comprehensive cancer center in the Deep South. PATIENTS Older adults (aged ≥60 years) with colorectal cancer. MAIN OUTCOME MEASURES Measure of frailty and geriatric assessment subdomains of physical function, functional status, cognitive complaints, psychological function, and health-related quality of life. RESULTS Black patients lived in areas with a higher social vulnerability index compared to White patients (0.69 vs 0.49; p < 0.01) and had limited social support more often (54.5% vs 34.9%; p = 0.01). After adjustment for age, cancer stage, comorbidities, and social vulnerability index, Black patients were found to have a higher rate of frailty than White patients (adjusted OR 3.77; 95% CI, 1.76-8.18; p = 0.01). In addition, Black patients had more physical limitations (walking 1 block: adjusted OR 1.93; 95% CI, 1.02-3.69; p = 0.04), functional limitations (activities of daily living: adjusted OR 3.21; 95% CI, 1.42-7.24; p = 0.01), and deficits in health-related quality of life (poor global self-reported health: adjusted OR 2.45; 95% CI, 1.23-5.13; p = 0.01). Similar findings were shown after stratification by stage I to III vs IV. LIMITATIONS Retrospective study at a single institution. CONCLUSIONS Among older patients with colorectal cancer, Black patients were more likely to be frail than White patients, with deficits observed specifically in physical function, functional status, and health-related quality of life. Geriatric assessment may provide an important tool in addressing racial inequities in colorectal cancer. DIFERENCIAS RACIALES EN LOS DFICITS RELACIONADOS CON EL ENVEJECIMIENTO ENTRE ADULTOS MAYORES CON CNCER COLORRECTAL ANTECEDENTES: A pesar de las influencias conocidas de los factores relacionados con la raza y el envejecimiento en los resultados y la mortalidad del cáncer colorectal, hay muy poca literatura sobre la intersección entre los impedimentos relacionados con la raza y el envejecimiento.OBJETIVO: El objetivo era explorar las diferencias raciales en los subdominios de fragilidad y déficit geriátrico entre los pacientes con cáncer colorectal.DISEÑO: Estudio retrospectivo utilizando datos del registro Cancer and Aging Resilience Evaluation.AJUSTES: Un centro oncológico integral en el Sur Profundo.PACIENTES: Adultos mayores (≥60 años) con cáncer colorrectal de raza Negra o Blanca.PRINCIPALES MEDIDAS DE RESULTADO: Medida compuesta de fragilidad y subdominios de evaluación geriátrica de función física, estado funcional, quejas cognitivas, función psicológica y calidad de vida relacionada con la salud.RESULTADOS: De los 304 pacientes incluidos, el 21,7% (n = 66) eran negros y la edad media era de 69 años. Los pacientes negros vivían en áreas con un índice de vulnerabilidad social (SVI) más alto en comparación con los pacientes blancos (SVI 0,69 vs 0,49; p < 0,01) y con mayor frecuencia tenían apoyo social limitado (54,5% vs 34,9%; p = 0,01). Después de ajustar por edad, estadio del cáncer, comorbilidades y SVI, los pacientes de raza negra tenían una mayor tasa de fragilidad en comparación con los pacientes de raza blanca (ORa 3,77, IC del 95%: 1,76-8,18; p = 0,01). Además, los pacientes negros tenían más limitaciones físicas (caminar 1 cuadra: ORa 1,93, IC 95% 1,02-3,69; p = 0,04), limitaciones funcionales (actividades de la vida diaria: ORa 3,21, IC 95% 1,42-7,24; p = 0,01 ) y déficits en la calidad de vida relacionada con la salud (mala salud global autoinformada: ORa 2,45, IC 95% 1,23-5,13; p = 0,01). Las quejas cognitivas y las funciones psicológicas no difirieron según la raza (p > 0,05). Se mostraron hallazgos similares después de la estratificación por estadio I-III frente a IV.LIMITACIONES: Estudio retrospectivo en una sola institución.CONCLUSIONES: Entre los pacientes mayores con cáncer colorrectal, los pacientes negros tenían más probabilidades que los pacientes blancos de ser frágiles, observándose déficits específicamente en la función física, el estado funcional y la calidad de vida relacionada con la salud. La evaluación geriátrica puede proporcionar una herramienta importante para abordar las desigualdades raciales en el cáncer colorrectal.
