Socioeconomic “Distressed Communities Index” Improves Surgical Risk-adjustment

Defect width and operative time are the most significant predictors of venous thromboembolism in ventral hernia repair

BACKGROUND

Venous thromboembolism is a significant cause of morbidity and mortality among patients undergoing ventral hernia repair. Several risk-assessment models have been developed to predict venous thromboembolism risk for various surgical procedures. However, these models do not include hernia-specific risk factors. Therefore, we sought to evaluate the predictors of venous thromboembolism in patients with a ventral hernia repair in a national hernia-specific database.

METHODS

The Abdominal Core Health Quality Collaborative database was retrospectively queried for ventral hernia repair data. The ventral hernia repair procedures were divided into 2 groups on the basis of whether the patients developed perioperative venous thromboembolism. Baseline and operative characteristics and perioperative outcomes were compared between the 2 groups. The logistic regression was used to assess the association between different risk factors and venous thromboembolism.

RESULTS

A total of 43,558 patients were included in the study. The 30-day venous thromboembolism rate among these patients was 0.62% (n = 269). Venous thromboembolism was associated with greater 30-day readmission (odds ratio, 4.29; 95% confidence interval, 3.20-5.76), reoperation (odds ratio, 3.97, 95% confidence interval, 2.63-6.00), and mortality rates (odds ratio, 5.95, 95% confidence interval, 2.62-13.48), all P < .001. Bivariate analysis identified a statistically significant association between several patient characteristics, operation, and hernia- related details; however, multivariate analysis revealed that that only hernia width (each increasing centimeter: odds ratio, 1.07, 95% CI, 1.05-1.09) and operative time compared with 0-59 minutes (60-119 minutes: odds ratio, 4.23; 95% confidence interval, 1.86-9.62; 120-179 minutes: odds ratio, 5.78; 95% confidence interval, 2.57-13.0; 180-239 minutes: odds ratio, 8.01; 95% confidence interval, 3.54-18.10; and 240+ minutes: odds ratio, 17.4; 95% confidence interval, 7.88-38.37) were significantly associated with venous thromboembolism risk.

CONCLUSIONS

Venous thromboembolism is an uncommon complication of ventral hernia repair. It is associated with increased readmission, reoperation, and mortality rates. Larger defect width and operative time are most predictive of perioperative venous thromboembolism risk for patients undergoing ventral hernia repair.

Social Vulnerability and Peri-Operative Outcomes after Colectomy for Colon Cancer

BACKGROUND

The Social Vulnerability Index (SVI) has previously been demonstrated to correlate with worse postoperative outcomes after surgery, but the association of SVI with short- and long-term outcomes after colon cancer surgery has been underexplored.

METHODS

This is a retrospective cross-sectional study of Medicare patients aged 65-99 years who underwent colectomy for colon cancer between 2016 and 2020, merged with SVI at the census tract level. We tested the association between SVI with emergent colectomy and 30-day and 1-year mortality using a multivariable logistic regression model adjusted for patient demographics and hospital characteristics.

RESULTS

The cohort included 169,498 patients who underwent colectomy for colon cancer. Medicare patients living in areas in the highest quintile of social vulnerability were more likely to undergo unplanned colectomy for colon cancer compared to those in the lowest quintile (35.6% vs. 28.9%; adjusted odds ratio (aOR) 1.36 [95% CI 1.31-1.41], p<0.001). Similarly, patients living in areas in the highest quintile of social vulnerability experienced higher risk-adjusted rates of 30-day mortality (3.4% vs 2.9%; aOR 1.20 [1.12, 1.29], p<0.001), and 1-year mortality (10.8% vs 8.6%, aOR 1.30 [1.22, 1.37], p<0.001) as compared to patients living in the lowest quintile of social vulnerability. When evaluating the elective and unplanned cohorts separately, these differences persisted.

CONCLUSION

Among Medicare patients undergoing colectomy for colon cancer, high social vulnerability was associated with an increased risk of unplanned operations and worse short- and long-term postoperative outcomes in both the emergent and elective settings. Providers should seek to mitigate disparate surgical outcomes by addressing structural inequities in social resources.

Factors contributing to telemedicine efficacy in pediatric urology

INTRODUCTION

Despite swift implementation of telemedicine with the coronavirus disease 2019 pandemic, there is a paucity of research on its use for management of pediatric urology patients. Specifically, there is limited knowledge and inconsistent data on the effectiveness of telemedicine for various pediatric urologic conditions. Our aim was to evaluate the efficacy of pediatric urological care provided via video visits (VVs) at a large tertiary care children's hospital.

MATERIAL AND METHODS

We performed a prospective assessment of pediatric urology patients younger than 21 years who had a VV between 5/18/2022 and 5/17/2023. New patients with a testicular diagnosis were not eligible for VVs. After entering the diagnosis and submitting billing using a modifier for telemedicine, clinicians were mandated to select whether the VV allowed for: complete case management (CCM), suboptimal case management (SCM), or incomplete case management (ICM) requiring an in-person visit. Case management categorizations were analyzed according to patient pathology, visit type (i.e., new or established), and patient-centered variables including age, sex, race, insurance type, need for an interpreter, and distress score [a proxy for socioeconomic status].

RESULTS

During the one-year period, there were 3267 telemedicine patients with a median age of 9 years (IQR 3-13) and 57.0% were male. Most VVs (89.3%) were established encounters. Almost 12% of telemedicine patients had external organ pathology (EOP, e.g., phimosis), 43.0% had internal organ pathology (IOP, e.g., hydronephrosis), and 45.1% had functional urological pathology (FUP, e.g., dysfunctional voiding). Clinicians deemed 96.9%, 2.7%, and 0.5% of VVs as having CCM, SCM or ICM, respectively. Telemedicine patients with IOP or FUP were more likely to have CCM, than those with EOP (98.5% and 97.8% vs 87.1%, p < 0.0001). On multivariable analysis, patient age, pathology, and visit type were predictive of VV efficacy.

DISCUSSION

Now that telemedicine use has slowed, it is necessary to evaluate and establish its optimal role in pediatric urology. Factors associated with VV efficacy included older patient age, internal organ or functional urological pathology, and established encounters. The long-term success of telemedicine requires suitable patient selection.

CONCLUSIONS

Telemedicine is quite effective for the management of a wide variety of pediatric urology patients. Continued evaluation of telemedicine, including multi-institutional investigation and corroboration, is necessary for the development of evidence-based best practice guidelines regarding appropriate, safe, and effective integration of telemedicine that drives pediatric urological care forward to meet the demands of the future.

The effects of socioeconomic status on complex ventral hernia repair operative decision-making and outcomes

BACKGROUND

Patients from low socioeconomic backgrounds have greater rates of morbidity and mortality across disease processes. The Distressed Communities Index identified several socioeconomic components that were used to create a Distressed Communities Index score for every ZIP code, then broken into quintiles from prosperous to distressed. We aimed to explore whether socioeconomic distress as defined by the Distressed Communities Index affects the outcome of complex ventral hernia repair in the elderly population.

METHODS

Retrospective analysis was performed using the Abdominal Core Health Collaborative data. Included were adults aged 65+ years undergoing elective complex ventral hernia repair from 2013 to 2021. Primary outcomes were postoperative outcomes and composite hernia recurrence by Distressed Communities Index quintile. The Cox proportional hazards model was used for composite recurrence, and logistic regression was used for postoperative outcomes.

