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Katayama ES, Thammachack R, Woldesenbet S, Khalil M, Munir MM, Tsilimigras D, Pawlik TM. The Association of Established Primary Care with Postoperative Outcomes Among Medicare Patients with Digestive Tract Cancer. Ann Surg Oncol 2024:10.1245/s10434-024-16042-w. [PMID: 39158639 DOI: 10.1245/s10434-024-16042-w] [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: 06/13/2024] [Accepted: 07/31/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Primary care (PC) is essential to overall wellness and management of comorbidities. In turn, patients without adequate access to PC may face healthcare disparities. We sought to characterize the impact of established PC on postoperative outcomes among patients undergoing a surgical procedure for a digestive tract cancer. METHODS Medicare beneficiaries with a diagnosis of hepatobiliary, pancreas, and colorectal cancer between 2005 and 2019 were identified within the Surveillance, Epidemiology, and End Results program and Medicare-linked database. Individuals who did versus did not have PC encounters within 1-year before surgery were identified. A postoperative textbook outcome (TO) was defined as the absence of complications, no prolonged hospital stay, no readmission within 90 days, and no mortality. RESULTS Among 63,177 patients, 50,974 (80.7%) had at least one established PC visit before surgery. Patients with established PC were more likely to achieve TO (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.09-1.19) with lower odds for complications (OR, 0.85; 95% CI, 0.72-0.89), extended hospital stay (OR, 0.86; 95% CI, 0.81-0.94), 90-day readmission (OR, 0.94; 95% CI, 0.90-0.99), and 90-day mortality (OR, 0.87; 95% CI, 0.79-0.96). In addition, patients with established PC had a 4.1% decrease in index costs and a 5.2% decrease in 1-year costs. Notably, patients who had one to five visits with their PC in the year before surgery had improved odds of TO (OR, 1.21; 95% CI, 1.16-1.27), whereas individuals with more than 10 visits had lower odds of a postoperative TO (OR, 0.91; 95% CI, 0.84-0.98). CONCLUSION Most Medicare beneficiaries with digestive tract cancer had established PC within the year before their surgery. Established PC was associated with a higher probability of achieving ideal outcomes and lower costs. In contrast, patients with more than 10 PC appointments, which was likely a surrogate of overall comorbidity burden, experienced no improvement in postoperative outcomes.
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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
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Razeen Thammachack
- 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
| | - 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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Catalano G, Munir MM, Chatzipanagiotou OP, Woldesenbet S, Altaf A, Khan MMM, Rashid Z, Pawlik TM. The Association of Socio-Environmental Inequality and Outcomes Among Patients Undergoing Major Surgery. J Surg Res 2024; 301:664-673. [PMID: 39146835 DOI: 10.1016/j.jss.2024.07.063] [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: 04/22/2024] [Revised: 07/08/2024] [Accepted: 07/20/2024] [Indexed: 08/17/2024]
Abstract
INTRODUCTION Environmental hazards may influence health outcomes and be a driver of health inequalities. We sought to characterize the extent to which social-environmental inequalities were associated with surgical outcomes following a complex operation. METHODS In this cross-sectional study, patients who underwent abdominal aortic aneurysm repair, coronary artery bypass grafting, colectomy, pneumonectomy, or pancreatectomy between 2016 and 2021 were identified from Medicare claims data. Patient data were linked with social-environmental data sourced from Centers for Disease Control and Agency for Toxic Substances and Disease Registry data based on county of residence. The Environmental Justice Index social-environmental ranking (SER) was used as a measure of environmental injustice. Multivariable regression analysis was performed to assess the relationship between SER and surgical outcomes. RESULTS Among 1,052,040 Medicare beneficiaries, 346,410 (32.9%) individuals lived in counties with low SER, while 357,564 (33.9%) lived in counties with high SER. Patients experiencing greater social-environmental injustice were less likely to achieve textbook outcome (odds ratio 0.95, 95% confidence interval 0.94-0.96, P < 0.001) and to be discharged to an intermediate care facility or home with a health agency (odds ratio 0.97, 95% confidence interval 0.96-0.98, P < 0.001). CONCLUSIONS Cumulative social and environmental inequalities, as captured by the Environmental Justice Index SER, were associated with postoperative outcomes among Medicare beneficiaries undergoing a range of surgical procedures. Policy makers should focus on environmental, as well as socioeconomic injustice to address preventable health disparities.
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Affiliation(s)
- Giovanni Catalano
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio; Department of Surgery, University of Verona, Verona, Italy
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Odysseas P Chatzipanagiotou
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Abdullah Altaf
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Muhammad Muntazir M Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.
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Dubin JA, Bains SS, Hameed D, Monárrez R, Moore MC, Mont MA, Nace J, Delanois RE. The Utility of the Social Vulnerability Index as a Proxy for Social Disparities Following Total Knee Arthroplasty. J Arthroplasty 2024; 39:S33-S38. [PMID: 38325529 DOI: 10.1016/j.arth.2024.01.049] [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: 10/31/2023] [Revised: 12/18/2023] [Accepted: 01/28/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND In 2021, alternative payment models accounted for 40% of traditional Medicare reimbursements. As such, we sought to examine health disparities through a standardized categorization of social disparity using the social vulnerability index (SVI). We examined (1) risk factors for SVI ≥ 0.50, (2) incidences of complications, and (3) risk factors for total complications between patients who have SVI < 0.50 and SVI ≥ 0.50 who had a total knee arthroplasty (TKA). METHODS Patients who underwent TKA between January 1, 2022 and December 31, 2022 were identified in the state of Maryland. A total of 4,952 patients who had complete social determinants of health data were included. Patients were divided into 2 cohorts according to SVI: < 0.50 (n = 2,431) and ≥ 0.50 (n = 2,521) based on the national mean SVI of 0.50. The SVI identifies communities that may need support caused by external stresses on human health based on 4 themed scores: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. The SVI theme of household composition and disability encompassed patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies. The higher the SVI, the more social vulnerability or resources are needed to thrive in a geographic area. RESULTS When controlling for risk factors and patient comorbidities, the theme of household composition and disability (odds ratio 2.0, 95% confidence interval 1.1 to 5.0, P = .03) was the only independent risk factor for total complications. Patients who had an SVI ≥0.50 were more likely to be women (65.8% versus 61.0%, P < .001), Black (34.4% versus 12.9%, P < .001), and have a median household income < $87,999 (21.3% versus 10.2%, P < .001) in comparison to the patients who had an SVI < 0.50, respectively. CONCLUSIONS The SVI theme of household composition and disability, encompassing patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies, were independent risk factors for total complications following TKA. Together, these findings offer opportunities for interventions with selected patients to address social disparities.
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Affiliation(s)
- Jeremy A Dubin
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Sandeep S Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Daniel Hameed
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Rubén Monárrez
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Mallory C Moore
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Michael A Mont
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - James Nace
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Ronald E Delanois
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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Sakowitz S, Bakhtiyar SS, Porter G, Mallick S, Oxyzolou I, Benharash P. Association of socioeconomic vulnerability with outcomes after emergency general surgery. Surgery 2024; 176:406-413. [PMID: 38796388 DOI: 10.1016/j.surg.2024.03.044] [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: 12/04/2023] [Revised: 02/18/2024] [Accepted: 03/21/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE Social determinants of health are increasingly recognized to shape health outcomes. Yet, the effect of socioeconomic vulnerability on outcomes after emergency general surgery remains under-studied. METHODS All adult (≥18 years) hospitalizations for emergency general surgery operations (appendectomy, cholecystectomy, laparotomy, large bowel resection, perforated ulcer repair, or small bowel resection), within 2 days of non-elective admission were tabulated in the 2016 to 2020 Nationwide Readmissions Database. Socioeconomic vulnerability was defined using relevant diagnosis codes and comprised economic, educational, healthcare, environmental, and social needs. Patients demonstrating socioeconomic vulnerability were considered Vulnerable (others: Non-Vulnerable). Multivariable models were constructed to evaluate the independent associations between socioeconomic vulnerability and key outcomes. RESULTS Of ∼1,788,942 patients, 177,764 (9.9%) were considered Vulnerable. Compared to Non-Vulnerable, Vulnerable patients were older (67 [55-77] vs 58 years [41-70), P < .001), more often insured by Medicaid (16.4 vs 12.7%, P < .001), and had a higher Elixhauser Comorbidity Index (4 [3-5] vs 2 [1-3], P < .001). After risk adjustment and with Non-Vulnerable as a reference, Vulnerable remained linked with a greater likelihood of in-hospital mortality (adjusted odds ratio 1.64, confidence interval 1.58-1.70) and any perioperative complication (adjusted odds ratio 2.02, confidence interval 1.98-2.06). Vulnerable also experienced a greater duration of stay (β+4.64 days, confidence interval +4.54-4.74) and hospitalization costs (β+$1,360, confidence interval +980-1,740). Further, the Vulnerable cohort demonstrated increased odds of non-home discharge (adjusted odds ratio 2.44, confidence interval 2.38-2.50) and non-elective readmission within 30 days of discharge (adjusted odds ratio 1.29, confidence interval 1.26-1.32). CONCLUSION Socioeconomic vulnerability is independently associated with greater morbidity, resource use, and readmission after emergency general surgery. Novel interventions are needed to build hospital screening and care pathways to improve disparities in outcomes.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO
| | - Giselle Porter
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Ifigenia Oxyzolou
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA.