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Affiliation(s)
- Mary G Smithson
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - M Chandler McLeod
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mustafa Al-Obaidi
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christian A Harmon
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Arundhati Sawant
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Karin M Hardiman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Surgery, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Daniel I Chu
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Grant R Williams
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert H Hollis
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
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Lima HA, Moazzam Z, Woldesenbet S, Alaimo L, Endo Y, Munir MM, Shaikh CF, Resende V, Pawlik TM. Persistence of Poverty and its Impact on Surgical Care and Postoperative Outcomes. Ann Surg 2023; 278:347-356. [PMID: 37317875 DOI: 10.1097/sla.0000000000005953] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE We sought to characterize the association between prolonged county-level poverty with postoperative outcomes. BACKGROUND The impact of long-standing poverty on surgical outcomes remains ill-defined. METHODS Patients who underwent lung resection, colectomy, coronary artery bypass graft, or lower extremity joint replacement were identified from Medicare Standard Analytical Files Database (2015-2017) and merged with data from the American Community Survey and the United States Department of Agriculture. Patients were categorized according to the duration of high poverty status from 1980 to 2015 [ie, never high poverty (NHP), persistent poverty (PP)]. Logistic regression was used to characterize the association between the duration of poverty and postoperative outcomes. Principal component and generalized structural equation modeling were used to assess the effect of mediators in the achievement of Textbook Outcomes (TO). RESULTS Overall, 335,595 patients underwent lung resection (10.1%), colectomy (29.4%), coronary artery bypass graft (36.4%), or lower extremity joint replacement (24.2%). While 80.3% of patients lived in NHP, 4.4% resided in PP counties. Compared with NHP, patients residing in PP were at increased risk of serious postoperative complications [odds ratio (OR)=1.10, 95% CI: 1.05-1.15], 30-day readmission (OR=1.09, 95% CI: 1.01-1.16), 30-day mortality (OR=1.08, 95% CI: 1.00-1.17), and higher expenditures (mean difference, $1010.0, 95% CI: 643.7-1376.4) (all P <0.05). Notably, PP was associated with lower odds of achieving TO (OR=0.93, 95% CI: 0.90-0.97, P <0.001); 65% of this effect was mediated by other social determinant factors. Minority patients were less likely to achieve TO (OR=0.81, 95% CI: 0.79-0.84, P <0.001), and the disparity persisted across all poverty categories. CONCLUSIONS County-level poverty duration was associated with adverse postoperative outcomes and higher expenditures. These effects were mediated by various socioeconomic factors and were most pronounced among minority patients.
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Affiliation(s)
- Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Muhammad M Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Chanza F Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Vivian Resende
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
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Smith BP, Jones BA, Cofer KD, Hollis RH, Shao C, Gleason L, Waldrop MG, Katta MH, Wood L, McLeod MC, Morris MS, Chu DI. Racial disparities in postoperative outcomes persist for patients with inflammatory bowel disease under a colorectal enhanced recovery program. Am J Surg 2023; 226:227-232. [PMID: 37120415 PMCID: PMC10524897 DOI: 10.1016/j.amjsurg.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/29/2023] [Accepted: 04/16/2023] [Indexed: 05/01/2023]
Abstract
INTRODUCTION Enhanced recovery programs (ERPs) reduce racial disparities in surgical outcomes for general colorectal surgery populations. It is unclear, however, if disparities in IBD populations are impacted by ERPs. METHODS Retrospective study comparing IBD patients undergoing major elective colorectal operations before (2006-2014) and after (2015-2021) ERP implementation using ACS-NSQIP data. The primary outcome of length of stay (LOS) was analyzed by negative binomial regression, and secondary outcomes (complications and readmissions) by logistic regression. RESULTS Of 466 IBD patients, 47% were pre-ERP and 53% were ERP patients. In multivariable analysis stratified by ERP period, Black race was associated with increased odds of complications in the pre-ERP (OR 3.6, 95%CI 1.4-9.3) and ERP groups (OR 3.1 95%CI 1.3-7.6). Race was not a predictor of LOS or readmission in either group. High social vulnerability was associated with increased odds of readmission pre-ERP (OR 15.1, 95%CI 2.1-136.3), but this disparity was mitigated under ERPs (OR 1.4, 95%CI 0.4-5.6). CONCLUSION While ERPs mitigated some disparities by social vulnerability, racial disparities persist in IBD populations even under ERPs. Further work is needed to achieve surgical equity for IBD patients.
