Social vulnerability is associated with increased postoperative morbidity following esophagectomy

Social vulnerability and surgery outcomes: a cross-sectional analysis

BACKGROUND

Post-operative complications present a challenge to the healthcare system due to the high unpredictability of their incidence. Socioeconomic conditions have been established as social determinants of health. However, their contribution relating to postoperative complications is still unclear as it can be heterogeneous based on community, type of surgical services, and sex and gender. Uncovering these relations can enable improved public health policy to reduce such complications.

METHODS

In this study, we conducted a large population cross-sectional analysis of social vulnerability and the odds of various post-surgical complications. We collected electronic health records data from over 50,000 surgeries that happened between 2012 and 2018 at a quaternary health center in St. Louis, Missouri, United States and the corresponding zip code of the patients. We built statistical logistic regression models of postsurgical complications with the social vulnerability index of the tract consisting of the zip codes of the patient as the independent variable along with sex and race interaction.

RESULTS

Our sample from the St. Louis area exhibited high variance in social vulnerability with notable rapid increase in vulnerability from the south west to the north of the Mississippi river indicating high levels of inequality. Our sample had more females than males, and females had slightly higher social vulnerability index. Postoperative complication incidence ranged from 0.75% to 41% with lower incidence rate among females. We found that social vulnerability was associated with abnormal heart rhythm with socioeconomic status and housing status being the main association factors. We also found associations of the interaction of social vulnerability and female sex with an increase in odds of heart attack and surgical wound infection. Those associations disappeared when controlling for general health and comorbidities.

CONCLUSIONS

Our results indicate that social vulnerability measures such as socioeconomic status and housing conditions could affect postsurgical outcomes through preoperative health. This suggests that the domains of preventive medicine and public health should place social vulnerability as a priority to achieve better health outcomes of surgical interventions.

Social vulnerability is associated with higher risk-adjusted rates of postoperative complications in a broad surgical population

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.

The Effect of Social Vulnerability on Initial Stage and Treatment for Non-Small Cell Lung Cancer

OBJECTIVE

The Social Vulnerability Index (SVI) is a composite metric for social determinants of health. The objective of this study was to determine if SVI influences stage at presentation for non-small cell lung cancer (NSCLC) patients and subsequent therapies.

MATERIALS AND METHODS

NSCLC patients from our local contribution to the National Cancer Database (2011-2021) were grouped into low SVI (<75 %ile) and high SVI (>75 %ile) cohorts. Demographics, cancer-related variables, and treatment modalities were compared. Multivariable logistic regression was performed to control for the impact of demographics on cancer presentation and for the impact of oncologic variables on treatment outcomes.

RESULTS

Of 1,662 NSCLC patients, 435 (26 %) were defined as high SVI. Compared to the 1,227 (74 %) low SVI patients, highly vulnerable patients were more likely to be male (53.3 % vs 46.0 %, p = 0.009), non-White (17.2 % vs 9.7 %, p < 0.0001), have comorbidities (29.4 % vs 23.1 %, p = 0.009) and present at a higher AJCC clinical T, M and overall stage (all p < 0.05). These findings persisted on multivariable analysis, with highly vulnerable patients having 1.5x the odds (95 %CI: 1.23-1.86, p < 0.001) of presenting at more advanced stage. Patients with high SVI were less likely to be recommended for and receive surgery (40.9 % vs 53.2 %, p < 0.001), and this finding persisted after controlling for stage at presentation (OR 1.37, 95 %CI 1.04-1.80).

CONCLUSIONS

Highly vulnerable patients present at a more advanced clinical stage and are less likely to be recommended and receive surgery, even after controlling for stage at presentation. Further investigation into these findings is warranted to achieve more equitable oncologic care.