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Paul RW, Osman A, Nigro A, Muchintala R, Destine H, Tjoumakaris FP, Freedman KB. The effects of social determinants of health on rotator cuff repair utilization and outcomes: a systematic review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:346-352. [PMID: 39157253 PMCID: PMC11329048 DOI: 10.1016/j.xrrt.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
Background Since various social determinants of health (SDOH) have the potential to impact the utilization and postoperative outcomes of rotator cuff repair (RCR), a review of the literature is warranted. Therefore, the purpose of this systematic review was to evaluate the effects of SDOH on RCR utilization and postoperative outcomes in order to recognize external factors that may influence patients' access to RCR and optimal clinical outcomes. Methods Search terms related to RCR, utilization, outcomes, and SDOH were used to identify studies that reported associations between any SDOH (as defined by the World Health Organization) and RCR utilization, access, cost, or postoperative outcomes. Articles that did not isolate RCR or did not evaluate an SDOH were excluded. Nonrandomized studies were evaluated for study quality using the Methodological Index for Nonrandomized Studies score. Due to the heterogeneity of the reported data, only qualitative analysis was possible. Results Overall, 842 articles were considered for inclusion and 14 studies were included in qualitative analysis. The average Methodological Index for Nonrandomized Studies score of included studies was 14.1 ± 5.0. The SDOH most frequently evaluated were insurance status and race/ethnicity. Non-White race is associated with lower odds of surgery and physical therapy (PT) utilization, as well as delayed treatment. Similarly, public insurance is associated with lower PT and surgery utilization rates and decreased acceptance for postoperative PT. Postoperatively, public insurance is associated with worse patient-reported outcome scores and lower return to work rates. Conclusion Various SDOH can influence access, utilization, and outcomes of RCR. Orthopedic surgeons should be aware of how factors of race and insurance type can influence a patient's treatment and recovery after RCR.
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Affiliation(s)
- Ryan W. Paul
- Division of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
- Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Alim Osman
- Eastern Virginia Medical School, Norfolk, VA, USA
| | | | - Rahul Muchintala
- Division of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Henson Destine
- Division of Sports Medicine, Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
| | - Fotios P. Tjoumakaris
- Division of Sports Medicine, Rothman Orthopaedic Institute, Egg Harbor Township, NJ, USA
| | - Kevin B. Freedman
- Division of Sports Medicine, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Schutt J, Bohr NL, Cao K, Pocivavsek L, Milner R. Social Determinants of Health Factors and Loss-To-Follow-Up in the Field of Vascular Surgery. Ann Vasc Surg 2024; 105:316-324. [PMID: 38609010 DOI: 10.1016/j.avsg.2024.01.010] [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: 11/12/2023] [Revised: 12/27/2023] [Accepted: 01/21/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND It is estimated that 22-57% of vascular patients are lost to follow-up (LTF) which is of concern as the Society of Vascular Surgery recommends annual patient follow-up. The purpose of this report was to identify social determinants of health factors (SDoH) and their relationship to LTF in vascular patients. METHODS The methods employed were a systematic literature review of 29 empirical articles and a retrospective quality improvement report with 27 endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) patients at the University of Chicago. RESULTS The systematic literature review resulted in 2,931 articles which were reduced to 29 articles meeting the inclusion criteria. Demographic variables were more frequently cited than SDoH factors, but the most common were smoking, transportation, and socioeconomic status/insurance. Additionally, 176 EVAR and TEVAR patients were called resulting in 27 patients who completed a SDoH questionnaire. Twenty-six percent indicated they had missed at least 1 appointment with the top reasons being work or family responsibilities. Due to limited patient size no statistical analyses were performed, but frequencies of responses to SDoH questions were reported to augment the existing limited literature and guide future research into variables such as one's ability to pay for basics like food or mortgage. CONCLUSIONS SDoH factors are important yet understudied aspects of endovascular repairs that require more research to understand their impact on vascular surgery follow-up rates and outcomes. Additional research is needed as lack of consideration of such factors may impact the generalizability of existing research and such knowledge may help in informing clinician treatment plans.
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Affiliation(s)
- Jonathon Schutt
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL.
| | - Nicole L Bohr
- Department of Nursing Research, UChicago Medicine, Chicago, IL; Department of Surgery, University of Chicago, Chicago, IL
| | - Kathleen Cao
- Department of Surgery, University of Chicago, Chicago, IL
| | | | - Ross Milner
- Department of Surgery, University of Chicago, Chicago, IL
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Cockrell HC, Shah NR, Krinock D, Siddiqui SM, Englum BR, Meckmongkol TT, Koo N, Murphy J, Richards MK, Martin K. Health Disparities Research: What Every Pediatric Surgeon Should Know. J Pediatr Surg 2024:S0022-3468(24)00432-9. [PMID: 39122610 DOI: 10.1016/j.jpedsurg.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 06/05/2024] [Accepted: 07/15/2024] [Indexed: 08/12/2024]
Abstract
While the earliest published health disparity research in the United States dates to 1899, the field was not formally established until the late 20th century. Initially focused on race and ethnicity, the field has broadened to include socioeconomic status. Several measures have been developed to quantify socioeconomic disadvantage, including the Social Vulnerability Index, Area Deprivation Index, and Child Opportunity Index. These indices have been validated and demonstrate correlation with health outcomes. However, socioeconomic status cannot fully explain health inequities experienced by people of minoritized racial and ethnic identities. Three generations of health disparities research have been described-identification of disparities, root analysis, and development of interventions to mitigate health inequities. While there has been an increase in publication of health disparity research, there is little third generation work. It is imperative that health disparities research move beyond defining the problem and toward interventions that will reduce health inequities. LEVELS OF EVIDENCE: Level IV.
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Affiliation(s)
- Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; Department of Surgery, University of Washington, Box 356410, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Nikhil R Shah
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, 1540 E. Hospital Dr, Ann Arbor, MI 48109, USA
| | - Derek Krinock
- Department of Surgery, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA
| | - Sabina M Siddiqui
- Division of Pediatric Surgery, Arkansas Children's Northwest Hospital, 2601 Gene George Blvd, Springdale, AR 72762, USA
| | - Brian R Englum
- Division of Pediatric Surgery, University of Maryland Children's Hospital, 29 South Greene St Suite GS110, Baltimore, MD 21201, USA
| | - Teerin T Meckmongkol
- Division of Pediatric Surgery, Nemours Children's Health Orlando, 6535 Nemours Pkwy, Orlando, FL 32827, USA
| | - Nathaniel Koo
- Division of Pediatric Surgery, University of Illinois Hospital and Health Sciences System, 840 S. Wood Street, Suite 416, Chicago, IL 60612, USA
| | - Jennifer Murphy
- Division of Pediatric Surgery, Atlantic Medical Group, 1000 Madison Ave, Morristown, NJ 07960, USA
| | - Morgan K Richards
- Division of Pediatric Surgery, St. Luke's Children's Hospital, 305 E Jefferson St, Boise, ID 83712, USA
| | - Kathryn Martin
- Division of Pediatric Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, 100 Woods Rd, MFCH 1123, Valhalla, NY 10595, USA
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Mota L, Jayaram A, Wu WW, Roth EM, Darling JD, Hamdan AD, Wyers MC, Stangenberg L, Schermerhorn ML, Liang P. The impact of travel distance in patient outcomes following revascularization for chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)01529-5. [PMID: 39025281 DOI: 10.1016/j.jvs.2024.07.026] [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: 05/22/2024] [Revised: 06/30/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Patient travel distance to the hospital is a key metric of individual and social disadvantage and its impact on the management and outcomes following intervention for chronic limb-threatening ischemia (CLTI) is likely underestimated. We sought to evaluate the effect of travel distance on outcomes in patients undergoing first-time lower extremity revascularization at our institution. METHODS We retrospectively reviewed all consecutive patients undergoing first-time lower extremity revascularization, both endovascular and open, for CLTI from 2005 to 2014. Patients were stratified into 2 groups based on travel distance from home to hospital greater than or less than 30 miles. Outcomes included reintervention, major amputation, restenosis, primary patency, wound healing, length of stay, length of follow-up and mortality. Kaplan-Meier estimates were used to determine event rates. Logistic and cox regression was used to evaluate for an independent association between travel distance and these outcomes. RESULTS Of the 1293 patients were identified, 38% traveled >30 miles. Patients with longer travel distances were younger (70 years vs 73 years; P = .001), more likely to undergo open revascularization (65% vs 41%; P < .001), and had similar Wound, Ischemia, foot Infection stages (P = .404). Longer distance travelled was associated with an increase in total hospital length of stay (9.6 days vs 8.6 days; P = .031) and shorter total duration of postoperative follow-up (2.1 years vs 3.0 years; P = .001). At 5 years, there was no definitive difference in the rate of restenosis (hzard ratio [HR], 1.3; 95% confidence interval [CI], 0.91-1.9; P = .155) or reintervention (HR, 1.4; 95% CI, 0.96-2.1; P = .065), but longer travel distance was associated with an increased rate of major amputation (HR, 2.1; 95% CI, 1.2-3.7; P = .011), and death (HR, 1.6; 95% CI, 1.2-2.2; P = .002). Longer travel distance was also associated with higher rate of nonhealing wounds (HR, 2.3; 95% CI, 1.5-3.5; P = .001). CONCLUSIONS Longer patient travel distance was found to be associated with a lower likelihood of limb salvage and survival in patients undergoing first-time lower extremity revascularization for CLTI. Understanding and addressing the barriers to discharge, need for multidisciplinary follow-up, and appropriate postoperative wound care management will be key in improving outcomes at tertiary care regional specialty centers.