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Affiliation(s)
- Burkely P Smith
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Bayley A Jones
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Kevin D Cofer
- The Ohio State University, Department of Emergency Medicine, 750 Prior Hall, 376 W 10th Avenue, Columbus, OH, 43210, USA
| | - Robert H Hollis
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Connie Shao
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Lauren Gleason
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Mary G Waldrop
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Meghna H Katta
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Lauren Wood
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - M Chandler McLeod
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Melanie S Morris
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA
| | - Daniel I Chu
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL, 35294, USA.
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Rajasingh CM, Baker LC, Wren SM. Freestanding Ambulatory Surgery Centers and Patients Undergoing Outpatient Knee Arthroplasty. JAMA Netw Open 2023; 6:e2328343. [PMID: 37561458 PMCID: PMC10415959 DOI: 10.1001/jamanetworkopen.2023.28343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 06/30/2023] [Indexed: 08/11/2023] Open
Abstract
Importance In 2018, Medicare removed total knee arthroplasty from the list of inpatient-only procedures, resulting in a new pool of patients eligible for outpatient total knee arthroplasty. How this change was associated with the characteristics of patients undergoing outpatient knee arthroplasty at hospital-owned surgery centers (HOSCs) vs freestanding ambulatory surgery centers (FASCs) is unknown. Objectives To describe the characteristics of patients undergoing outpatient, elective total and partial knee arthroplasty in 2017 and 2018 and to compare the cohorts receiving treatment at FASCs and HOSCs. Design, Setting, and Participants This observational retrospective cohort study included 5657 patients having elective, outpatient partial and total knee arthroplasty in the Florida and Wisconsin State Ambulatory Surgery Databases in 2017 and 2018. Prior admissions were identified in the State Inpatient Database. Statistical analysis was performed from March to June 2022. Main Outcomes and Measures Characteristics of patients undergoing surgery at a FASC vs a HOSC in 2017 and 2018 were compared. Results A total of 5657 patients (mean [SD] age, 64.2 [9.9] years; 2907 women [51.4%]) were included in the study. Outpatient knee arthroplasties increased from 1910 in 2017 to 3747 in 2018 and were associated with an increase in total knee arthroplasties (474 in 2017 vs 2065 in 2018). The influx of patients undergoing outpatient knee arthroplasty was associated with an amplification of differences between the patients treated at FASCs and the patients treated at HOSCs. Patients with private payer insurance seen at FASCs increased from 63.4% in 2017 (550 of 867) to 72.7% in 2018 (1272 of 1749) (P < .001), while the percentage of patients with private payer insurance seen at HOSCs increased, but to a lesser extent (41.6% [427 of 1027] in 2017 vs 46.4% [625 of 1346] in 2018; P < .001). In 2017, the percentages of White patients seen at FASCs and HOSCs were similar (85.0% [737 of 867] vs 88.2% [906 of 1027], respectively); in 2018, the percentage of White patients seen at FASCs had increased and was significantly different from the percentage of White patients seen at HOSCs (90.6% [1585 of 1749] vs 87.9% [1183 of 1346]; P = .01). Both types of facilities saw an increase from 2017 to 2018 in the percentage of patients from communities of low social vulnerability, but this increase was greater for FASCs (FASCs: 6.7% [58 of 867] in 2017 vs 33.9% [593 of 1749] in 2018; HOSCs: 7.6% [78 of 1027] in 2017 vs 21.2% [285 of 1346] in 2018). Finally, while FASCs and HOSCs had cared for a similar portion of patients with prior admissions in 2017 (7.8% [68 of 867] vs 9.4% [97 of 1027], respectively; P = .25), in 2018, FASCs cared for fewer patients with prior admissions than HOSCs (4.0% [70 of 1749] vs 8.1% [109 of 1346]; P < .001). Conclusions This study suggests that the increase in the number of patients undergoing outpatient knee arthroplasty in 2018 corresponded to FASCs treating a greater share of patients who were White, covered by private payer insurance, and healthier. These findings raise a concern that as more operations transition to the outpatient setting, variability in access to FASCs may increase, leaving hospital-owned centers to bear a greater share of the burden of caring for more vulnerable patients with more severe illness.