RESULTS

A total of 4,172 patients were included. Patients in distressed communities were more likely to identify as female or racial minority and had greater body mass index and American Society of Anesthesiologists class. Lower Distressed Communities Index quintile was associated with larger hernia (P = .012), open repair (P = .019), and 30-day complication (P = .05). There was no association between time to recurrence and Distressed Communities Index quintile (P = .24). After adjusted analysis, there was no significant difference for readmission, reoperation, recurrence, and complications.

CONCLUSION

Patients from more distressed communities presented in worse clinical status with larger hernias. This likely contributed to greater rates of open repair and complications. However, when adjusted for these variables, outcomes were similar across Distressed Communities Index quintile. This supports the efficacy of complex hernia repair across socioeconomic classes.

The relationship between neighborhood socioeconomic status and short-term outcomes following colon resection

BACKGROUND

This study investigates the association between neighborhood socioeconomic status, measured by the Distressed Communities Index (DCI), and short-term outcomes following colon resection.

METHODS

Utilizing the Maryland State Inpatient Sample database (SID 2018-2020), we determined the association between DCI and post-op outcomes following colon resection including length of stay, readmissions, 30-day in-hospital mortality, and non-routine discharges. Multivariate regression analysis was performed to control for potential confounding factors.

RESULTS

Of the 13,839 patients studied, median age was 63, with 54.3 ​% female and 64.5 ​% elective admissions. Laparoscopic surgery was performed in 36.9 ​% cases, with a median hospital stay of 5 days. Patients in distressed communities faced higher risks of emergency admission (OR: 1.31), prolonged hospitalization (OR: 1.29), non-routine discharges (OR: 1.36), and readmission (OR: 1.33). Black patients had longer stays than White patients (OR: 1.3). Despite adjustments, in-hospital mortality did not significantly differ among neighborhoods.

CONCLUSION

Our study reveals that patients residing in distressed neighborhoods face a higher risk of prolonged hospitalization, non-routine discharges, and readmission rate after colon resection.

High Community-Level Social Vulnerability is Associated with Worse Recurrence-Free Survival (RFS) After Resection of Extremity and Truncal Soft Tissue Sarcoma

BACKGROUND

Although social vulnerability has been associated with worse postoperative and oncologic outcomes in other cancer types, these effects have not been characterized in patients with soft tissue sarcoma. This study evaluated the association of social vulnerability and oncologic outcomes.

METHODS

The authors conducted a single-institution cohort study of adult patients with primary and locally recurrent extremity or truncal soft tissue sarcoma undergoing resection between January 2016 and December 2021. The social vulnerability index (SVI) was measured on a low (SVI 1-39%, least vulnerable) to high (60-100%, most vulnerable) SVI scale. The association of SVI with overall survival (OS) and recurrence-free survival (RFS) was evaluated by Kaplan-Meier analysis and Cox proportional hazard regression.

RESULTS

The study identified 577 patients. The median SVI was 44 (interquartile range [IQR], 19-67), with 195 patients categorized as high SVI and 265 patients as low SVI. The median age, tumor size, histologic subtype, grade, comorbidities, stage, follow-up time, and perioperative chemotherapy and radiation utilization were similar between the high and low SVI cohorts. The patients with high SVI had worse OS (p = 0.07) and RFS (p = 0.016) than the patients with low SVI. High SVI was independently associated with shorter RFS in the multivariate analysis (hazard ratio, 1.64; 95% confidence interval, 1.06-2.54) but not with OS (HR, 1.47; 95% CI 0.84-2.56).

CONCLUSION

High community-level social vulnerability appears to be independently associated with worse RFS for patients undergoing resection of extremity and truncal soft tissue sarcoma. The effect of patient and community-level social risk factors should be considered in the treatment of patients with extremity sarcoma.

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.

Impact of Community Socioeconomic Distress on Survival Following Heart Transplantation

OBJECTIVE

The aim of this study was to assess the impact of community-level socioeconomic deprivation on survival outcomes following heart transplantation.

BACKGROUND

Despite growing awareness of socioeconomic disparities in the US health care system, significant inequities in outcomes remain. While recent literature has increasingly considered the effects of structural socioeconomic deprivation, the impact of community socioeconomic distress on outcomes following heart transplantation has not yet been elucidated.

METHODS

All adult heart transplant recipients from 2004 to 2022 were ascertained from the Organ Procurement and Transplantation Network. Community socioeconomic distress was assessed using the previously validated Distressed Communities Index, a metric that represents education level, housing vacancies, unemployment, poverty rate, median household income, and business growth by zip code. Communities in the highest quintile were considered the Distressed cohort (others: Non-Distressed ). Outcomes were considered across 2 eras (2004-2018 and 2019-2022) to account for the 2018 UNOS Policy Change. Three- and 5-year patient and graft survival were assessed using Kaplan-Meier and Cox proportional hazards models.

RESULTS

Of 36,777 heart transplants, 7450 (20%) were considered distressed . Following adjustment, distressed recipients demonstrated a greater hazard of 5-year mortality from 2004 to 2018 [hazard ratio (HR)=1.10, 95% confidence interval (CI): 1.03-1.18; P =0.005] and 3-year mortality from 2019 to 2022 (HR=1.29, 95% CI: 1.10-1.51; P =0.002), relative to nondistressed . Similarly, the distressed group was associated with increased hazard of graft failure at 5 years from 2004 to 2018 (HR=1.10, 95% CI: 1.03-1.18; P =0.003) and at 3 years from 2019 to 2022 (HR=1.31, 95% CI: 1.11-1.53; P =0.001).

CONCLUSIONS

Community-level socioeconomic deprivation is linked with inferior patient and graft survival following heart transplantation. Future interventions are needed to address pervasive socioeconomic inequities in transplantation outcomes.

Orthopaedic Sports Medicine Randomized Controlled Trials Infrequently Report on the Social Determinants of Health Factors of Their Patient Cohorts

PURPOSE

To describe the prevalence of randomized controlled trials (RCTs) in orthopaedic sports medicine-related journals reporting on the social determinants of health (SDOH) of their patient cohorts, including factors receiving less attention, such as education level, employment status, insurance status, and socioeconomic status.

METHODS

The PubMed/MEDLINE database was used to search for RCTs between 2020 and 2022 from 3 high-impact orthopaedic sports medicine-related journals: American Journal of Sports Medicine, Arthroscopy, and Journal of Shoulder and Elbow Surgery. The following information was extracted from each article: age, sex/gender, body mass index, year published, corresponding author country, and self-reported SDOH factors (race, ethnicity, education level, employment status, insurance status, and socioeconomic status).

RESULTS

A total of 189 articles were analyzed. Articles originated from 34 different countries, with the United States (n = 66) producing the greatest number of articles. Overall, age (n = 186; 98.4%) and sex/gender (n = 184; 97.4%) were the factors most commonly reported, followed by body mass index (n = 112; 59.3%), race (n = 17; 9.0%), ethnicity (n = 10; 5.3%), employment status (n = 9; 4.8%), insurance status (n = 7; 3.7%), and education level (n = 5; 2.6%). Socioeconomic status was not reported in any of the articles analyzed. Articles from the United States report on SDOH factors more frequently than international articles, most notably race (24.2% vs 0.8%, respectively) and ethnicity (15.2% and 0%, respectively).

CONCLUSIONS

RCTs from 3 high-impact orthopaedic sports medicine journals infrequently report on SDOH.