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Affiliation(s)
- Lucas Mota
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Anusha Jayaram
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Winona W Wu
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eve M Roth
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Lars Stangenberg
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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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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Knobel P, Colicino E, Klog I, Litke R, Lane K, Federman A, Mobbs C, Sade MY. Social Vulnerability and Biological Aging in New York City: An Electronic Health Records-Based Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.29.24309707. [PMID: 38978670 PMCID: PMC11230307 DOI: 10.1101/2024.06.29.24309707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Chronological age is not an accurate predictor of morbidity and mortality risk, as individuals' aging processes are diverse. Phenotypic age acceleration (PhenoAgeAccel) is a validated biological age measure incorporating chronological age and biomarkers from blood samples commonly used in clinical practice that can better reflect aging-related morbidity and mortality risk. The heterogeneity of age-related decline is not random, as environmental exposures can promote or impede healthy aging. Social Vulnerability Index (SVI) is a composite index accounting for different facets of the social, economic, and demographic environment grouped into four themes: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. We aim to assess the concurrent and combined associations of the four SVI themes on PhenoAgeAccel and the differential effects on disadvantaged groups. We use electronic health records data from 31,913 patients from the Mount Sinai Health System (116,952 person-years) and calculate PhenoAge for years with available laboratory results (2011-2022). PhenoAge is calculated as a weighted linear combination of lab results and PhenoAgeAccel is the differential between PhenoAge and chronological age. A decile increase in the mixture of SVI dimensions was associated with an increase of 0.23 years (95% CI: 0.21, 0.25) in PhenoAgeAccel. The socioeconomic status dimension was the main driver of the association, accounting for 61% of the weight. Interaction models revealed a more substantial detrimental association for women and racial and ethnic minorities with differences in leading SVI themes. These findings suggest that neighborhood-level social vulnerability increases the biological age of its residents, increasing morbidity and mortality risks. Socioeconomic status has the larger detrimental role amongst the different facets of social environment.
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Vyas N, Zaheer A, Wijeysundera HC. Untangling the Complex Multidimensionality of the Social Determinants of Cardiovascular Health: A Systematic Review. Can J Cardiol 2024; 40:1000-1006. [PMID: 38513932 DOI: 10.1016/j.cjca.2024.03.008] [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: 10/31/2023] [Revised: 02/21/2024] [Accepted: 03/09/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The cardiovascular literature is limited by the lack of consensus on what are the best metrics for reporting social determinants of health (SDH) or social deprivation, and if they should be reported as a single metric or separately by their domains. METHODS A systematic review of the literature on cardiovascular surgeries and procedures was conducted, identifying articles from January 1, 2010, to December 31, 2023, that studied the relationship between health outcomes after cardiovascular procedures or surgeries and SDH/social deprivation. The cardiovascular procedures/surgeries of interest were coronary and valve surgeries and procedures including coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), valve replacement or repair, and transcatheter aortic valve intervention. RESULTS After screening 638 articles, we identified 47 papers that met our inclusion and exclusion criteria. The most common procedure evaluated was CABG and PCI; 46 of the studies focused on these 2 procedures. Almost all of the articles reported a different metric for SDH/social deprivation (41 different metrics); despite this, all of the metrics showed a consistent relationship with worse outcomes associated with greater degrees of SDH/deprivation. Only 9 reported on the individual domains of SDH/social deprivation; 3 studies showed a discordant relationship. CONCLUSIONS Although our systematic review identified numerous articles evaluating the relationship between SDH/social deprivation in cardiovascular disease, there was substantial heterogeneity in which metric was used and how it was reported. This reinforces the need for standards as to the best metrics for SDH/social deprivation as well as best practices for reporting.
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Affiliation(s)
- Navya Vyas
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aida Zaheer
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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12
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Woo HY, Joh JH, Kang JM, Yoo YS, Lee T, Ahn S. Comparison between intermittent claudication versus chronic limb-threatening ischemia in peripheral arterial disease: a retrospective multicenter cohort study. Ann Surg Treat Res 2024; 106:344-353. [PMID: 38868587 PMCID: PMC11164664 DOI: 10.4174/astr.2024.106.6.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/29/2024] [Accepted: 04/11/2024] [Indexed: 06/14/2024] Open
Abstract
Purpose The anatomical distribution, characteristics of lesions, and treatment modalities for peripheral artery disease (PAD) are diverse. Endovascular intervention is popular for symptomatic PAD, for both intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI). We aimed to investigate the endovascular devices used by comparing patients with PAD referred for endovascular revascularization with IC and CLTI. Methods We identified 736 patients with PAD enrolled in the multicenter PAD registry in South Korea from 2019 to 2022. Of these patients, 636 received endovascular treatment at the time of this study. After excluding missing data, we analyzed 506 patients with IC or CLTI. Patients' characteristics, target lesions, and endovascular device data such as type, length, balloon diameter, and stent, were examined. Procedure outcomes of the aortoiliac, femoropopliteal, and below-the-knee lesions were analyzed. Results Patients with CLTI were more likely to have diabetes mellitus, below-the-knee interventions, and multilevel PAD than the IC group. Patients with IC had more aortoiliac artery lesions and underwent atherectomies than the CLTI group (63.3% and 61.1% vs. 39.7% and 40.6%, respectively; P < 0.001). In patients with femoropopliteal lesions, those with CLTI were more revascularized with stents than the patients with IC, without significant differences (35.3% vs. 29.1%, P = 0.161). Compared to the IC group, the CLTI patients showed significantly worse rates of primary patency, amputation, and mortality (P = 0.029, P < 0.001, and P < 0.001, respectively). Conclusion Among Korean patients with PAD, there is a significant difference in baseline and lesion characteristics, endovascular strategies, and short-term follow-up outcomes among those with IC and CLTI.
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Affiliation(s)
- Hye Young Woo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University Hospital, Seoul, Korea
| | - Jin Mo Kang
- Department of Surgery, Gachon University Gil Medical Center, Inchon, Korea
| | - Young Sun Yoo
- Department of Surgery, Chosun University College of Medicine, Gwangju, Korea
| | - Taeseung Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sanghyun Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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13
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Sullivan GA, Krishnan V, Silver C, Smith C, Raval MV, Gulack BC, Shah AN. Association of social determinants of health-related diagnosis codes with postoperative outcomes. World J Surg 2024; 48:1004-1013. [PMID: 38502094 DOI: 10.1002/wjs.12135] [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: 12/21/2023] [Accepted: 02/20/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND The association of an individual's social determinants of health-related problems with surgical outcomes has not been well-characterized. The objective of this study was to determine whether documentation of social determinants of a health-related diagnosis code (Z code) is associated with postoperative outcomes. METHODS This retrospective cohort study included surgical cases from a single institution's national surgical quality improvement program (NSQIP) clinical registry from October 2015 to December 2021. The primary predictor of interest was documentation of a Z code for social determinants of health-related problems. The primary outcome was 30-day postoperative morbidity. Secondary outcomes included postoperative length of stay, disposition, and 30-day postoperative mortality, reoperation, and readmission. Multivariable regression models were fit to evaluate the association between the documentation of a Z code and outcomes. RESULTS Of 10,739 surgical cases, 348 patients (3.2%) had a documented social determinants of health-related Z code. In multivariable analysis, documentation of a Z code was associated with increased odds of morbidity (20.7% vs. 9.9%; adjusted odds ratio [aOR], 1.88; 95% confidence interval [CI], 1.39-2.53), length of stay (median, 3 vs. 1 day; incidence rate ratio, 1.49; 95% CI, 1.33-1.67), odds of disposition to a location other than home (11.3% vs. 3.9%; aOR, 2.86; 95% CI, 1.89-4.33), and odds of readmission (15.3% vs. 6.1%; aOR, 1.99; 95% CI, 1.45-2.73). CONCLUSIONS Social determinants of health-related problems evaluated using Z codes were associated with worse postoperative outcomes. Improved documentation of social determinants of health-related problems among surgical patients may facilitate improved risk stratification, perioperative planning, and clinical outcomes.
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Affiliation(s)
- Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Vaishnavi Krishnan
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Casey Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Charesa Smith
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Brydges HT, Laspro M, Verzella AN, Alcon A, Schechter J, Cassidy MF, Chaya BF, Iturrate E, Flores RL. Contemporary Prevalence of Oral Clefts in the US: Geographic and Socioeconomic Considerations. J Clin Med 2024; 13:2570. [PMID: 38731101 PMCID: PMC11084882 DOI: 10.3390/jcm13092570] [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: 04/03/2024] [Revised: 04/20/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Socio-economic status, living environments, and race have been implicated in the development of different congenital abnormalities. As orofacial clefting is the most common anomaly affecting the face, an understanding of its prevalence in the United States and its relationship with different determinants of health is paramount. Therefore, the purpose of this study is to determine the modern prevalence of oral-facial clefting in the United States and its association with different social determinants of health. Methods: Utilizing Epic Cosmos, data from approximately 180 US institutions were queried. Patients born between November 2012 and November 2022 were included. Eight orofacial clefting (OC) cohorts were identified. The Social Vulnerability Index (SVI) was used to assess social determinants of health. Results: Of the 15,697,366 patients identified, 31,216 were diagnosed with OC, resulting in a prevalence of 19.9 (95% CI: 19.7-20.1) per 10,000 live births. OC prevalence was highest among Asian (27.5 CI: 26.2-28.8) and Native American (32.8 CI: 30.4-35.2) patients and lowest among Black patients (12.96 CI: 12.5-13.4). Male and Hispanic patients exhibited higher OC prevalence than female and non-Hispanic patients. No significant differences were found among metropolitan (20.23/10,000), micropolitan (20.18/10,000), and rural populations (20.02/10,000). SVI data demonstrated that OC prevalence was positively associated with the percentage of the population below the poverty line and negatively associated with the proportion of minority language speakers. Conclusions: This study examined the largest US cohort of OC patients to date to define contemporary US prevalence, reporting a marginally higher rate than previous estimates. Multiple social determinants of health were found to be associated with OC prevalence, underscoring the importance of holistic prenatal care. These data may inform clinicians about screening and counseling of expectant families based on socio-economic factors and direct future research as it identifies potential risk factors and provides prevalence data, both of which are useful in addressing common questions related to screening and counseling.