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Affiliation(s)
- Charlotte M. Rajasingh
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Laurence C. Baker
- Department of Health Policy, Stanford University, Stanford, California
| | - Sherry M. Wren
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
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Martenies SE, Zhang M, Corrigan AE, Kvit A, Shields T, Wheaton W, Around Him D, Aschner J, Talavera-Barber MM, Barrett ES, Bastain TM, Bendixsen C, Breton CV, Bush NR, Cacho F, Camargo CA, Carroll KN, Carter BS, Cassidy-Bushrow AE, Cowell W, Croen LA, Dabelea D, Duarte CS, Dunlop AL, Everson TM, Habre R, Hartert TV, Helderman JB, Hipwell AE, Karagas MR, Lester BM, LeWinn KZ, Magzamen S, Morello-Frosch R, O’Connor TG, Padula AM, Petriello M, Sathyanarayana S, Stanford JB, Woodruff TJ, Wright RJ, Kress AM. Developing a National-Scale Exposure Index for Combined Environmental Hazards and Social Stressors and Applications to the Environmental Influences on Child Health Outcomes (ECHO) Cohort. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6339. [PMID: 37510572 PMCID: PMC10379099 DOI: 10.3390/ijerph20146339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/12/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023]
Abstract
Tools for assessing multiple exposures across several domains (e.g., physical, chemical, and social) are of growing importance in social and environmental epidemiology because of their value in uncovering disparities and their impact on health outcomes. Here we describe work done within the Environmental influences on Child Health Outcomes (ECHO)-wide Cohort Study to build a combined exposure index. Our index considered both environmental hazards and social stressors simultaneously with national coverage for a 10-year period. Our goal was to build this index and demonstrate its utility for assessing differences in exposure for pregnancies enrolled in the ECHO-wide Cohort Study. Our unitless combined exposure index, which collapses census-tract level data into a single relative measure of exposure ranging from 0-1 (where higher values indicate higher exposure to hazards), includes indicators for major air pollutants and air toxics, features of the built environment, traffic exposures, and social determinants of health (e.g., lower educational attainment) drawn from existing data sources. We observed temporal and geographic variations in index values, with exposures being highest among participants living in the West and Northeast regions. Pregnant people who identified as Black or Hispanic (of any race) were at higher risk of living in a "high" exposure census tract (defined as an index value above 0.5) relative to those who identified as White or non-Hispanic. Index values were also higher for pregnant people with lower educational attainment. Several recommendations follow from our work, including that environmental and social stressor datasets with higher spatial and temporal resolutions are needed to ensure index-based tools fully capture the total environmental context.
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Affiliation(s)
- Sheena E. Martenies
- Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Urbana, IL 61801, USA
| | - Mingyu Zhang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Anne E. Corrigan
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Anton Kvit
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Timothy Shields
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - William Wheaton
- Research Triangle Institute, Research Triangle Park, NC 27709, USA
| | | | - Judy Aschner
- Department of Pediatrics, Hackensack Meridian School of Medicine, Nutley, NJ 07110, USA
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | | | - Emily S. Barrett
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ 08854, USA
| | - Theresa M. Bastain
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | | | - Carrie V. Breton
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Nicole R. Bush
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA 94143, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, CA 94143, USA
| | - Ferdinand Cacho
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Carlos A. Camargo
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Kecia N. Carroll
- Department of Pediatrics, The Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Brian S. Carter
- Department of Pediatrics-Neonatology, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | | | - Whitney Cowell
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Lisa A. Croen
- Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA;
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Cristiane S. Duarte
- New York State Psychiatric Institute, Columbia University, New York, NY 10032, USA
| | - Anne L. Dunlop
- Department of Obstetrics and Gynecology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Todd M. Everson
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA 30322, USA
| | - Rima Habre
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Tina V. Hartert
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37203, USA
| | - Jennifer B. Helderman
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Alison E. Hipwell
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Margaret R. Karagas
- Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Lebanon, NH 03756, USA
| | - Barry M. Lester
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Kaja Z. LeWinn
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA 94143, USA
| | - Sheryl Magzamen
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO 80523, USA
| | - Rachel Morello-Frosch
- Department of Environmental Science, Policy and Management and School of Public Health, University of California Berkeley, Berkeley, CA 94720, USA
| | - Thomas G. O’Connor
- Departments of Psychiatry, Psychology, Neuroscience, and Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY 41642, USA
| | - Amy M. Padula
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA 94158, USA
| | - Michael Petriello
- Institute of Environmental Health Sciences and Department of Pharmacology, Wayne State University, Detroit, MI 48202, USA
| | - Sheela Sathyanarayana