CLINICAL RELEVANCE

Better understanding patient SDOH factors in RCTs is important to help orthopaedic surgeons and other practitioners best apply study results to their patients, as well as help researchers and our field ensure that research is being done transparently with relevance to as many patients as possible.

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.

Area Deprivation Index Predicts Mortality for Critically Ill Surgical Patients With Sepsis

Background: The impact of socioeconomic status on outcomes after sepsis has been challenging to define, and no polysocial metric has been shown to predict mortality in sepsis. The primary objective of this study was to evaluate the association between the Area Deprivation Index (ADI) and mortality in patients admitted to the surgical intensive care unit (SICU) with sepsis. Patients and Methods: All patients admitted to the SICU with sepsis (Sequential Organ Failure Assessment [SOFA] score ≥2) were retrospectively reviewed. The ADI scores were obtained and classified as "high ADI" (≥85th percentile, n = 400, representative of high socioeconomic deprivation) and "control ADI" (ADI <85th percentile, n = 976). Baseline demographic and clinical characteristics were compared between groups. The primary outcome was 90-day mortality. Results: High ADI patients were younger (mean age 58.5 vs. 60.8; p = 0.01) and more likely to be non-white (23.7% vs. 10.0%; p < 0.0005) and to present with chronic obstructive pulmonary disease (26.5% vs. 19.0%; p = 0.002). High ADI patients had increased in-hospital (27.3% vs. 21.6%; p = 0.025) and 90-day mortality (35.0% vs. 28.9%; p = 0.03). High ADI patients also had increased rates of renal failure (20.3% vs. 15.3%; p = 0.02). Both cohorts had similar intensive care unit (ICU) lengths of stay and median hospital stay, Charlson comorbidity index, and rate of discharge to home. High ADI is an independent risk factor for 90-day mortality after admission for surgical sepsis (odds ratio [OR], 1.39 ± 0.24; p = 0.014). Conclusions: High ADI is an independent predictor of 90-day mortality in patients with surgical sepsis. Targeted community interventions are needed to reduce sepsis mortality for these at-risk patients.

Gender, racial, and socioeconomic disparity of preoperative optimization goals in ventral hernia repair

BACKGROUND

Preoperative optimization cut-offs are frequently utilized to determine eligibility for elective ventral hernia repair. Our objective was to assess the relationship between gender, race, and socioeconomic status and preoperative optimization goals.

METHODS

We queried our institutional database for adults with ventral hernia diagnoses between 2016 and 2021. Demographics, comorbidities, laboratory, and operative data were collected and analyzed. The following cut-offs were used to determine eligibility for elective repair: body mass index (BMI) < 40 kg/m2, no active smoking, and glycated hemoglobin (HbA1c) < 8%. Socioeconomic status was assessed using the Distressed Communities Index.

RESULTS

A total of 5638 patients were included [Whites = 4321 (77%), Blacks = 794 (14%), Hispanics = 318 (6%), and other/unknown 205 (4%)]. Median age was 61 years and 50% were male. Most common hernia types were umbilical (36%) and incisional (20%). 10% had BMI > 40 kg/m2, 9% were active smokers and 4% had HbA1c > 8%. 21% of all patients did not meet the preoperative optimization cut-offs at time of diagnosis and those were less likely to undergo hernia repair during the study timeframe compared to those who did (OR 0.50; 95% CI [0.42-0.60]). There was a higher proportion of females (21%) and Blacks (22%) with BMI > 40 kg/m2 compared to males (11%) and other races (11-15%), p = 0.002. As the level of socioeconomic distress increased, there was a corresponding increase in the proportion of patients who did not meet preoperative optimization cut-offs from 16% in prosperous communities to 25% in distressed communities (p < 0.0001).

CONCLUSION

Nearly 1 of 5 patients with ventral hernias is affected by commonly used arbitrary preoperative optimization cut-offs. These cut-offs disproportionately impact females, Black patients and those with higher socioeconomic distress. These disparities need to be considered when planning preoperative optimization protocols and resource allocation to ensure equitable access to elective ventral hernia repair.

Machine Learning Analysis of Postlaparoscopy Hernias and "I'm Leaving You to Close" Strategy

INTRODUCTION

Contributing factors to postlaparoscopy hernia are unknown. We hypothesized that postlaparoscopy incisional hernias are increased when the index surgery was performed in teaching hospitals. Laparoscopic cholecystectomy was chosen as the archetype for open umbilical access.

MATERIALS AND METHODS

Maryland and Florida SID/SASD databases (2016-2019) wereused to track 1-year hernia incidence in both inpatient and outpatient settings, which was then linked to Hospital Compare, Distressed Communities Index (DCI), and ACGME. Postoperative umbilical/incisional hernia following laparoscopic cholecystectomy was identified using CPT and ICD-10. Propensity matching and eight machine learning modes were utilized including logistic regression, neural network, gradient boosting machine, random forest, gradient boosted trees, classification and regression trees, k nearest neighbors and support vector machines.

RESULTS

Postoperative hernia incidence was 0.2% (total = 286; 261 incisional and 25 umbilical) in 117,570 laparoscopic cholecystectomy cases. Days to presentation (mean ± SD) were incisional 141 ± 92 and umbilical 66 ± 74. Logistic regression performed best (AUC 0.75 (95% ci 0.67-0.82) and accuracy 0.68 (95% ci 0.60-0.75) using 10-fold cross validation) in propensity matched groups (1:1; n = 279). Postoperative malnutrition (OR 3.5), hospital DCI of comfortable, mid-tier, at risk or distressed (OR 2.2 to 3.5), LOS >1 d (OR 2.2), postop asthma (OR 2.1), hospital mortality below national average (OR 2.0) and emergency admission (OR 1.7) were associated with increased hernias. A decreased incidence was associated with patient location of small metropolitan areas with <1 million residents (OR 0.5) and Charlson Comorbidity Index-Severe (OR 0.5). Teaching hospitals were not associated with postoperative hernia after laparoscopic cholecystectomy.

CONCLUSIONS

Different patient factors as well as underlying hospital factors are associated with postlaparoscopy hernias. Performance of laparoscopic cholecystectomy at teaching hospitals is not associated with increased postoperative hernias.

Causal analysis of socioeconomic influence on cost of care: The emergency general surgery model

BACKGROUND

This study characterizes the relationship between SES and cost of emergency general surgery (EGS).

METHODS

Utilizing Florida AHCA (2016-2020), patients undergoing the 7 most common EGS were identified. Distressed Community Index (DCI) was linked, which quantifies SES through unemployment, poverty, and other factors. Zipcodes are assigned DCI 0 (no distress) to 100 (severe distress). Linear regression with stepwise elimination was conducted. Top and bottom DCI quintiles were propensity matched for demographics, comorbidities, and procedure.

RESULTS

144,924 admissions were included. Linear regression eliminated 5 of 28 variables, including DCI. Top cost contributors were discharge-43%; comorbidities-14%; age-9%. Distressed patients received less home health and inpatient rehab. Distressed patients utilized 4-/5-star hospitals less and had higher odds of mortality.

CONCLUSION

Discharge, mortality, and hospital characteristics differ significantly between DCI communities. Total cost was similar, and is strongly influenced by discharge status, while DCI had no effect.