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Affiliation(s)
- Hilliard T. Brydges
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY 10017, USA; (H.T.B.); (M.L.); (A.N.V.); (A.A.); (J.S.); (M.F.C.); (B.F.C.)
| | - Matteo Laspro
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY 10017, USA; (H.T.B.); (M.L.); (A.N.V.); (A.A.); (J.S.); (M.F.C.); (B.F.C.)
| | - Alexandra N. Verzella
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY 10017, USA; (H.T.B.); (M.L.); (A.N.V.); (A.A.); (J.S.); (M.F.C.); (B.F.C.)
| | - Andre Alcon
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY 10017, USA; (H.T.B.); (M.L.); (A.N.V.); (A.A.); (J.S.); (M.F.C.); (B.F.C.)
| | - Jill Schechter
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY 10017, USA; (H.T.B.); (M.L.); (A.N.V.); (A.A.); (J.S.); (M.F.C.); (B.F.C.)
| | - Michael F. Cassidy
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY 10017, USA; (H.T.B.); (M.L.); (A.N.V.); (A.A.); (J.S.); (M.F.C.); (B.F.C.)
| | - Bachar F. Chaya
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY 10017, USA; (H.T.B.); (M.L.); (A.N.V.); (A.A.); (J.S.); (M.F.C.); (B.F.C.)
| | - Eduardo Iturrate
- Department of Medicine, NYU Grossman School of Medicine, New York, NY 10017, USA;
| | - Roberto L. Flores
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY 10017, USA; (H.T.B.); (M.L.); (A.N.V.); (A.A.); (J.S.); (M.F.C.); (B.F.C.)
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15
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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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Munir MM, Lima HA, Endo Y, Moazzam Z, Woldesenbet S, Azap L, Katayama E, Dilhoff M, Cloyd J, Ejaz A, Pawlik TM. Association of Racial and Economic Privilege on Postoperative Outcomes Among Medicare Beneficiaries. J Surg Res 2024; 296:37-46. [PMID: 38215675 DOI: 10.1016/j.jss.2023.12.005] [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: 06/12/2023] [Revised: 11/15/2023] [Accepted: 12/17/2023] [Indexed: 01/14/2024]
Abstract
INTRODUCTION Social determinants of health can play an important role in patient health. Privilege is a right, benefit, advantage, or opportunity that can positively affect all social determinants of health. We sought to assess variations in the prevalence of privilege among patient populations and define the association of privilege on postoperative surgical outcomes. METHODS Medicare beneficiaries who underwent elective coronary artery bypass grafting, abdominal aortic aneurysm repair, total hip arthroplasty, total knee arthroplasty, colectomy, and lung resection were identified. The Index of Concentration of Extremes (ICE), a validated metric of both social spatial polarization and privilege was calculated and merged with county-level data obtained from the American Community Survey. Textbook outcome (TO) was defined as absence of postoperative complications, extended length of stay, 90-day mortality, and 90-day readmission. Multivariable regression analysis was performed to assess the relationship between ICE and TO. RESULTS Among 1,885,889 Medicare beneficiaries who met inclusion criteria, 655,980 (34.8%) individuals resided in areas with the highest privilege (i.e., White, high-income homogeneity), whereas 221,314 (11.7%) individuals resided in areas of the lowest privilege (i.e., Black, low-income homogeneity). The overall incidence of TO was 66.2% (n = 1,247,558). On multivariable regression, residence in the most advantaged neighbourhoods was associated with a lower chance of surgical complications (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.88-0.91), a prolonged length of stay (OR 0.81, 95% CI 0.79-82), 90-day readmission (OR 0.94, 95% CI 0.92-0.95), and 90-day mortality (OR 0.71, 95% CI 0.68-0.74) (all P < 0.001). Residence in the most privileged areas was associated with 19% increased odds of achieving TO (OR 1.19, 95% CI 1.18-1.21), as well as a 6% reduction in Medicare expenditures versus individuals in the least privileged counties (OR 0.94, 95% CI 0.94-0.94) (both P < 0.001). CONCLUSIONS Privilege, based on the ICE joint measure of racial/ethnic and economic spatial concentration, was strongly associated with the likelihood to achieve an "optimal" TO following surgery. As healthcare is a basic human right, privilege should not be associated with disparities in surgical care.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Lovette Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Erryk Katayama
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Mary Dilhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.
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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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Sharma S, Miller AS, Pearson Z, Tran A, Bahoravitch TJ, Stadecker M, Ahmed AF, Best MJ, Srikumaran U. Social determinants of health disparities impact postoperative complications in patients undergoing total shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:640-647. [PMID: 37572748 DOI: 10.1016/j.jse.2023.07.006] [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: 02/22/2023] [Revised: 06/30/2023] [Accepted: 07/02/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Understanding the role of social determinants of health disparities (SDHDs) in surgical outcomes can better prepare providers to improve postoperative care. In this study, we use International Classification of Diseases (ICD) codes to identify SDHDs and investigate the risk of postoperative complication rates among patients undergoing total shoulder arthroplasty (TSA). METHODS A retrospective cohort analysis was conducted using a national insurance claims database. Using ICD and Current Procedural Terminology (CPT) codes, patients who underwent primary TSA with at least 2 years of follow-up in the database were identified. Patients with a history of SDHDs were identified using appropriate ICD-9 and ICD-10 codes. Patients were grouped in one of 2 cohorts: (1) patients with no history of SDHDs (control) and (2) patients with a history of SDHDs (SDHD group) prior to TSA. The SDHD and control groups were matched 1:1 for comorbidities and demographics prior to conducting multivariable analysis for 90-day medical complications and 2-year surgical complications. RESULTS After matching, there were 8023 patients in the SDHD group and 8023 patients in the control group. The SDHD group had significantly higher odds for 90-day medical complications including heart failure, cerebrovascular accident, renal failure, deep vein thrombosis, pneumonia, sepsis, and urinary tract infection. Additionally, the SDHD group had significantly higher odds for revision surgery within 2 years following TSA. Patients in the SDHD group also had a significantly longer length of hospital stay following TSA. DISCUSSION This study highlights the association between SDHDs and postoperative complications following TSA. Quantifying the risk of complications and differences in length of stay for TSA patients with a history of SDHDs is important in determining value-based payment models and risk stratifying to optimize patient care.
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Affiliation(s)
- Sribava Sharma
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew S Miller
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zachary Pearson
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew Tran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tyler J Bahoravitch
- Department of Orthopaedic Surgery, George Washington University School of Medicine, Washington, DC, USA
| | - Monica Stadecker
- Department of Orthopaedic Surgery, George Washington University School of Medicine, Washington, DC, USA
| | - Abdulaziz F Ahmed
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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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: 4] [Impact Index Per Article: 4.0] [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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22
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Khan MMM, Munir MM, Woldesenbet S, Endo Y, Rawicz-Pruszyński K, Katayama E, Ejaz A, Cloyd J, Dilhoff M, Pawlik TM. Association of surgeon-patient sex concordance with postoperative outcomes following complex cancer surgery. J Surg Oncol 2024; 129:489-498. [PMID: 37990862 DOI: 10.1002/jso.27527] [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: 08/13/2023] [Revised: 10/21/2023] [Accepted: 10/28/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Sex concordance may impact the therapeutic relationship and provider-patient interactions. We sought to define the association of surgeon-patient sex concordance on postoperative patient outcomes following complex cancer surgery. METHODS Patients who underwent surgery for lung, breast, hepato-pancreato-biliary, or colorectal cancer between 2014 and 2020 were identified from the Medicare Standard Analytic Files. The impact of surgeon-patient sex concordance or discordance on achieving an optimal postoperative textbook outcome (TO) was assessed using multivariable logistic regression. RESULTS Among 495 628 patients, 241 938 (48.8%) patients were sex concordant with their surgeon while 253 690 (51.2%) patients were sex discordant. Sex discordance between surgeon and patient was associated with a decreased likelihood to achieve a postoperative TO (odds ratio [OR]: 0.95, 95% CI: 0.93-0.97; p < 0.001). Sex discordance was associated with a higher risk of complications (OR: 1.05, 95% CI: 1.03-1.07; p < 0.001) and 90-day mortality (OR: 1.05, 95% CI: 1.01-1.09; p = 0.011). Of note, male patients treated by female surgeons (OR: 0.96, 95% CI: 0.93-0.99; p = 0.017) had a similar lower likelihood to achieve a TO as female patients treated by male surgeons (OR: 0.90, 95% CI: 0.86-0.93; p < 0.001). CONCLUSIONS Sex discordance was associated with a reduced likelihood of achieving an "optimal" postoperative course following complex cancer surgery.
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Affiliation(s)
- Muhammad Muntazir Mehdi Khan
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad M Munir
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Selamawit Woldesenbet
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Yutaka Endo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Karol Rawicz-Pruszyński
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | - Erryk Katayama
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Jordan Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mary Dilhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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Diallo MS, Hasnain-Wynia R, Vetter TR. Social Determinants of Health and Preoperative Care. Anesthesiol Clin 2024; 42:87-101. [PMID: 38278595 DOI: 10.1016/j.anclin.2023.07.002] [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] [Indexed: 01/28/2024]
Abstract
Preoperative care exists as part of perioperative continuum during which anesthesiologists and surgeons optimize patients for surgery. These multispecialty efforts are important, particularly for patients with complex medical histories and those requiring major surgery. Preoperative care improves planning and determines the clinical pathway and discharge disposition. The role of nonmedical social factors in the preoperative planning is not well described in anesthesiology. Research to improve outcomes based on social factors is not well described for anesthesiologists but could be instrumental in decreasing disparities and advancing health equity in surgical patients.