- Seattle Children’s Research Institute, Seattle, WA 98105, USA
- Department of Pediatrics, University of Washington, Seattle, WA 98195, USA
| | - Joseph B. Stanford
- Department of Pediatrics, Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Tracey J. Woodruff
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA 94158, USA
| | - Rosalind J. Wright
- Department of Pediatrics, The Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Amii M. Kress
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
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Smith BP, Girling I, Hollis RH, Rubyan M, Shao C, Jones B, Abbas A, Herbey I, Oates GR, Pisu M, Chu DI. A socioecological qualitative analysis of barriers to care in colorectal surgery. Surgery 2023; 174:36-45. [PMID: 37088570 PMCID: PMC10272108 DOI: 10.1016/j.surg.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/21/2023] [Accepted: 03/12/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Although specific social determinants of health have been associated with disparities in surgical outcomes, there exists a gap in knowledge regarding the mechanisms of these associations. Gaining perspectives from multiple socioecological levels can help elucidate these mechanisms. Our study aims to identify social determinants of health that act as barriers or facilitators to surgical care among colorectal surgery stakeholders. METHODS We recruited participants representing 5 socioecological levels: patients (individual); caregivers/surgeons (interpersonal); and leaders in hospitals (organizational), communities (community), and government (policy). Patients participated in focus groups, and the remaining participants underwent individual interviews. Semistructured interview guides were used to explore barriers and facilitators to surgical care at each socioecological level. Transcripts were analyzed by 3 coders in an inductive thematic approach with content analyses. The intercoder agreement was 93%. RESULTS Six patient focus groups (total n = 18) and 12 key stakeholder interviews were conducted. The mean age of patients was 54.7 years, 66% were Black, and 61% were female. The most common diseases were colorectal cancer (28%), inflammatory bowel disease (28%), and diverticulitis (22%). Key social determinants of health impacting surgical care emerged at each level: individual (clear communication, mental stress), interpersonal (provider communication and trust, COVID-related visitation restrictions), organizational (multiple forms of contact, quality educational materials, scheduling systems, discrimination), community (community and family support and transportation), and policy (charity care, patient advocacy organizations, insurance coverage). CONCLUSION Key social determinants of health-impacting care among colorectal surgery patients emerged at each socioecological level and may provide targets for interventions to reduce surgical disparities.
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Affiliation(s)
- Burkely P Smith
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, AL
| | - Isabel Girling
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, AL
| | - Robert H Hollis
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, AL
| | - Michael Rubyan
- University of Michigan School of Public Health, Ann Arbor, MI
| | - Connie Shao
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, AL
| | - Bayley Jones
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, AL
| | - Alizeh Abbas
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, AL
| | - Ivan Herbey
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, AL
| | - Gabriela R Oates
- Department of Pediatrics, University of Alabama at Birmingham, AL
| | - Maria Pisu
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham and O'Neal Comprehensive Cancer Center, AL
| | - Daniel I Chu
- Department of Surgery, Division of Gastrointestinal Surgery, University of Alabama at Birmingham, AL.
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Lima HA, Alaimo L, Moazzam Z, Endo Y, Woldesenbet S, Katayama E, Munir MM, Shaikh C, Ruff SM, Dillhoff M, Beane J, Cloyd J, Ejaz A, Resende V, Pawlik TM. Disparities in NCCN Guideline-Compliant Care for Patients with Early-Stage Pancreatic Adenocarcinoma at Minority-Serving versus Non-Minority-Serving Hospitals. Ann Surg Oncol 2023; 30:4363-4372. [PMID: 36800128 DOI: 10.1245/s10434-023-13230-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/27/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Racial/ethnic disparities in pancreatic adenocarcinoma (PDAC) outcomes may relate to receipt of National Comprehensive Cancer Network (NCCN) guideline-compliant care. We assessed the association between treatment at minority-serving hospitals (MSH) and receipt of NCCN-compliant care. PATIENTS AND METHODS Patients who underwent resection of early-stage PDAC between 2006 and 2019 were identified from the National Cancer Database (NCDB). MSH was defined as the top decile of facilities treating minority ethnicities (Black and/or Hispanic). Factors associated with receipt of NCCN-compliant care and its impact on overall survival (OS) were assessed. RESULTS Among 44,873 patients who underwent resection of PDAC, most were treated at non-MSH (n = 42,571, 94.9%), while a smaller subset were treated at MSH (n = 2302, 5.1%). Patients treated at MSH were more likely to be at a younger median age (MSH 66 years versus non-MSH 67 years), Black or Hispanic (MSH 58.4% versus non-MSH 12.0%), and not insured (MSH 7.8% versus non-MSH 1.6%). While 71.7% (n = 31,182) of patients were compliant with NCCN care, guideline-compliant care was lower at MSH (MSH 62.5% versus non-MSH 72.2%). On multivariable analysis, receiving care at MSH was associated with not receiving guideline-compliant care [odds ratio (OR) 0.63, 95% confidence interval (CI) 0.53-0.74]. At non-MSH, non-white patients had lower odds of receiving guideline-compliant PDCA care (OR 0.85, 95% CI 0.78-0.91). Failure to comply was associated with worse overall survival (OS) [hazard ratio (HR) 1.50, 95% CI 1.46-1.54, all p < 0.001]. CONCLUSIONS Patients with PDAC treated at MSH and minorities treated at non-MSH were less likely to receive NCCN-compliant care. Failure to comply with guideline-based PDAC treatment was associated with worse OS.