Characterizing digital access in pediatric urology

BACKGROUND

Virtual medicine has the potential to improve access for underserved populations by facilitating timely remote evaluation. However, challenges in the real-world implementation of this technology may paradoxically exacerbate health disparities. We sought to characterize families' digital access and how social determinants of health may impact virtual medicine access within pediatric urology. We hypothesized that disadvantaged socioeconomic status would be a barrier to virtual medicine access.

STUDY DESIGN

A digital access screening tool was prospectively developed and launched in July 2021. Schedulers are prompted to complete this optional screening questionnaire at the time of patient intake, for video or in-person encounters. The parent is screened for access to a device and reliable internet or cellular data that could be used to participate in a video visit. These represented the primary study outcomes. A modality preference for an in-person visit, video visit, or no preference was also recorded. Patient demographics were retrospectively evaluated, and socioeconomic status was estimated using the Distressed Communities Index generated for each patient's zip code. For each zip code, the Distressed Communities Index produces a normalized, comparative distress score ranging from 0 ("prosperous") to 100 ("distressed").

RESULTS

3885 patients were included, with median age of 5 years (IQR 1-11). Almost 74% were male, 71.3% were White, 20.9% had public insurance, and 2.9% required an interpreter. The median distress score was 14.2 (IQR 7.2-27.5). Screening revealed that 136 families (3.5%) lacked digital access. On multivariable logistic regression analysis, insurance type (p = 0.0020) and distress score (p = 0.0125) were significant predictors of digital access (Summary Table). Those patients who lacked access to a device (p < 0.0001) or reliable internet/cellular data (p < 0.0001) were more likely to prefer an in-person visit.

DISCUSSION

Family screening revealed that there is a small but significant proportion of families who lack digital access, and this cohort disproportionately represents underserved communities with higher distress scores, likely reflecting lower socioeconomic status. Those families without digital access were more likely to prefer an in-person visit. Improved identification of these socially complex "at-risk" patients can assist in the development of more inclusive health care strategies.

CONCLUSIONS

Despite the chance for virtual medicine to expand access for underserved populations, lack of digital tools may hinder its potential impact on health disparities in pediatric urology. Ongoing digital access screening and further studies are needed to design interventions tailored to the specific needs of our patients, allowing for more equitable pediatric urological care.

Race, Class, and Place Modify Mortality Rates for the Leading Causes of Death in the United States, 1999-2021

BACKGROUND

Race and ethnicity, socioeconomic class, and geographic location are well-known social determinants of health in the US. Studies of population mortality often consider two, but not all three of these risk factors.

OBJECTIVES

To disarticulate the associations of race (whiteness), class (socioeconomic status), and place (county) with risk of cause-specific death in the US.

DESIGN

We conducted a retrospective analysis of death certificate data. Bayesian regression models, adjusted for age and race/ethnicity from the American Community Survey and the county Area Deprivation Index, were used for inference.

MAIN MEASURES

County-level mortality for 11 leading causes of death (1999-2019) and COVID-19 (2020-2021).

KEY RESULTS

County "whiteness" and socioeconomic status modified death rates; geospatial effects differed by cause of death. Other factors equal, a 20% increase in county whiteness was associated with 5-8% increase in death from three causes and 4-15% reduction in death from others, including COVID-19. Other factors equal, advantaged counties had significantly lower death rates, even when juxtaposed with disadvantaged ones. Patterns of residual risk, measured by spatial county effects, varied by cause of death; for example: cancer and heart disease death rates were better explained by age, socioeconomic status, and county whiteness than were COVID-19 and suicide deaths.

CONCLUSIONS

There are important independent contributions from race, class, and geography to risk of death in the US.

The long weight: association between distressed communities index and long-term weight outcomes following bariatric surgery

BACKGROUND

Socioeconomic status (SES) is multifactorial, and its effect on post-bariatric weight recurrence is unclear. Distressed Community Index (DCI) is a composite SES score measuring community economic well-being. This study aims to evaluate the effect of DCI on long-term post-bariatric weight outcomes.

METHODS

Retrospective analysis of patients undergoing primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between 2015 and 2020 was performed. All weights in the electronic medical record (EMR), including non-bariatric visits, were captured. Patients were stratified into low tier (LT) and high tier (HT) DCI groups.

RESULTS

Of 583 patients, 431 (73.9%) were HT and 152 (26.1%) were LT. Average bariatric follow up was 1.78 ± 1.6 years and average postoperative weight in the EMR was 3.96 ± 2.26 years. Rates of bariatric follow up within the last year were similar (13.8% LT vs 16.2% HT, p = 0.47). LT had higher percent total body weight loss (%TWL; 26% LT vs 23% HT, p < 0.01) and percent excess weight loss (%EWL; 62% vs 57%, p = 0.04) at 1 year on univariate analysis. On multivariate linear regression adjusting for baseline characteristics and surgery type, there were no differences in %EWL between groups at 1 year (p = 0.22), ≥ 3 years (p = 0.53) or ≥ 5 years (p = 0.34) postop. While on univariate analysis LT only trended towards greater percentage of patients with > 15% increase from their 1-year weight (33.3% LT vs 21.0% HT, p = 0.06), on multivariate analysis this difference was significant (OR 2.0, LT 95%CI 1.41-2.84). There were no differences in the percentage of patients with > 15% decrease in %EWL from 1 to 3 + years postop between groups (OR 0.98, LT 95% CI 0.72-1.35).

CONCLUSIONS

While low tier patients had similar weight loss at 1 year, they were twice as likely to have weight recurrence at ≥ 3 years. Further studies are needed to identify factors contributing to greater weight recurrence among this population.

Disparities in anterior cervical discectomy and fusion provision and outcomes for cervical stenosis

Background

Disparities in neurosurgical care have emerged as an area of interest when considering the impact of social determinants on access to health care. Decompression via anterior cervical discectomy and fusion (ACDF) for cervical stenosis (CS) may prevent progression towards debilitating complications that may severely compromise one's quality of life. This retrospective database analysis aims to elucidate demographic and socioeconomic trends in ACDF provision and outcomes of CS-related pathologies.

Methods

The Healthcare Cost and Utilization Project National Inpatient Sample database was queried between 2016 and 2019 using International Classification of Diseases 10th edition codes for patients undergoing ACDF as a treatment for spinal cord and nerve root compression. Baseline demographics and inpatient stay measures were analyzed.

Results

Patients of White race were significantly less likely to present with manifestations of CS such as myelopathy, plegia, and bowel-bladder dysfunction. Meanwhile, Black patients and Hispanic patients were significantly more likely to experience these impairments representative of the more severe stages of the degenerative spine disease process. White race conferred a lesser risk of complications such as tracheostomy, pneumonia, and acute kidney injury in comparison to non-white race. Insurance by Medicaid and Medicare conferred significant risks in terms of more advanced disease prior to intervention and negative inpatient. Patients in the highest quartile of median income consistently fared better than patients in the lowest quartile across almost every aspect ranging from degree of progression at initial presentation to incidence of complications to healthcare resource utilization. All outcomes for patients age > 65 were worse than patients who were younger at the time of the intervention.

Conclusions

Significant disparities exist in the trajectory of CS and the risks associated with ACDF amongst various demographic cohorts. The differences between patient populations may be reflective of a larger additive burden for certain populations, especially when considering patients' intersectionality.