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Affiliation(s)
- Mofya S Diallo
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Keck School of Medicine at the University of Southern California, 4650 Sunset Boulevard, MS#3, Los Angeles, CA 90027, USA.
| | - Romana Hasnain-Wynia
- Academic Affairs and Public Health, Denver Health, University of Colorado School of Medicine, 601 Broadway Street, 9th Floor, MC 6551, Denver, CO 80203, USA
| | - Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Health Discovery Building, Room 6.812, 1701 Trinity Street, Austin, TX 78712-1875, USA
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Collins RA, Abla H, Dhanasekara CS, Shrestha K, Dissanaike S. Association of social vulnerability with receipt of hernia repair in Texas. Surgery 2024; 175:457-462. [PMID: 38016898 DOI: 10.1016/j.surg.2023.10.026] [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: 06/08/2023] [Revised: 09/21/2023] [Accepted: 10/25/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND The effect of social health determinants on hernia surgery receipt is unclear. We aimed to assess the association of the social vulnerability index with the likelihood of undergoing elective and emergency hernia repair in Texas. METHODS This is a retrospective cohort analysis of the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Public Use Data File from 2016 to 2019. Patients ≥18 years old with inguinal or umbilical hernia were included. Social vulnerability index and urban/rural status were merged with the database at the county level. Patients were stratified based on social vulnerability index quartiles, with the lowest quartile (Q1) designated as low vulnerability, Q2 and Q3 as average, and Q4 as high vulnerability. Wilcoxon rank sum, t test, and χ2 analysis were used, as appropriate. The relative risk of undergoing surgery was calculated with subgroup sensitivity analysis. RESULTS Of 234,843 patients assessed, 148,139 (63.1%) underwent surgery. Compared to patients with an average social vulnerability index, the low social vulnerability index group was 36% more likely to receive surgery (relative risk: 1.36, 95% CI 1.34-1.37), whereas the high social vulnerability index group was 14% less likely to receive surgery (relative risk: 0.86, 95% CI 0.85-0.86). This remained significant after stratifying for age, sex, insurance status, ethnicity, and urban/rural status (P < .05). For emergency admissions, there was no difference in receipt of surgery by social vulnerability index. CONCLUSION Vulnerable patients are less likely to undergo elective surgical hernia repair, even after adjusting for demographics, insurance, and urbanicity. The social vulnerability index may be a useful indicator of social determinants of health barriers to hernia repair.
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Affiliation(s)
- Reagan A Collins
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX. https://twitter.com/ReaganACollins
| | - Habib Abla
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Science Center, Lubbock, TX.
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Das RK, Galdyn IA, Perdikis G, Drolet BC, Terhune KP. National patterns in the use of International Statistical Classification of Diseases and Health Related Problems, tenth revision Z codes in ambulatory surgery from 2016 to 2019. Am J Surg 2024; 228:54-61. [PMID: 37407393 DOI: 10.1016/j.amjsurg.2023.06.030] [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: 04/29/2023] [Revised: 05/23/2023] [Accepted: 06/24/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND In the tenth revision of the International Statistical Classification of Disease and Health Related Problems (ICD-10), Z codes were added to improve documentation and understanding of health-related social needs. We estimated national Z code use in the ambulatory surgery setting from 2016 to 2019. METHODS Using the Nationwide Ambulatory Surgery Sample (NASS), we identified encounters for ambulatory surgery with an ICD-10 code between Z55.0 and Z65.9. Data were stratified by Z code domains from the Centers for Medicare and Medicaid Services (CMS). RESULTS This analysis of 41,827 ambulatory surgery encounters with documented Z codes found that the most documented determinants of health related to multiparity or unwanted pregnancy, homelessness, and incarceration. There was a 16.1% increase in the use of Z codes from 2016 to 2019. CONCLUSION Rates of Z code use in the ambulatory surgery setting are increasing with current documentation serving as a specific but not sensitive measure of socioeconomic need.
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Affiliation(s)
- Rishub K Das
- Vanderbilt University School of Medicine, Nashville, TN, United States.
| | - Izabela A Galdyn
- Vanderbilt University School of Medicine, Department of Plastic Surgery, Nashville, TN, United States
| | - Galen Perdikis
- Vanderbilt University School of Medicine, Department of Plastic Surgery, Nashville, TN, United States
| | - Brian C Drolet
- Vanderbilt University School of Medicine, Department of Plastic Surgery, Nashville, TN, United States
| | - Kyla P Terhune
- Vanderbilt University School of Medicine, Department of Surgery, Nashville, TN, United States
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Sullivan GA, Gely Y, Palmisano ZM, Donaldson A, Rangel M, Gulack BC, Johnson JK, Shah AN. Surgeon Understanding and Perceptions of Social Determinants of Health. J Surg Res 2024; 294:73-81. [PMID: 37864961 DOI: 10.1016/j.jss.2023.08.050] [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: 05/04/2023] [Revised: 06/28/2023] [Accepted: 08/27/2023] [Indexed: 10/23/2023]
Abstract
INTRODUCTION Social determinants of health impact surgical outcomes. Characterization of surgeon understanding of social determinants of health is necessary prior to implementation of interventions to address patient needs. The study objective was to explore understanding, perceived importance, and practices regarding social determinants of health among surgeons. METHODS Surgical residents and attending surgeons at a single academic medical center completed surveys regarding social determinants of health. We conducted semi-structured interviews to further explore understanding and perceived importance. A conceptual framework from the World Health Organization (WHO) Commission on Social Determinants of Health informed the thematic analysis. RESULTS Survey response rate was 47.9% (n = 69, 44 residents [63.8%], 25 attendings [36.2%]). Respondents primarily reported good (n = 29, 42.0%) understanding of social determinants of health and perceived this understanding to be very important (n = 42, 60.9%). Documentation occurred seldom (n = 35, 50.7%), and referrals occurred seldom (n = 26, 37.7%) or never (n = 20, 29.0%). Residents reported a higher rate of prior training than attendings (95.5% versus 56.0%, P < 0.001). Ten interviews were conducted (six residents, four attendings). Residents demonstrated greater understanding of socioeconomic positions and hierarchies shaped by structural mechanisms than attendings. Both residents and attendings demonstrated understanding of intermediary determinants of health status and linked social determinants to impacting patients' health and well-being. Specific knowledge gaps were identified regarding underlying structural mechanisms including the social, economic, and political context that influence an individual's socioeconomic position. CONCLUSIONS Self-reported understanding and importance of social determinants of health among surgeons were high. Interviews revealed gaps in understanding that may contribute to limited practices.
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Affiliation(s)
- Gwyneth A Sullivan
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Yumiko Gely
- Rush Medical College, Rush University Medical Center, Chicago, Illinois
| | | | - Andrew Donaldson
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Melissa Rangel
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Julie K Johnson
- Department of Surgery, Surgical Northwestern Quality Improvement, Research, and Education in Surgery (NQUIRES), Feinberg School of Medicine, Northwestern University, Illinois
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois.
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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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Gholami S, Kleber KT, Perry LM, Abidalhassan M, McFadden NR, Bateni SB, Maguire FB, Stewart SL, Morris C, Chen M, Gaskill CE, Merkow RP, Keegan TH. Disparities in treatment and survival in early-stage hepatocellular carcinoma in California. J Surg Oncol 2023; 128:1302-1311. [PMID: 37610042 PMCID: PMC10841249 DOI: 10.1002/jso.27423] [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: 05/14/2023] [Revised: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Curative intent therapy is the standard of care for early-stage hepatocellular carcinoma (HCC). However, these therapies are under-utilized, with several treatment and survival disparities. We sought to demonstrate whether the type of facility and distance from treatment center (with transplant capabilities) contributed to disparities in curative-intent treatment and survival for early-stage HCC in California. METHODS We performed a retrospective analysis of the California Cancer Registry for patients diagnosed with stage I or II primary HCC between 2005 and 2017. Primary and secondary outcomes were receipt of treatment and overall survival, respectively. Multivariable logistic regression and Multivariable Cox proportional hazards regression were used to evaluate associations. RESULTS Of 19 059 patients with early-stage HCC, only 36% (6778) received curative-intent treatment. Compared to Non-Hispanic White patients, Hispanic patients were less likely, and Asian/Pacific Islander patients were more likely to receive curative-intent treatment. Our results showed that rural residence, public insurance, lower neighborhood SES, and care at non-National Cancer Institute-designated cancer center were associated with not receiving treatment and decreased survival. CONCLUSIONS Although multiple factors influence receipt of treatment for early-HCC, our findings suggest that early intervention programs should target travel barriers and access to specialist care to help improve oncologic outcomes.
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Affiliation(s)
- Sepideh Gholami
- Division of Surgical Oncology, Department of Surgery, Northwell Health, New Hyde Park, NY USA
| | - Kara T. Kleber
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Lauren M. Perry
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Mustafa Abidalhassan
- Division of Surgical Oncology, Department of Surgery, Northwell Health, New Hyde Park, NY USA
| | - Nikia R. McFadden
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Sarah B. Bateni
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Frances B. Maguire
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Susan L. Stewart
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Cyllene Morris
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Moon Chen
- Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Cameron E. Gaskill
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Ryan P. Merkow
- Division of Surgical Oncology, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Theresa H. Keegan
- Department of Public Health Sciences, University of California Davis, Sacramento, CA, USA
- Center for Oncology Hematology Outcomes Research and Training (COHORT) and Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA, 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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Reinke CE, Slawson DC. Maintenance Matters and Compliance Conundrums-Optimization of Emergency General Surgery Outcomes in the Prehospital Phase of Care. JAMA Surg 2023; 158:1030-1031. [PMID: 37466989 DOI: 10.1001/jamasurg.2023.2748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Caroline E Reinke
- Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina
| | - David C Slawson
- Department of Family Medicine, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina
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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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Halada S, Chen AT, Ramadan OI, Li EH, Goldshore M, Morris JB, Morales CZ. Incorporation and Utilization of an Additional Needs Screener by Surgical Trainees for Comprehensive Care of Underserved and Underinsured Surgical Patients. JOURNAL OF SURGICAL EDUCATION 2023; 80:1287-1295. [PMID: 37451882 DOI: 10.1016/j.jsurg.2023.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/01/2023] [Accepted: 06/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Comprehensive, socially-minded healthcare has historically been delivered in the primary care setting. For underserved patient populations, however, a surgical care episode may serve as the health care access point. To maximize patient wellbeing during the perioperative period, our surgical center developed the Additional Needs Screener (ANS). Operationalized into practice by GME and UME trainees, this tool screens surgical patients across 3 domains (social, emotional, and immigration needs) and connects patients to partner organizations if appropriate. This study describes the pilot utilization of the ANS among underserved and underinsured surgical patients. DESIGN Clinical quality improvement and retrospective cohort study of patients completing the ANS from implementation in September 2021 to September 2022. SETTING The Hospital of the University of Pennsylvania, PA-a tertiary care center. PARTICIPANTS One hundred and 10 underinsured and/or underserved patients completed at least 1 ANS domain. RESULTS Patients were majority female (55F, 53M, 2 other) and Hispanic/Latinx (72%) with a median age of 38 (IQR = 34-48). Most patients spoke a primary language other than English (77%), and nearly all were either uninsured (82%) or received emergency medical assistance or Medicaid (14%) at referral. Patients demonstrated significant needs; 39% endorsed difficulty affording housing, 32% endorsed difficulty paying for food, 29% endorsed experiencing current life-interfering distress, and 75% had undocumented immigration status. Ultimately, 57% of screened patients accepted referrals to our needs response teams. CONCLUSIONS Underserved and underinsured patients presenting for surgical care face significant challenges relating to social, emotional, and immigration needs. Through adoption of the ANS, trainees gained competency identifying and addressing these barriers in the perioperative period. Future works will focus on categorizing referral outcomes, developing interventions to increase patient trust, and improving screener dissemination.