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Affiliation(s)
- Henrique A Lima
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Laura Alaimo
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Chanza Shaikh
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Samantha M Ruff
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Joal Beane
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Vivian Resende
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Katayama ES, Moazzam Z, Woldesenbet S, Lima HA, Endo Y, Azap L, Yang J, Dillhoff M, Ejaz A, Cloyd J, Pawlik TM. Suicidal Ideation Among Patients with Gastrointestinal Cancer. Ann Surg Oncol 2023; 30:3929-3938. [PMID: 37061648 DOI: 10.1245/s10434-023-13471-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/22/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Mental illness (MI) and suicidal ideation (SI) often are associated with a diagnosis of cancer. We sought to define the incidence of MI and SI among patients with gastrointestinal cancers, as well as ascertain the predictive factors associated with SI. METHODS Patients diagnosed between 2004 and 2016 with stomach, liver, pancreatic, and colorectal cancer were identified from the SEER-Medicare database. County-level social vulnerability index (SVI) was extracted from the Centers for Disease Control database. Multivariable logistic regression was used to identify factors associated with SI. RESULTS Among 382,266 patients, 83,514 (21.9%) individuals had a diagnosis of MI. Only 1410 (0.4%) individuals experienced SI, and 359 (0.1%) committed suicide. Interestingly, SI was least likely among patients with pancreatic cancer (ref: hepatic cancer; odds ratio [OR] 0.67, 95% confidence interval [CI] 0.52-0.86; p = 0.002), as well as individuals with stage III/IV disease (OR 0.59, 95% CI 0.52-067; p < 0.001). In contrast, male (OR 1.34, 95% CI 1.19-1.50), White (OR 1.34, CI 1.13-1.59), and single (OR 2.03, 95% CI 1.81-2.28) patients were at higher odds of SI risk (all p < 0.001). Furthermore, individuals living in relative privilege (low SVI) had markedly higher risk of SI (OR 1.33, 95% CI 1.14-1.54; p < 0.001). Moreover, living in a county with a shortage of mental health professionals was associated with increased odds of developing SI (OR 1.21, 95% CI 1.04-1.40; p = 0.012). CONCLUSIONS Oncology care teams should incorporate routine mental health and SI screening in the treatment of patients with gastrointestinal cancers, as well as target suicide prevention towards patients at highest risk.
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Affiliation(s)
- Erryk S Katayama
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Henrique A Lima
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lovette Azap
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jason Yang
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Smith BP, Hollis RH, Shao CC, Gleason L, Wood L, McLeod MC, Kay DI, Oates GR, Pisu M, Chu DI. The association of social vulnerability with colorectal enhanced recovery program failure. Surg Open Sci 2023; 13:1-8. [PMID: 37012979 PMCID: PMC10066546 DOI: 10.1016/j.sopen.2023.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 04/05/2023] Open
Abstract
Background Enhanced recovery programs (ERPs) improve outcomes, but over 20 % of patients fail ERP and the contribution of social vulnerability is unknown. This study aimed to characterize the association between social vulnerability and ERP adherence and failure. Methods This was a retrospective cohort study of colorectal surgery patients between 2015 and 2020 utilizing ACS-NSQIP data. Patients who failed ERP (LOS > 6 days) were compared to patients not failing ERP. The CDC's social vulnerability index (SVI) was used to assess social vulnerability. Result 273 of 1191 patients (22.9 %) failed ERP. SVI was a significant predictor of ERP failure (OR 4.6, 95 % CI 1.3-16.8) among those with >70 % ERP component adherence. SVI scores were significantly higher among patients non-adherent with 3 key ERP components: preoperative block (0.58 vs. 0.51, p < 0.01), early diet (0.57 vs. 0.52, p = 0.04) and early foley removal (0.55 vs. 0.50, p < 0.01). Conclusions Higher social vulnerability was associated with non-adherence to 3 key ERP components as well as ERP failure among those who were adherent with >70 % of ERP components. Social vulnerability needs to be recognized, addressed, and included in efforts to further improve ERPs. Key message Social vulnerability is associated with non-adherence to enhanced recovery components and ERP failure among those with high ERP adherence. Social vulnerability needs to be addressed in efforts to improve ERPs.