Area Deprivation Index and Distress Community Index Scores Are Not Associated With Short-Term and Long-Term Extracorporeal Life Support Outcomes

Distressed Communities Index (DCI) and Area Deprivation Index (ADI) are two composite ranking scores that report community level socioeconomic status (SES) by ZIP codes. The objective of this study was to evaluate the impact of SES as estimated by DCI and ADI scores on short-term and long-term outcomes after extracorporeal life support (ECLS) at a quaternary medical center. All patients on ECLS between January 1, 2015 and August 31, 2020 (N = 428) at Vanderbilt University Medical Center in Nashville, Tennessee, had their ADI and DCI scores calculated. Primary outcome was mortality during index hospitalization, and secondary outcome was survival to end of study follow-up. There was no significant difference in primary outcome between the top 25% ADI vs . bottom 75% ADI (53.8% vs . 50.6%; p = 0.56) or between top 25% DCI vs . bottom 75% DCI (56.1 vs . 49.2; p = 0.21). Adjusted odds ratio for the primary outcome with ADI and DCI was 1.13 (95% CI, 0.63-2.0; p = 0.67) and 1.28 (95% CI, 0.70-2.34; p = 0.41), respectively. Additionally, there was no significant difference in long-term survival curves based on their ADI or DCI scores. In conclusion, SES as estimated by baseline DCI and ADI scores does not appear to impact short- or long-term survival post-ECLS at a large volume center. http://links.lww.com/ASAIO/A951.

Racial Differences in Presentation and Outcomes After Peripheral Arterial Interventions: Insights From the NCDR-PVI Registry

BACKGROUND

We assess the rates of device use and outcomes by race among patients undergoing lower extremity peripheral arterial intervention using the American College of Cardiology National Cardiovascular Data Registry-Peripheral Vascular Intervention (PVI) registry.

METHODS

Patients who underwent PVI between April 2014 and March 2019 were included. Socioeconomic status was evaluated using the Distressed Community Index score for patients' zip codes. Multivariable logistic regression was used to assess factors associated with utilization of drug-eluting technologies, intravascular imaging, and atherectomy. Among patients with Centers for Medicare and Medicaid Services data, we compared 1-year mortality, rates of amputation, and repeat revascularizations.

RESULTS

Of 63 150 study cases, 55 719 (88.2%) were performed in White patients and 7431 (11.8%) in Black patients. Black patients were younger (67.9 versus 70.0 years), had higher rates of hypertension (94.4% versus 89.5%), diabetes (63.0% versus 46.2%), less likely to be able to walk 200 m (29.1% versus 24.8%), and higher Distressed Community Index scores (65.1 versus 50.6). Black patients were provided drug-eluting technologies at a higher rate (adjusted odds ratio, 1.14 [95% CI, 1.06-1.23]) with no difference in atherectomy (adjusted odds ratio, 0.98 [95% CI, 0.91-1.05]) or intravascular imaging (adjusted odds ratio, 1.03 [95% CI, 0.88-1.22]) use. Black patients experienced a lower rate of acute kidney injury (adjusted odds ratio, 0.79 [95% CI, 0.72-0.88]). In Centers for Medicare and Medicaid Services-linked analyses of 7429 cases (11.8%), Black patients were significantly less likely to have surgical (adjusted hazard ratio, 0.40 [95% CI, 0.17-0.96]) or repeat PVI revascularization (adjusted hazard ratio, 0.42 [95% CI, 0.30-0.59]) at 1 year compared with White patients. There was no difference in mortality (adjusted hazard ratio [0.8-1.4]) or major amputation (adjusted hazard ratio, 2.5 [95% CI, 0.8-7.6]) between Black and White patients.

CONCLUSIONS

Black patients presenting for PVI were younger, had higher prevalence of comorbidities and lower socioeconomic status. After adjustment, Black patients were less likely to have surgical or repeat PVI revascularization after the index PVI procedure.

Transition-of-care program from emergency department to gastroenterology clinics improves follow-up

OBJECTIVES

Patients discharged from the emergency department (ED) with gastrointestinal (GI) symptoms need to appropriately transition their care to a GI outpatient clinic in a timely manner to have their health needs met and avoid significant morbidity. When this transition isn't optimal, patients are lost to follow-up, potentially placing them at risk for adverse events. We sought to study the effectiveness of implementing an electronic medical record (EMR) based transition-of-care (TOC) program from the ED to outpatient GI clinics.

METHODS

We performed a retrospective single center cohort study of patients discharged from the ED of a tertiary care academic medical center referred to outpatient GI clinic before (Pre-TOC patients) and after implementation of an EMR based TOC program (TOC patients). We further stratified patients based on the Distressed Communities Index (DCI), which is a composite measure of economic well-being. We compared rates of appointment scheduling and appointment attendance between the two groups, as well as 30-day readmission rates to the ED. We also performed a subgroup analysis to determine if socioeconomic status would affect patient follow-up rates.

RESULTS

We included 380 Pre-TOC and 399 TOC patients in our analysis. TOC patients were found to both schedule appointments (50% vs 27% p-value <0.01) as well as show up to appointments (34% vs 24% p-value <0.01) at significantly higher rates compared to Pre-TOC patients. There was no significant difference between 30-day readmission rates between the two groups. In addition, TOC patients from At-Risk and Distressed Communities were over 22 times more likely to schedule an appointment compared to Pre-TOC patients from similar neighborhoods (OR 22.18, 95% CI 4.23-116.32).

CONCLUSION

Our study shows that patients who are discharged from the ED with outpatient GI follow-up are more likely to both schedule and show up to appointments with implementation of an EMR-based direct referral program compared to no patient navigation, particularly among patients of lower socioeconomic status.

Socioeconomic Distress Associated With Increased Use of Percutaneous Coronary Intervention Over Coronary Artery Bypass Grafting

BACKGROUND

The influence of socioeconomic determinants of health on choice of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) for coronary artery disease is unknown. We hypothesized that higher Distressed Communities Index (DCI) scores, a comprehensive socioeconomic ranking by zip code, would be associated with more frequent PCI.

METHODS

All patients undergoing isolated CABG or PCI in a regional American College of Cardiology CathPCI registry and The Society of Thoracic Surgeons database (2018-2021) were assigned DCI scores (0 = no distress, 100 = severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. Patients who presented with ST-segment elevation myocardial infarction or emergent procedures were excluded. The most distressed quintile (DCI ≥80) was compared with all other patients. Multivariable logistic regression analyzed the association between DCI and procedure type.

RESULTS

A total of 23 223 patients underwent either PCI (n = 16 079) or CABG (n = 7144) for coronary artery disease across 28 centers during the study period. Before adjustment, high socioeconomic distress occurred more frequently among CABG patients (DCI ≥80, 12.4% vs 8.42%; P < .001). After multivariable adjustment, high socioeconomic distress was associated with greater odds of receiving PCI, relative to CABG (odds ratio 1.26; 95% CI, 1.07-1.49; P = .007). High socioeconomic distress was significantly associated with postprocedural mortality (odds ratio 1.52; 95% CI, 1.02-2.26; P = .039).

CONCLUSIONS

High socioeconomic distress is associated with greater risk-adjusted odds of receiving PCI, relative to CABG, as well as higher postprocedural mortality. Targeted resource allocation in high DCI areas may help eliminate barriers to CABG.