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Affiliation(s)
- Stephen Halada
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Angela T Chen
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Eric H Li
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Matthew Goldshore
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Jon B Morris
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania
| | - Carrie Z Morales
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgical Health, Department of Surgery, University of Pennsylvania.
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Munir MM, Pawlik TM. ASO Author Reflections: Disparities in Socioeconomic Factors Mediate Impact of Racial Segregation Among Patients with Hepatopancreaticobiliary Cancer. Ann Surg Oncol 2023; 30:4836-4837. [PMID: 37046131 DOI: 10.1245/s10434-023-13493-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Muhammad Musaab Munir
- 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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Munir MM, Woldesenbet S, Endo Y, Moazzam Z, Lima HA, Azap L, Katayama E, Alaimo L, Shaikh C, Dillhoff M, Cloyd J, Ejaz A, Pawlik TM. Disparities in Socioeconomic Factors Mediate the Impact of Racial Segregation Among Patients With Hepatopancreaticobiliary Cancer. Ann Surg Oncol 2023; 30:4826-4835. [PMID: 37095390 DOI: 10.1245/s10434-023-13449-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/21/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Structural racism within the U.S. health care system contributes to disparities in oncologic care. This study sought to examine the socioeconomic factors that underlie the impact of racial segregation on hepatopancreaticobiliary (HPB) cancer inequities. METHODS Both Black and White patients who presented with HPB cancer were identified from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2005-2015) and 2010 Census data. The Index of Dissimilarity (IoD), a validated measure of segregation, was examined relative to cancer stage at diagnosis, surgical resection, and overall mortality. Principal component analysis and structural equation modeling were used to determine the mediating effect of socioeconomic factors. RESULTS Among 39,063 patients, 86.4 % (n = 33,749) were White and 13.6 % (n = 5314) were Black. Black patients were more likely to reside in segregated areas than White patients (IoD, 0.62 vs. 0.52; p < 0.05). Black patients in highly segregated areas were less likely to present with early-stage disease (relative risk [RR], 0.89; 95 % confidence interval [CI] 0.82-0.95) or undergo surgery for localized disease (RR, 0.81; 95% CI 0.70-0.91), and had greater mortality hazards (hazard ratio 1.12, 95% CI 1.06-1.17) than White patients in low segregation areas (all p < 0.05). Mediation analysis identified poverty, lack of insurance, education level, crowded living conditions, commute time, and supportive income as contributing to 25 % of the disparities in early-stage presentation. Average income, house price, and income mobility explained 17 % of the disparities in surgical resection. Notably, average income, house price, and income mobility mediated 59 % of the effect that racial segregation had on long-term survival. CONCLUSION Racial segregation, mediated through underlying socioeconomic factors, accounted for marked disparities in access to surgical care and outcomes for patients with HPB cancer.
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Affiliation(s)
- Muhammad Musaab Munir
- 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
| | - 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
| | - Lovette Azap
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Erryk Katayama
- 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
| | - Chanza Shaikh
- 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
| | - Jordan Cloyd
- 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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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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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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Munir MM, Endo Y, Pawlik TM. ASO Author Reflections: Racial Segregation Among Patients with Cholangiocarcinoma: Impact on Diagnosis, Treatment, and Outcomes. Ann Surg Oncol 2023; 30:4247-4248. [PMID: 36705814 DOI: 10.1245/s10434-023-13138-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 01/28/2023]
Affiliation(s)
- 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
| | - 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, Health Services Management and Policy, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Munir MM, Woldesenbet S, Endo Y, Lima HA, Alaimo L, Moazzam Z, Shaikh C, Cloyd J, Ejaz A, Azap R, Azap L, Pawlik TM. Racial Segregation Among Patients with Cholangiocarcinoma-Impact on Diagnosis, Treatment, and Outcomes. Ann Surg Oncol 2023; 30:4238-4246. [PMID: 36695990 DOI: 10.1245/s10434-023-13122-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/02/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Racial segregation, an effect of historical marginalization, may impact cancer care and outcomes. We sought to examine the impact of racial segregation on the diagnosis, treatment, and outcomes of patients with cholangiocarcinoma (CCA). PATIENTS AND METHODS Data on Black and White patients with CCA were obtained from the linked SEER-Medicare database (2004-2015) and 2010 Census data. The index of dissimilarity (IoD), a validated measure of segregation, was used to assess Black-White disparities in stage disease presentation, surgery for localized disease, and cancer-specific mortality. Multivariable Poisson regression was performed, and competing risk regression analysis was used to determine cancer-specific survival. RESULTS Among 7480 patients with CCA, 90.2% (n = 6748) were White and 9.8% (n = 732) were Black. Overall, Black patients were more likely to reside in segregated areas compared with White patients (IoD, 0.42 vs. 0.38; p < 0.05). On multivariable Poisson regression, Black patients were more likely to present with advanced-stage disease [relative risk (RR) 1.17, 95% confidence interval (CI) 1.08-1.27; p < 0.001] and were less likely to undergo surgery for localized disease (RR 0.62, 95% CI 0.51-0.76; p < 0.001). Black patients also had worse cancer-specific survival (CSS) compared with White patients (median CSS: 4 vs. 8 months; p < 0.01). Black patients living in the highest areas of segregation had 40% increased hazard of mortality versus White patients residing in the lowest IoD areas (hazard ratio 1.40, 95% CI 1.10-1.80; p < 0.01). CONCLUSION Racial segregation, as a proxy for structural racism, had a marked effect on Black-White disparities among patients with CCA.
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Affiliation(s)
- Muhammad Musaab Munir
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Henrique A Lima
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Chanza Shaikh
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rosevine Azap
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lovette Azap
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Jacobs M, Morris E, Haleem Z, Mandato N, Marlow NM, Revere L. Drivers of Individual and Regional Variation in CMS Hierarchical Condition Categories Among Florida Beneficiaries. Risk Manag Healthc Policy 2023; 16:1011-1022. [PMID: 37323190 PMCID: PMC10266376 DOI: 10.2147/rmhp.s401474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/31/2023] [Indexed: 06/17/2023] Open
Abstract
Objective To explore hierarchical condition categories (HCC) risk score variation among Florida Fee for Service (FFS) Medicare beneficiaries between 2016 and 2018. Data Sources This study analyzed HCC risk score variation using Medicare claims data for Florida beneficiaries enrolled in Parts A & B between 2016 and 2018. Study Design The CMS methodology analyzed HCC risk score variation using annual mean county- and beneficiary-level risk score changes. The association between variation and beneficiary characteristics, diagnoses, and geographic location was characterized using mixed-effects negative binomial regression models. Data Collection Not applicable. Principal Findings Counties in the Northeast [marginal effect (ME)=-0.003], Central (ME=-0.021), and Southwest (ME=-0.009) Florida have relatively lower mean risk scores. A higher number of lifetime (ME=0.246) and treatable (ME=0.288) conditions were associated with higher county-level risk scores, while more preventable conditions (ME=-0.249) were associated with lower risk scores. Counties with older beneficiaries (ME=0.015) and more Blacks (ME=0.070) have higher risk scores, while having female beneficiaries reduced risk scores (ME=-0.005). Individual risk scores did not vary by age (ME=0.000), but Blacks (ME=0.001) had higher rates of variation relative to Whites, while other races had comparatively lower variation (ME=-0.003). In addition, individuals diagnosed with more lifetime (ME=0.129), treatable (ME=0.235), and preventable (ME=0.001) conditions had higher risk score variation. Most condition-specific indicators showed small associations with risk score changes; however, metastatic cancer/acute leukemia, respirator dependence/tracheostomy, and pressure ulcers of the skin were significantly associated with both types of HCC risk score variation. Conclusion Results showed demographics, HCC condition classifications (ie, lifetime, preventable, and treatable), and some specific conditions were associated with higher variation in mean county-level and individual risk scores. Results suggest consistent coding and reductions in the prevalence of certain treatable or preventable conditions could reduce the county and individual HCC risk score year-to-year change.