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Affiliation(s)
- Burkely P. Smith
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Robert H. Hollis
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Connie C. Shao
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Lauren Gleason
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Lauren Wood
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Marshall C. McLeod
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Danielle I. Kay
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
| | - Gabriela R. Oates
- University of Alabama at Birmingham, Department of Pediatrics, 1600 7th Ave S, Birmingham, AL 35233, United States of America
| | - Maria Pisu
- University of Alabama at Birmingham, Division of Preventive Medicine and O'Neal Comprehensive Cancer Center, 1808 7th Ave S, Birmingham, AL 35233, United States of America
| | - Daniel I. Chu
- University of Alabama at Birmingham, Department of Surgery, Division of Gastrointestinal Surgery, BDB 581, 1720 2nd Avenue South, Birmingham, AL 35294, United States of America
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Tran T, Rousseau MA, Farris DP, Bauer C, Nelson KC, Doan HQ. The social vulnerability index as a risk stratification tool for health disparity research in cancer patients: a scoping review. Cancer Causes Control 2023; 34:407-420. [PMID: 37027053 PMCID: PMC10080510 DOI: 10.1007/s10552-023-01683-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 03/06/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE The social vulnerability index (SVI), developed by the Centers for Disease Control and Prevention, is a novel composite measure encompassing multiple variables that correspond to key social determinants of health. The objective of this review was to investigate innovative applications of the SVI to oncology research and to employ the framework of the cancer care continuum to elucidate further research opportunities. METHODS A systematic search for relevant articles was performed in five databases from inception to 13 May 2022. Included studies applied the SVI to analyze outcomes in cancer patients. Study characteristics, patent populations, data sources, and outcomes were extracted from each article. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS In total, 31 studies were included. Along the cancer care continuum, five applied the SVI to examine geographic disparities in potentially cancer-causing exposures; seven in cancer diagnosis; fourteen in cancer treatment; nine in treatment recovery; one in survivorship care; and two in end-of-life care. Fifteen examined disparities in mortality. CONCLUSION In highlighting place-based disparities in patient outcomes, the SVI represents a promising tool for future oncology research. As a reliable geocoded dataset, the SVI may inform the development and implementation of targeted interventions to prevent cancer morbidity and mortality at the neighborhood level.
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Affiliation(s)
- Tiffaney Tran
- Department of Dermatology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Morgan A Rousseau
- The University of Texas Health Science Center at Houston John P. and Kathrine G. McGovern Medical School, Houston, TX, USA
| | - David P Farris
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cici Bauer
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Kelly C Nelson
- Department of Dermatology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Hung Q Doan
- Department of Dermatology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.
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Moazzam Z, Lima HA, Endo Y, Alaimo L, Ejaz A, Dillhoff M, Cloyd J, Pawlik TM. The implications of fragmented practice in hepatopancreatic surgery. Surgery 2023; 173:1391-1397. [PMID: 36907781 DOI: 10.1016/j.surg.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/09/2023] [Accepted: 02/06/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Familiarity with the surgical work environment has been demonstrated to improve outcomes. We sought to investigate the impact of the rate of fragmented practice on textbook outcomes, a validated composite outcome representing an "optimal" postoperative course. METHODS Patients who underwent a hepatic or pancreatic surgical procedure between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The rate of fragmented practice was defined as the surgeon's volume over the study period relative to the number of facilities practiced at. The association between the rate of fragmented practice and textbook outcomes was assessed using multivariable logistic regression. RESULTS A total of 37,599 patients were included (pancreatic: n = 23,701, 63.0%; hepatic: n = 13,898, 37.0%). After controlling for relevant characteristics, patients who underwent surgery by surgeons in higher rate of fragmented practice categories had lower odds of achieving a textbook outcome (reference: low rate of fragmented practice; intermediate rate of fragmented practice: odds ratio = 0.88 [95% confidence interval 0.84-0.93]; high rate of fragmented practice: odds ratio = 0.58 [95% confidence interval 0.54-0.61]) (both P < .001). Of note, the adverse effect of a high rate of fragmented practice on the achievement of textbook outcomes remained substantial, regardless of the county-level social vulnerability index [high rate of fragmented practice; low social vulnerability index: odds ratio = 0.58 (95% confidence interval 0.52-0.66); intermediate social vulnerability index: odds ratio = 0.56 (95% confidence interval 0.52-0.61); high social vulnerability index: odds ratio = 0.60 (95% confidence interval 0.54-0.68)] (all P < .001). Patients in intermediate and high social vulnerability index counties had 19% and 37% greater odds of undergoing surgery by a high rate of fragmented practice surgeon (reference: low social vulnerability index; intermediate social vulnerability index: odds ratio = 1.19 [95% confidence interval 1.12-1.26]; high social vulnerability index: odds ratio = 1.37 [95% confidence interval 1.28-1.46]). CONCLUSION Owing to the impact of the rate of fragmented practice on postoperative outcomes, decreasing fragmentation of care may be an important target for quality initiatives and a means to alleviate social disparities in surgical care.