National Documentation and Coding Practices of Noncompliance: The Importance of Social Determinants of Health and the Stigma of African-American Bias

Patient records serve many purposes, one of which includes monitoring the quality of care provided that they can be analyzed through coding and documentation. Z-codes can provide additional information beyond a specific clinical disorder that may still warrant treatment. Social Determinants of Health have specific Z-codes that may help clinicians address social factors that may contribute to patients' health care outcomes. However, there are Z-codes that specify patient noncompliance which has a pejorative connotation that may stigmatize patients and prevent clinicians from examining nonadherence from a social determinant of health perspective. A retrospective cross-sectional study was performed to examine the associations of patient and encounter characteristics with the coding of patient noncompliance. Included in the study were all patients >18 years of age who were admitted to hospitals participating in the Vizient Clinical Data Base (CDB) between January 1, 2019 and December 31, 2019. Almost 9 million US inpatients were included in the study. Of those, 6.3% had a noncompliance Z-code. Use of noncompliance Z-codes was associated with the following odds estimate ratio in decreasing order: the presence of a social determinant of health (odds ratio [OR], 4.817), African American race (OR, 2.010), Medicaid insurance (OR, 1.707), >3 chronic medical conditions (OR, 1.546), living in an economically distressed community (OR, 1.320), male gender (OR, 1.313), nonelective admission status (OR, 1.245), age <65 years (OR, 1.234). More than 1 in 15 patient hospitalizations had a noncompliance code. Factors associated with these codes are difficult, if not impossible, for patients to modify. Disproportionate representation of Africa-Americans among hospitalizations with noncompliance coding is concerning and urgently deserves further exploration to determine the degree to which it may be a product of clinician bias, especially if the term noncompliance prevents health care providers from looking into socioeconomic factors that may contribute to patient nonadherence.

Independent Associations of Neighborhood Deprivation and Patient-level Social Determinants of Health with Textbook Outcomes after Inpatient Surgery

Objective

Assess associations of Social Determinants of Health (SDoH) using Area Deprivation Index (ADI), race/ethnicity and insurance type with Textbook Outcomes (TO).

Summary Background Data

Individual- and contextual-level SDoH affect health outcomes, but only one SDoH level is usually included.

Methods

Three healthcare system cohort study using National Surgical Quality Improvement Program (2013-2019) linked with ADI risk-adjusted for frailty, case status and operative stress examining TO/TO components (unplanned reoperations, complications, mortality, Emergency Department/Observation Stays and readmissions).

Results

Cohort (34,251 cases) mean age 58.3 [SD=16.0], 54.8% females, 14.1% Hispanics, 11.6% Non-Hispanic Blacks, 21.6% with ADI>85, and 81.8% TO. Racial and ethnic minorities, non-Private insurance, and ADI>85 patients had increased odds of urgent/emergent surgeries (aORs range: 1.17-2.83, all P<.001). Non-Hispanic Black patients, ADI>85 and non-Private insurances had lower TO odds (aORs range: 0.55-0.93, all P<.04), but ADI>85 lost significance after including case status. Urgent/emergent versus elective had lower TO odds (aOR=0.51, P<.001). ADI>85 patients had higher complication and mortality odds. Estimated reduction in TO probability was 9.9% (CI=7.2%-12.6%) for urgent/emergent cases, 7.0% (CI=4.6%-9.3%) for Medicaid, and 1.6% (CI=0.2%-3.0%) for non-Hispanic Black patients. TO probability difference for lowest-risk (White-Private-ADI≤85-elective) to highest-risk (Black-Medicaid-ADI>85-urgent/emergent) was 29.8% for very frail patients.

Conclusion

Multi-level SDoH had independent effects on TO, predominately affecting outcomes through increased rates/odds of urgent/emergent surgeries driving complications and worse outcomes. Lowest-risk versus highest-risk scenarios demonstrated the magnitude of intersecting SDoH variables. Combination of insurance type and ADI should be used to identify high-risk patients to redesign care pathways to improve outcomes. Risk adjustment including contextual neighborhood deprivation and patient-level SDoH could reduce unintended consequences of value-based programs.

Distressed Communities Index Is Not Associated with Mortality for Critically Ill Surgical Patients with Sepsis

Background: The impact of socioeconomic metrics on outcomes after sepsis is unclear. The Distressed Communities Index (DCI) is a composite score quantifying socioeconomic well-being by zip code. The primary objective of this study was to evaluate the association between DCI and mortality in patients with sepsis admitted to the surgical intensive care unit (SICU). Patients and Methods: All patients with sepsis admitted to the SICU (Sequential Organ Failure Assessment [SOFA] score ≥2) were reviewed retrospectively. Composite DCI scores were obtained for each patient and classified into high-distress (DCI ≥75th percentile; n = 331) and control distress (DCI <50th percentile; n = 666) groups. Baseline demographic and clinical characteristics were compared between groups. The primary outcomes were in-hospital and 90-day mortality. Results: The high-distress cohort was younger and more likely to be African American (19.6% vs. 6.2%), transferred from an outside facility (52% vs. 42%), have chronic obstructive pulmonary disease (25.1% vs. 18.8%), and baseline liver disease (8.2% vs. 4.2%). Sepsis presentation was comparable between groups. Compared with the control cohort, high-distress patients had similar in-house (23% vs. 24%) and 90-day mortality (30% vs. 28%) but were associated with longer hospital stay (23 vs. 19 days). High DCI failed to predict in-hospital or 90-day mortality but was an independent risk factor for longer hospital length of stay (odds ratio [OR], 2.83 ± 1.42; p = 0.047). Conclusions: High DCI was not associated with mortality but did independently predict longer length of stay. This may reflect limitations of DCI score in evaluating mortality for patients with sepsis. Future studies should elucidate its association with length of stay, re-admissions, and follow-up.

Socioeconomic Profile is Associated with the Type of Firearm Injuries to the Head and Neck

PURPOSE

Socioeconomic status (SES) describes social standing of an individual or a group. SES has been directly associated with violence. The purpose of this study is to measure the association between SES profiles and firearm injuries (FIs) to the head and neck.

METHODS

This cross-sectional study reviewed patients at Grady Memorial Hospital in Atlanta, Georgia from January 2016 to June 2021. The study included patients who sustained FIs to the head and neck. The primary predictor variable was Distressed Community Index as a surrogate for SES. The primary outcome variable was type of FI (assault-induced firearm injury [AFI] or self-inflicted firearm injury [SFI]). Covariates were patient characteristics, distribution, and severity of FI. Univariate and bivariate analyses were calculated. The χ² test was used for categorical variables. Independent t test was used for continuous variables. Statistical significance was P < .05.

RESULTS

Six hundred ninety-four patients met inclusion criteria. AFIs were statistically more frequent in young (AFI = 32.2; SFI = 42.2; P ≤ .001) and/or Black patients (AFI: n = 483, 86.3%; SFI: n = 40, 29.9%; P ≤ .001). Patients who sustained AFIs were statistically more likely to live in areas associated with high Distressed Community Index score (AFI: 64.8, range = 3.7 to 99.7; SFI: 54.4, range = 2.8 to 98; P ≤ .001). A statistically significant number of SFI patients presented with lower Glasgow Coma Scale score (AFI: 10.7, range = 3 to 15; SFI: 5.5, range = 3 to 15; P ≤ .001), and/or required tracheostomy (AFI: n = 56, 10%; SFI: n = 27, 20.1%; P = .005).

CONCLUSIONS

Patients who lived in economically distressed areas were positively associated with AFIs to the head and neck. However, SFIs were statistically more sever. More studies on the impact of current gun prevention programs and how to be addressed to at-risk populations is needed.