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Affiliation(s)
- Molly Jacobs
- Department of Health Services Research Management and Policy, University of Florida, Gainesville, FL, USA
| | - Earl Morris
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL, USA
| | - Zuhair Haleem
- Department of Health Services Research Management and Policy, University of Florida, Gainesville, FL, USA
| | - Nicholas Mandato
- Department of Biology, University of Florida, Gainesville, FL, USA
| | - Nicole M Marlow
- Department of Health Services Research Management and Policy, University of Florida, Gainesville, FL, USA
| | - Lee Revere
- Department of Health Services Research Management and Policy, University of Florida, Gainesville, FL, USA
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Vo A, Tao Y, Li Y, Albarrak A. The Association Between Social Determinants of Health and Population Health Outcomes: Ecological Analysis. JMIR Public Health Surveill 2023; 9:e44070. [PMID: 36989028 PMCID: PMC10131773 DOI: 10.2196/44070] [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: 11/04/2022] [Revised: 12/21/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND With the increased availability of data, a growing number of studies have been conducted to address the impact of social determinants of health (SDOH) factors on population health outcomes. However, such an impact is either examined at the county level or the state level in the United States. The results of analysis at lower administrative levels would be useful for local policy makers to make informed health policy decisions. OBJECTIVE This study aimed to investigate the ecological association between SDOH factors and population health outcomes at the census tract level and the city level. The findings of this study can be applied to support local policy makers in efforts to improve population health, enhance the quality of care, and reduce health inequity. METHODS This ecological analysis was conducted based on 29,126 census tracts in 499 cities across all 50 states in the United States. These cities were grouped into 5 categories based on their population density and political affiliation. Feature selection was applied to reduce the number of SDOH variables from 148 to 9. A linear mixed-effects model was then applied to account for the fixed effect and random effects of SDOH variables at both the census tract level and the city level. RESULTS The finding reveals that all 9 selected SDOH variables had a statistically significant impact on population health outcomes for ≥2 city groups classified by population density and political affiliation; however, the magnitude of the impact varied among the different groups. The results also show that 4 SDOH risk factors, namely, asthma, kidney disease, smoking, and food stamps, significantly affect population health outcomes in all groups (P<.01 or P<.001). The group differences in health outcomes for the 4 factors were further assessed using a predictive margin analysis. CONCLUSIONS The analysis reveals that population density and political affiliation are effective delineations for separating how the SDOH affects health outcomes. In addition, different SDOH risk factors have varied effects on health outcomes among different city groups but similar effects within city groups. Our study has 2 policy implications. First, cities in different groups should prioritize different resources for SDOH risk mitigation to maximize health outcomes. Second, cities in the same group can share knowledge and enable more effective SDOH-enabled policy transfers for population health.
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Affiliation(s)
- Ace Vo
- Information Systems and Business Analytics Department, Loyola Marymount University, Los Angeles, CA, United States
| | - Youyou Tao
- Information Systems and Business Analytics Department, Loyola Marymount University, Los Angeles, CA, United States
| | - Yan Li
- Center for Information Systems and Technology, Claremont Graduate University, Claremont, CA, United States
| | - Abdulaziz Albarrak
- Information Systems Department, King Faisal University, Al-Ahsa, Saudi Arabia
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Jaramillo EA, Smith EJT, Matthay ZA, Sanders KM, Hiramoto JS, Gasper WJ, Conte MS, Iannuzzi JC. Racial and ethnic disparities in major adverse limb events persist for chronic limb threatening ischemia despite presenting limb threat severity after peripheral vascular intervention. J Vasc Surg 2023; 77:848-857.e2. [PMID: 36334848 DOI: 10.1016/j.jvs.2022.10.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/14/2022] [Accepted: 10/19/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Racial and ethnic disparities have been well-documented in the outcomes for chronic limb threatening ischemia (CLTI). One purported explanation has been the disease severity at presentation. We hypothesized that the disparities in major adverse limb events (MALE) after peripheral vascular intervention (PVI) for CLTI would persist despite controlling for disease severity at presentation using the WIfI (Wound, Ischemia, foot Infection) stage. METHODS The Vascular Quality Initiative PVI dataset (2016-2021) was queried for CLTI. Patients were excluded if they were missing the WIfI stage. The primary end point was the incidence of 1-year MALE, defined as major amputation (through the tibia or fibula or more proximally) or reintervention (endovascular or surgical) of the initial treatment limb. A multivariate hierarchical Fine-Gray analysis was performed, controlling for hospital variation, competing risk of death, and presenting WIfI stage, to assess the independent association of Black/African American race and Latinx/Hispanic ethnicity with MALE. A Cox proportional hazard regression model was used for the 1-year survival analysis. RESULTS Overall, 47,830 patients (60%) had had WIfI scores reported (73% White, 20% Black, and 7% Latinx). The 1-year unadjusted cumulative incidence of MALE was 13.1% (95% confidence interval [CI], 12.6%-13.5%) for White, 14.3% (95% CI, 13.5%-15.3%) for Black, and 17.0% (95% CI, 15.3%-18.9%) for Latinx patients. On bivariate analysis, the occurrence of MALE was significantly associated with younger age, Black race, Latinx ethnicity, coronary artery disease, cerebrovascular disease, congestive heart failure, hypertension, diabetes, dialysis, intervention level, any prior minor or major amputation, and WIfI stage (P < .001). The cumulative incidence of 1-year MALE increased by increasing WIfI stage: stage 1, 11.7% (95% CI, 10.9%-12.4%); stage 2, 12.4% (95% CI, 11.8%-13.0%); stage 3, 14.8% (95% CI, 13.8%-15.8%); and stage 4, 15.4% (95% CI, 14.3%-16.6%). The cumulative incidence also increased by intervention level: inflow, 10.7% (95% CI, 9.8%-11.7%), femoropopliteal, 12.3% (95% CI, 11.7%-12.9%); and infrapopliteal, 14.1% (95% CI, 13.5%-14.8%). After adjustment for WIfI stage only, Black race (subdistribution hazard ratio [SHR], 1.30; 95% CI, 1.17-1.44; P < .001) and Latinx ethnicity (SHR, 1.58; 95% CI, 1.37-1.81; P < .001) were associated with an increased 1-year hazard of MALE compared with White race. On adjusted multivariable analysis, MALE disparities persisted for Black/African American race (SHR, 1.12; 95% CI, 1.01-1.25; P = .028) and Latinx/Hispanic ethnicity (SHR, 1.34; 95% CI, 1.16-1.54; P < .001) compared with White race. CONCLUSIONS Black/African American and Latinx/Hispanic patients had a higher associated hazard of MALE after PVI for CLTI compared with White patients despite an adjustment for WIfI stage at presentation. These results suggest that disease severity at presentation does not account for disparities in outcomes. Further work should focus on better understanding the underlying mechanisms for disparities in historically marginalized racial and ethnic groups presenting with CLTI.
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Affiliation(s)
- Emanuel A Jaramillo
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA; Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Eric J T Smith
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Zachary A Matthay
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Katherine M Sanders
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Iott BE, Adler-Milstein J, Gottlieb LM, Pantell MS. Characterizing the relative frequency of clinician engagement with structured social determinants of health data. J Am Med Inform Assoc 2023; 30:503-510. [PMID: 36545752 PMCID: PMC9933071 DOI: 10.1093/jamia/ocac251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/19/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Electronic health records (EHRs) are increasingly used to capture social determinants of health (SDH) data, though there are few published studies of clinicians' engagement with captured data and whether engagement influences health and healthcare utilization. We compared the relative frequency of clinician engagement with discrete SDH data to the frequency of engagement with other common types of medical history information using data from inpatient hospitalizations. MATERIALS AND METHODS We created measures of data engagement capturing instances of data documentation (data added/updated) or review (review of data that were previously documented) during a hospitalization. We applied these measures to four domains of EHR data, (medical, family, behavioral, and SDH) and explored associations between data engagement and hospital readmission risk. RESULTS SDH data engagement was associated with lower readmission risk. Yet, there were lower levels of SDH data engagement (8.37% of hospitalizations) than medical (12.48%), behavioral (17.77%), and family (14.42%) history data engagement. In hospitalizations where data were available from prior hospitalizations/outpatient encounters, a larger proportion of hospitalizations had SDH data engagement than other domains (72.60%). DISCUSSION The goal of SDH data collection is to drive interventions to reduce social risk. Data on when and how clinical teams engage with SDH data should be used to inform informatics initiatives to address health and healthcare disparities. CONCLUSION Overall levels of SDH data engagement were lower than those of common medical, behavioral, and family history data, suggesting opportunities to enhance clinician SDH data engagement to support social services referrals and quality measurement efforts.
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Affiliation(s)
- Bradley E Iott
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco (UCSF), San Francisco, California, USA
- Social Interventions Research and Evaluation Network, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Julia Adler-Milstein
- Center for Clinical Informatics and Improvement Research, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Laura M Gottlieb
- Social Interventions Research and Evaluation Network, University of California, San Francisco (UCSF), San Francisco, California, USA
- Center for Health and Community, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Family and Community Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Matthew S Pantell
- Center for Health and Community, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Pediatrics, University of California, San Francisco (UCSF), San Francisco, California, USA
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Dawood ZS, Hamad A, Moazzam Z, Alaimo L, Lima HA, Shaikh C, Munir MM, Endo Y, Pawlik TM. Colonoscopy, imaging, and carcinoembryonic antigen: Comparison of guideline adherence to surveillance strategies in patients who underwent resection of colorectal cancer - A systematic review and meta-analysis. Surg Oncol 2023; 47:101910. [PMID: 36806402 DOI: 10.1016/j.suronc.2023.101910] [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: 11/01/2022] [Revised: 01/22/2023] [Accepted: 02/04/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION Almost one-third of patients with colorectal cancer (CRC) experience recurrence after resection. Adherence to surveillance guidelines largely dictates efficacy in early detection of recurrence. We sought to assess and compare adherence to postoperative surveillance guidelines for colonoscopy, imaging, and Carcinoembryonic Antigen (CEA). METHODS PubMed, Medline, Embase, Scopus, Cochrane, Web of Science, and CINAHL were systematically searched. Random-effects meta-analysis was performed and pooled adherence to each surveillance strategy was assessed for CEA, imaging, and colonoscopy. RESULTS Overall 14 studies (55,895 patients) met the inclusion criteria. Adherence to colonoscopy guidelines was the highest (70%, 95%CI 67-73), followed by imaging (63%, 95%CI 47-80), and CEA (54%; 95%CI 42-66). Among 7 (50%) studies that examined adherence to the American Society of Clinical Oncology guidelines, compliance with colonoscopy was the highest (73%; 95% CI 70-76), followed by imaging (58%; 95% CI 37-78), and CEA (45%; 95%CI 37-52). Of note, guideline adherence to CEA testing was much lower than colonoscopy among patients with colon (OR 0.21; 95%CI 0.20-0.22) and rectal cancer (OR 0.25; 95%CI 0.23-0.28) (both p < 0.05). This was also noted when compared with imaging recommendations among older patients (OR = 0.62; 95%CI 0.42-0.93) and patients with stage II, (OR = 0.80; 95%CI 0.76-0.84) and stage III disease (OR = 0.88; 95%CI 0.82-0.94) (all p < 0.05). CONCLUSION While guideline adherence to postoperative surveillance with colonoscopy was high, adherence to CEA testing and imaging surveillance strategies was markedly lower following CRC resection. Future studies should investigate avenues to improve compliance with surveillance guidelines among health care providers and patients to optimize postoperative follow-up for CRC.