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Affiliation(s)
- Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/ZoraysM
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/HLimaSurg
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/YutakaEndoSurg
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/LauraAlaimo5
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/AEjaz85
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/mary_dillhoff
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/jcloydmd
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH.
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Schmidt S, Kim J, Jacobs MA, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. Independent Associations of Neighborhood Deprivation and Patient-level Social Determinants of Health with Textbook Outcomes after Inpatient Surgery. ANNALS OF SURGERY OPEN 2023; 4:e237. [PMID: 37588414 PMCID: PMC10427124 DOI: 10.1097/as9.0000000000000237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Objective Assess associations of Social Determinants of Health (SDoH) using Area Deprivation Index (ADI), race/ethnicity and insurance type with Textbook Outcomes (TO). Summary Background Data Individual- and contextual-level SDoH affect health outcomes, but only one SDoH level is usually included. Methods Three 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). Results Cohort (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. Conclusion Multi-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.
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Affiliation(s)
- Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Karyn B. Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio, Texas
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan C. Silverstein
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- University Health, San Antonio, Texas
- Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, Texas
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Loehrer AP, Chen L, Wang Q, Colla CH, Wong SL. Rural Disparities in Lung Cancer-directed Surgery: A Medicare Cohort Study. Ann Surg 2023; 277:e657-e663. [PMID: 36745766 PMCID: PMC9902761 DOI: 10.1097/sla.0000000000005091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The primary objective of this study was to determine the influence of rural residence on access to and outcomes of lung cancer-directed surgery for Medicare beneficiaries. SUMMARY OF BACKGROUND DATA Lung cancer is the leading cause of cancerrelated death in the United States and rural patients have 20% higher mortality. Drivers of rural disparities along the continuum of lung cancercare delivery are poorly understood. METHODS Medicare claims (2015-2018) were used to identify 126,352 older adults with an incident diagnosis of nonmetastatic lung cancer. Rural Urban Commuting Area codes were used to define metropolitan, micropolitan, small town, and rural site of residence. Multivariable logistic regression models evaluated influence of place of residence on 1) receipt of cancer-directed surgery, 2) time from diagnosis to surgery, and 3) postoperative outcomes. RESULTS Metropolitan beneficiaries had higher rate of cancer-directed surgery (22.1%) than micropolitan (18.7%), small town (17.5%), and isolated rural (17.8%) (P < 0.001). Compared to patients from metropolitan areas, there were longer times from diagnosis to surgery for patients living in micropolitan, small, and rural communities. Multivariable models found nonmetropolitan residence to be associated with lower odds of receiving cancer-directed surgery and MIS. Nonmetropolitan residence was associated with higher odds of having postoperative emergency department visits. CONCLUSIONS Residence in nonmetropolitan areas is associated with lower probability of cancer-directed surgery, increased time to surgery, decreased use of MIS, and increased postoperative ED visits. Attention to timely access to surgery and coordination of postoperative care for nonmetropolitan patients could improve care delivery.
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Affiliation(s)
- Andrew P. Loehrer
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Geisel School of Medicine at Dartmouth, Hanover, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Louisa Chen
- Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Qianfei Wang
- Geisel School of Medicine at Dartmouth, Hanover, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Carrie H. Colla
- Geisel School of Medicine at Dartmouth, Hanover, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Sandra L. Wong
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Geisel School of Medicine at Dartmouth, Hanover, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
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