Sex-Related Differences in Acuity and Postoperative Complications, Mortality and Failure to Rescue

INTRODUCTION

Yentl syndrome describing sex-related disparities has been extensively studied in medical conditions but not after surgery. This retrospective cohort study assessed the association of sex, frailty, presenting with preoperative acute serious conditions (PASC), and the expanded Operative Stress Score (OSS) with postoperative complications, mortality, and failure-to-rescue.

METHODS

The National Surgical Quality Improvement Program from 2015 to 2019 evaluating 30-d complications, mortality, and failure-to-rescue.

RESULTS

Of 4,860,308 cases (43% were male; mean [standard deviation] age of 56 [17] y), 6.0 and 0.8% were frail and very frail, respectively. Frailty score distribution was higher in men versus women (P < 0.001). Most cases were low-stress OSS2 (44.9%) or moderate-stress OSS3 (44.5%) surgeries. While unadjusted 30-d mortality rates were higher (P < 0.001) in males (1.1%) versus females (0.8%), males had lower odds of mortality (adjusted odds ratio (aOR) = 0.92, 95% confidence interval [CI] = 0.90-0.94, P < 0.001) after adjusting for frailty, OSS, case status, PASC, and Clavien-Dindo IV (CDIV) complications. Males have higher odds of PASC (aOR = 1.33, CI = 1.31-1.35, P < 0.001) and CDIV complications (aOR = 1.13, CI = 1.12-1.15, P < 0.001). Male-PASC (aOR = 0.76, CI = 0.72-0.80, P < 0.001) and male-CDIV (aOR = 0.87, CI = 0.83-0.91, P < 0.001) interaction terms demonstrated that the increased odds of mortality associated with PASC or CDIV complications/failure-to-rescue were lower in males versus females.

CONCLUSIONS

Our study provides a comprehensive analysis of sex-related surgical outcomes across a wide range of procedures and health care systems. Females presenting with PASC or experiencing CDIV complications had higher odds of mortality/failure to rescue suggesting sex-related care differences. Yentl syndrome may be present in surgical patients; possibly related to differences in presenting symptoms, patient care preferences, or less aggressive care in female patients and deserves further study.

Area Deprivation Index is Associated with Variation in Quality of Life and Psychosocial Well-being Following Breast Cancer Surgery

BACKGROUND

Neighborhood-level factors have been shown to influence surgical outcomes through material deprivation, psychosocial mechanisms, health behaviors, and access to resources. To date, no study has examined the relationship between area-level deprivation (ADI) and post-mastectomy outcomes.

METHODS

A cross-sectional survey of adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 to June 2019 was carried out. Patient-specific characteristics and ADI information were abstracted and correlated with postoperative global- (SF-12) and condition-specific (BREAST-Q) quality-of-life performance via multivariable regression. Patients were classified into three ADI terciles: 0-39 (low deprivation), 40-59 (moderate deprivation), and 60-100 (high deprivation).

RESULTS

A total of 564 consecutive patients were identified, being mostly white (75%) with mean age of 60.2 ± 12.4 years, median body mass index of 27.8 [interquartile range (IQR) 24.3-32.2) kg/m², median Charlson Comorbidity Index of 3 (IQR 2-5), and mean ADI of 42.3 ± 25.7. African American and Hispanic patients and those with high BMI were more likely to reside in highly deprived neighborhoods (p = 0.003 and p < 0.001). In adjusted models, patients in highly deprived neighborhoods had significantly lower mean SF-12 physical (44.9 [95% CI, 43.8-46.0] versus 44.9 [95% CI, 43.7-46.1] versus 46.3 [95% CI, 45.3-47.3], p = 0.03) and BREAST-Q psychosocial well-being scores (63.5 [95% CI, 59.32-67.8] versus 69.3 [95% CI, 65.1-73.6] versus 69.7 [95% CI, 66.4-73.1], p = 0.01) relative to moderate- and low-deprivation groups.

CONCLUSIONS

Patients residing in the most deprived neighborhoods were identified to have worse psychological well-being and quality-of-life. The ADI should be incorporated into the shared decision-making process and perioperative counseling to engender value-based and personalized care, especially for vulnerable populations.

Predictors of participants' retention-socioeconomic factors or nonadherence: insights from a urological clinical prospective study

BACKGROUND

To investigate various patient-level variables, specifically socioeconomic status, as risk factors for withdrawal in a recently completed clinical study. We specifically investigated a non-interventional prospective study assessing the role of novel imaging as a biomarker for cancer upgradation in prostate cancer for this objective.

METHODS

In this retrospective analysis, we assessed the association between various patient-level factors including clinic-demographic factors, socioeconomic status, and the number of non-adherences with the participants' retention or withdrawal from the study. For socioeconomic status (SES), we used the zip code-based Economic Innovation Group Distressed Community Index (DCI) which classifies into five even distress tiers: prosperous, comfortable, mid-tier, at-risk, or distressed. Low SES was defined as those with a DCI Distress tier of at-risk or distressed. We compared values between the two retention and withdrawal groups using t-test, chi-square test, and logistic regression analysis.

RESULTS

Of 273 men screened, 123 men were enrolled. Among them, 86.2% (106/123) retained through the study whereas 13.8% (17/123) withdrew from the study. The mean (SD) age was 64 (6.4) years. Overall, 31.7% (39/123) were Hispanics and 24.3% (30/123) were African Americans. The median (IQR) DCI score was 34 (10.3, 68.1) and 30.8% (38/123) of patients belonged to low SES. The median DCI score in participants who retained in the study was statistically similar to those who withdrew from the study (p=0.4). Neither the DCI tiers (p=0.7) nor the low SES (p=0.9) were associated with participants' retention or withdrawal of the study. In terms of non-adherence, all participants in the withdrawn group had at least one non-adherent event compared to 48.1% in the retained group (p<0.001). Repetitive non-adherence was significantly higher in participants who withdrew from the study vs those who retained in the study [88.2% vs 16.9%, p <0.001]. On multivariate logistic regression analysis, the number of non-adherences (OR=12.5, p<0.001) and not DCI (OR=0.99, p=0.7) appeared to be an independent predictor for participants' retention or withdrawal from the study.

CONCLUSIONS

Expanding diverse inclusion and limiting withdrawal with real-time non-adherence monitoring will lead to more efficient clinical research and greater generalizability of results.

External Validation of the American College of Surgeons Surgical Risk Calculator in Elderly Patients Undergoing General Surgery Operations

Preoperative risk stratification in the elderly surgical patient is an essential part of contemporary perioperative care and can be done with the use of the American College of Surgeons Surgical Risk Calculator (ACS-SRC). However, data on the generalizability of the ACS-SRC in the elderly is scarce. In this study, we report an external validation of the ACS-RC in a geriatric cohort. A retrospective analysis of a prospectively maintained database was performed including patients aged > 65 who underwent general surgery procedures during 2012−2017 in a Greek academic centre. The predictive ability of the ACS-SRC for post-operative outcomes was tested with the use of Brier scores, discrimination, and calibration metrics. 471 patients were included in the analysis. 30-day postoperative mortality was 3.2%. Overall, Brier scores were lower than cut-off values for almost all outcomes. Discrimination was good for serious complications (c-statistic: 0.816; 95% CI: 0.762−0.869) and death (c-statistic: 0.824; 95% CI: 0.719−0.929). The Hosmer-Lemeshow test showed good calibration for all outcomes examined. Predicted and observed length of stay (LOS) presented significant differences for emergency and for elective cases. The ACS-SRC demonstrated good predictive performance in our sample and can aid preoperative estimation of multiple outcomes except for the prediction of post-operative LOS.