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Affiliation(s)
- Zaiba Shafik Dawood
- Medical College, The Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan
| | - Ahmad Hamad
- 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
| | - Laura Alaimo
- 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 Shaikh
- 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
| | - 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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Affiliation(s)
- Adrian Diaz
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH.
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Zhang Y, Kunnath N, Dimick JB, Scott JW, Ibrahim AM. Social Vulnerability and Emergency General Surgery among Medicare Beneficiaries. J Am Coll Surg 2023; 236:208-217. [PMID: 36519918 PMCID: PMC9764237 DOI: 10.1097/xcs.0000000000000429] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although the Social Vulnerability Index (SVI) was created to identify vulnerable populations after unexpected natural disasters, its ability to identify similar groups of patients undergoing unexpected emergency surgical procedures is unknown. We sought to examine the association between SVI and outcomes after emergency general surgery. STUDY DESIGN This study is a cross-sectional review of 887,193 Medicare beneficiaries who underwent 1 of 4 common emergency general surgery procedures (appendectomy, cholecystectomy, colectomy, and ventral hernia repair) performed in the urgent or emergent setting between 2014 and 2018. These data were merged with the SVI at the census-track level of residence. Risk-adjusted outcomes (30-day mortality, serious complications, readmission) were evaluated using a logistic regression model accounting for age, sex, comorbidity, year, procedure type, and hospital characteristics between high and low social vulnerability quintiles and within the 4 SVI subthemes (socioeconomic status; household composition and disability; minority status and language; and housing type and transportation). RESULTS Compared with beneficiaries with low social vulnerability, Medicare beneficiaries living in areas of high social vulnerability experienced higher rates of 30-day mortality (8.56% vs 8.08%; adjusted odds ratio 1.07; p < 0.001), serious complications (20.71% vs 18.40%; adjusted odds ratio 1.17; p < 0.001), and readmissions (16.09% vs 15.03%; adjusted odds ratio 1.08; p < 0.001). This pattern of differential outcomes was present in subgroup analysis of all 4 SVI subthemes but was greatest in the socioeconomic status and household composition and disability subthemes. CONCLUSIONS National efforts to support patients with high social vulnerability from natural disasters may be well aligned with efforts to identify communities that are particularly vulnerable to worse postoperative outcomes after emergency general surgery. Policies targeting structural barriers related to household composition and socioeconomic status may help alleviate these disparities.
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Affiliation(s)
- Yuqi Zhang
- National Clinician Scholars Program at the Clinical Research Training Program, Duke University, Durham, North Carolina 27705, USA
- Department of Surgery, Yale University, New Haven, Connecticut 06511, USA
| | - Nicholas Kunnath
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - John W Scott
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
| | - Andrew M Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan 48109, USA
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Structural evaluation of child physical abuse in trauma: Social determinants of health at the population level. J Pediatr Surg 2023; 58:106-110. [PMID: 36335011 DOI: 10.1016/j.jpedsurg.2022.09.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Child physical abuse (CPA) is closely linked to social factors like insurance status with limited evaluation at a structural population-level. This study evaluates the role of social determinants of health within the built environment on CPA. METHODS A single-institution retrospective review of pediatric trauma patients was conducted between January 2016 and December 2020. Patient address was geocoded to the census-tract level. Socioeconomic metrics, including poverty rate, supermarket access and Social Vulnerability Index (SVI) were estimated from the Food Access Research Atlas. Univariate and multivariable regression analyses were conducted to compare demographics and outcomes. RESULTS Of 3,540 patients, 317 (9.0%) had concern for physical abuse reported in the registry. CPA patients were younger (7.5 vs 9.6 years, p<0.0001) and more often Black (37.0%, N = 117 vs 23.5%, N = 753; p<0.0001). CPA had higher injury severity scores (ISS) (7.9 vs 5.8, p<0.0001) and longer length of stay (5.3 vs 2.9 days, p<0.0001). CPA had higher Medicaid (73.0%, N = 232 vs 53.8%, N = 1748, p<0.0001) and SVI (0.65 vs 0.59, p<0.0001) with lower median income ($52,100 vs $56,100, p<0.0001) and more low-food access tracts (59.6% vs 53.6%, p = 0.06). Combined low-income and low-food access populations showed widened disparities (40.0% vs 28.9%, p = 0.0002). On multivariate analysis, CPA was associated with poverty (OR 2.3, 95% CI [0.979, 3.60], p = 0.0006), low-access Black share (OR 3.3, 95% CI [1.18, 5.47], p = 0.002) and urban designation (OR 1.5, 95% CI [1.13, 1.87], p = 0.004). CONCLUSION The built-environment and population-level social determinants of health are related to child physical abuse and should influence advocacy and prevention. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective.
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Kaslow SR, Hani L, Sacks GD, Lee AY, Berman RS, Correa-Gallego C. Regional Patterns of Hospital-Level Guideline Adherence in Gastric Cancer: An Analysis of the National Cancer Database. Ann Surg Oncol 2023; 30:300-308. [PMID: 36123415 DOI: 10.1245/s10434-022-12549-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/17/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Adherence to evidence-based guidelines for gastric cancer is low, particularly at the hospital level, despite a strong association with improved overall survival (OS). We aimed to evaluate patterns of hospital and regional adherence to National Comprehensive Cancer Network guidelines for gastric cancer. METHODS Using the National Cancer Database (2004-2015), we identified patients with stage I-III gastric cancer. Hospital-level guideline adherence was calculated by dividing the patients who received guideline adherent care by the total patients treated at that hospital. OS was estimated for each hospital. Associations between adherence, region, and survival were compared using mixed-effects, hierarchical regression. RESULTS Among 576 hospitals, the median hospital guideline adherence rate was 25% (range 0-76%) and varied significantly by region (p = 0.001). Adherence was highest in the Middle Atlantic (29%) and lowest in the East South Central region (19%); hospitals in the New England, Middle Atlantic, and East North Central regions were more likely to be guideline adherent than those in the East South Central region (all p < 0.05), after adjusting for patient and hospital mix. Most (35%) of the adherence variation was attributable to the hospital. Median 2-year OS varied significantly by region. After adjusting for hospital and patient mix, hazard of mortality was 17% lower in the Middle Atlantic (hazard ratio 0.82, 95% confidence interval 0.74-0.90) relative to the East South Central region, with most of the variation (54%) attributable to patient-level factors. CONCLUSIONS Hospital-level guideline adherence for gastric cancer demonstrated significant regional variation and was associated with longer OS, suggesting that efforts to improve guideline adherence should be directed toward lower-performing hospitals.
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Affiliation(s)
- Sarah R Kaslow
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA.
| | - Leena Hani
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Greg D Sacks
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Ann Y Lee
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Russell S Berman
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
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Yap A, Laverde R, Thompson A, Ozgediz D, Ehie O, Mpody C, Vu L. Social vulnerability index (SVI) and poor postoperative outcomes in children undergoing surgery in California. Am J Surg 2023; 225:122-128. [PMID: 36184328 DOI: 10.1016/j.amjsurg.2022.09.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/27/2022] [Accepted: 09/18/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Area-based social determinants of health (SDoH) associated with disparities in children's surgical outcomes are not well understood, though some may be risk factors modifiable by public health interventions. METHODS This retrospective cohort study investigated the effect of high social vulnerability index (SVI), defined as ≥90th percentile, on postoperative outcomes in children classified as ASA 1-2 who underwent surgery at a large institution participating in the National Surgical Quality Improvement Program (2015-2021). Primary outcome was serious postoperative complications, defined as postoperative death, unplanned re-operation, or readmission at 30 days after surgery. RESULTS Among 3278 pediatric surgical procedures, 12.1% had SVI in the ≥90th percentile. Controlling for age, sex, racialization, insurance status, and language preference, serious postoperative complications were associated with high overall SVI (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.02-2.44) and high socioeconomic vulnerability (SVI theme 1, OR 1.75, 95% CI 1.03-2.98). CONCLUSION Neighborhood-level socioeconomic vulnerability is associated with worse surgical outcomes in apparently healthy children, which could serve as a target for community-based intervention.
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Affiliation(s)
- Ava Yap
- University of California San Francisco, Department of Surgery, USA.
| | - Ruth Laverde
- University of California San Francisco, School of Medicine, USA
| | - Avery Thompson
- University of California San Francisco, School of Medicine, USA
| | - Doruk Ozgediz
- University of California San Francisco, Department of Surgery, USA
| | | | - Christian Mpody
- Nationwide Children's Hospital, Department of Anesthesiology and Pain Medicine, USA
| | - Lan Vu
- University of California San Francisco, Department of Surgery, USA
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