Neighborhood socioeconomic status and length of stay after congenital heart disease surgery

Creating a predictive model and online calculator for high-value care outcomes following glioblastoma resection: incorporating neighborhood socioeconomic status index

PURPOSE

Social determinants of health including neighborhood socioeconomic status, have been established to play a profound role in overall access to care and outcomes in numerous specialized disease entities. To provide glioblastoma multiforme (GBM) patients with high-quality care, it is crucial to identify predictors of hospital length of stay (LOS), discharge disposition, and access to postoperative adjuvant chemoradiation. In this study, we incorporate a novel neighborhood socioeconomic status index (NSES) and develop three predictive algorithms for assessing post-operative outcomes in GBM patients, offering a tool for preoperative risk stratification of GBM patients.

METHODS

Adult GBM patients who underwent surgical resection from a single center were identified; NSES was identified via patient street address of residence, with lower scores representing disadvantaged neighborhoods. Multivariate logistic regression analysis was used to predict high value care outcomes. The Hosmer-Lemeshow test was used to assess model calibration.

RESULTS

A total of 467 patients were included, with a mean age of 59.85 ± 13.21 years and 58.7% being male. The mean NSES for our cohort was 63.77 ± 14.91, indicating that the majority resided in neighborhoods with a higher socioeconomic status compared to the national average NSES of 50. One hundred nine (23.3%) patients had extended LOS, 28.9% had non-routine discharge, and 19.1% did not follow the Stupp protocol following surgery. On multivariate regression, worse NSES was significantly and independently associated with extended LOS (OR = 0.981, p = 0.026), non-routine discharge disposition (OR = 0.984, p = 0.033), and non-compliance with the Stupp protocol (OR = 0.977, p = 0.014). Our three models predicting high-value care outcomes had acceptable C-statistics > 0.70, and all models demonstrated adequate calibration (p > 0.05). Final models are accessible via online calculator. https://neurooncsurgery4.shinyapps.io/GBM_NSES_Caclulator/ CONCLUSION: NSES scores are readily available and may be utilized via our open-access calculators. After external validation, our predictive models have the potential to assist in providing patients with individualized risk estimates for post-operative outcomes following GBM resection.

Neighborhood Income Disparities in Unplanned Hospital Admission and In-Hospital Outcomes Among Children with Congenital Heart Disease

Unplanned admissions are associated with worse clinical outcomes and increased hospital resource utilization. We hypothesized that children with congenital heart disease (CHD) from lower-income neighborhoods have higher rates of unplanned hospital admissions and greater resource utilization. Utilizing the Kids' Inpatient Database (2016 and 2019), we included children under 21 years of age with CHD, excluding newborn hospitalizations. CHD cases were categorized into simple lesions, complex biventricular lesions, and single ventricle lesions. Admissions were classified as surgical or non-surgical. A logistic regression model assessed the risk of unplanned hospital admission, mortality, and resource utilization across different neighborhood income levels. Out of 4,722,684 admitted children (excluding newborn hospitalizations), 199,757 had CHD and met the study criteria: 121,626 with mild CHD, 61,639 with complex biventricular lesions, and 16,462 with single ventricle lesions. Surgical admissions comprised 20% (n = 39,694). In the CHD cohort, 27% had planned admissions, while 73% were unplanned. Mortality was higher in unplanned admissions compared to planned admissions (3.0 vs. 0.93%, P < 0.001). Unplanned admissions were more common in the lowest-income neighborhoods compared to the highest-income neighborhoods (adjusted odds ratio [aOR] = 1.4; 95% confidence interval [CI]: 1.3-1.5; P < 0.001), consistent across different age groups. Higher rates of unplanned admissions in the lowest-income neighborhoods were observed for each CHD category and for both medical and surgical admissions. Median hospitalization length was longer in the poorest neighborhoods compared to the wealthiest (7 days [IQR 3-21] vs. 6 days [IQR 3-17], P < 0.001). In conclusion, children with CHD residing in the lowest-income neighborhoods have increased odds of unplanned hospitalization for both surgical and non-surgical admissions, along with higher mortality and resource utilization.

Socioeconomic Influences on Outcomes Following Congenital Heart Disease Surgery

Associations between social determinants of health (SDOH) and adverse outcomes for children with congenital heart disease (CHD) are starting to be recognized; however, such links remain understudied. We examined the relationship between community-level material deprivation on mortality, readmission, and length of stay (LOS) for children undergoing surgery for CHD. We performed a retrospective cohort study of patients who underwent cardiac surgery at our institution from 2015 to 2018. A community-level deprivation index (DI), a marker of community material deprivation, was generated to contextualize the lived experience of children with CHD. Generalized mixed-effects models were used to assess links between the DI and outcomes of mortality, readmission, and LOS following cardiac surgery. The DI and components were scaled to provide mean differences for a one standard deviation (SD) increase in deprivation. We identified 1,187 unique patients with surgical admissions. The median LOS was 11 days, with an overall mortality rate of 4.6% and readmission rate of 7.6%. The DI ranged from 0.08 to 0.85 with a mean of 0.37 (SD 0.12). The DI was associated with increased LOS for patients with more complex heart disease (STAT 3, 4, and 5), which persisted after adjusting for factors that could prolong LOS (all p < 0.05). The DI approached but did not meet a significant association with mortality (p = 0.0528); it was not associated with readmission (p = 0.36). Community-level deprivation is associated with increased LOS for patients undergoing cardiac surgery. Future work to identify the specific health-related social needs contributing to LOS and identify targets for intervention is needed.