Living experiences of people with advance cancer with low socioeconomic status: A systematic review of qualitative evidence

BACKGROUND

The number of patients with advanced cancer is rapidly increasing, and the subgroup of this population with low socioeconomic status has suffered more disease burden than others. However, there is no recent qualitative synthesis of primary research studies into advanced cancer patients with low socioeconomic status.

OBJECTIVE

To synthesise qualitative research findings into advanced cancer patients' experiences with low socioeconomic status, and then to help provide targeted and effective strategies to improve their quality of life.

DESIGN

A systematic review and meta-synthesis of qualitative evidence (PROSPERO: CRD42021250423).

DATA SOURCES

PubMed, Web of Science Core Collection (ISI Web of Science), Cochrane Library, Embase, OVID LWW, CINAHL Complete (EBSCO), PsycINFO (EBSCO) and MEDLINE (ISI Web of Science), China National Knowledge Infrastructure (CNKI), WangFang, and Vip databases were systematically searched from their original dates to July 2022. Qualitative data were appraised using the Joanna Briggs Institute (JBI) qualitative assessment.

FINDINGS

The findings were synthesised into the following three analytical themes: (1) multi-dimensional disease distresses; (2) barriers in coping with disease distresses; and (3) strategies for dealing with disease distresses.

CONCLUSIONS

Patients with advanced cancer with low socioeconomic status experienced complicated and interactional distresses, unique life barriers, and a wide range of adaptation strategies. These findings will provide a comprehensive perspective to promote individual-centred health care systems and services to help these vulnerable people deal with the challenges of disease and improve their quality of life.

Demographic factors as determinant of selection of sleeve gastrectomy or gastric bypass for surgical weight loss

INTRODUCTION

Use of sleeve gastrectomy (SG) for weight loss has grown exponentially; however, clear indications for SG versus Roux-en-Y gastric bypass (RNYGB) are lacking. Certain populations may be more likely to undergo SG due to its simpler technique and without clear clinical indications. We aim to examine underlying predictors of patients undergoing SG vs RNY across a single state.

METHODS

We queried the Colorado All Payers Claim Database for patients undergoing laparoscopic SG or RNY. Patient-level variables included patient demographics, comorbidities, distance traveled for surgery, and distressed communities index (DCI), a zip code-based measure of socioeconomic status. Hospital-level variables included annual bariatric surgery volume, academic status, and whether hospitals were a bariatric Center of Excellence. We performed mixed-effects logistic regression adjusting for demographics, insurance coverage, and comorbidities to compare odds of undergoing SG vs RNY, with a random effect for hospital.

RESULTS

5,017 patients were included with 3,042 (60.6%) undergoing SG and 1,975 (39.4%) undergoing RNY. On multivariable analysis, patients with a high DCI were not more likely to undergo a SG (OR 1.18, CI 0.89-1.55, p = 0.25). However, patients who underwent surgery at hospitals serving the greatest proportion of those from highly distressed communities were significantly more likely to undergo SG (OR 4.22, CI 1.38-12.96, p = 0.01). Patients managed at Bariatric Centers of Excellence were less likely to undergo SG (OR 0.22, CI 0.07-0.62, p = 0.005). Patients with higher BMI, diabetes, or GERD were all more likely to undergo RNY.

CONCLUSION

While patients with high DCI were more likely to undergo SG on univariate analysis, these associations disappeared after addition of a hospital-level random effect, suggesting that disparities may be due access to surgeons or systems with preference for one procedure. However, hospitals serving a higher proportion of high-DCI patients are more likely to utilize SG.

Evaluating the Bariatric Safety Net: Analysis of Socioeconomic Factors and Outcomes at a Bariatric Safety Net Program Compared to an Affiliated Private Center

PURPOSE

Obesity is prevalent among economically disadvantaged and racially underrepresented populations. It has been suggested that socioeconomic factors, race, and lifestyle habits are important factors associated with weight loss and comorbidity remission after bariatric surgery. This study analyzes outcomes of bariatric surgery at a private hospital (PH) versus an affiliated safety-net hospital (SNH).

METHODS

Retrospective review of laparoscopic sleeve gastrectomies (LSG) performed by the same surgeons at a PH and SNH in a large metropolitan setting. Demographics, socioeconomic status, insurance status, weight metrics, and perioperative outcomes were compared. A postoperative telephone survey was conducted to study dietary and lifestyle differences between cohorts.

RESULTS

Of the 243 LSG performed, 141 (58%) occurred at PH versus 102 (42%) at SNH. Most patients at SNH were Hispanic, lower socioeconomic status, and had government-sponsored insurance. Based off the results from the postoperative telephone survey, there were no significant differences in dietary and lifestyle habits between both cohorts. Postoperative weight loss outcomes were similar across cohorts. The two groups had similar percent excess weight loss (EWL) at all time points up to 36 months and similar rates of failure to achieve 50% EWL at 12 months. However, patients at PH had greater resolution of diabetes and hypertension after surgery.

CONCLUSION

Our study demonstrates outcomes after bariatric surgery are similar at a PH and its affiliated SNH. Despite differences in race and socioeconomic factors between the two cohorts, perioperative outcomes, short-term postoperative weight loss, and weight loss failure rates were equivalent between SNH and PH patients.

Community distress as a predictor of early hernia recurrence for older adults undergoing ventral hernia repair (VHR)

Background

Social cohesion and neighborhood support have been linked to improved health in a variety of fields, but is not well-studied among the elderly population. This is particularly evident in surgical populations. Therefore, this study sought to assess the potential role of community distress in predicting early hernia recurrence among older adults.

Methods

The Abdominal Core Health Quality Collaborative (ACHQC) was used to identify patients aged 65 or older undergoing elective ventral hernia repair with zip code data available. Patients were linked to the Distressed Communities Index (DCI), which is a national database that assigns a score of 0–100 to each zip code based on 7 measures of neighborhood prosperity. Quintiles were used to compare groups: prosperous (0–20), comfortable (21–40), mid-tier (41–60), at-risk (61–80), and distressed (81–100). Distressed (0–20), at-risk (21–40), mid-tier (41–60), comfortable (61–80), and prosperous (81–100). Time to recurrence for neighborhood distress quintiles was examined using a Cox proportional hazards model.

Results

In total, 9819 patients were included in the study, including 3056 (31.1%) prosperous, 2307 (23.5%) comfortable, 1795 (18.2%) mid-tier, 1390 (14.2%) at-risk, and 1271 (12.9%) distressed. Distressed communities had lower mean age and greater proportion of racial minorities (p < 0.001). Open repairs were significantly more common among the distressed group (66.7%), as were all comorbidities (p < 0.001). Recurrence-free survival was shorter for distressed communities compared to prosperous after adjusting for baseline characteristics (HR 1.3, 95% CI 1.07–1.67, p = 0.01). Mean time to recurrence was lowest for patients living in distressed communities, indicating the worst recurrence rates, while mean time to recurrence was greatest for those in prosperous zip codes (p < 0.001).

Conclusion

Older VHR patients presenting from distressed zip codes, as identified by the Distressed Communities Index, experience hernia recurrence significantly sooner as compared to patients from prosperous zip codes. This study may provide evidence of the role of neighborhood and environmental factors in caring for older patients following VHR.

Graphical abstract

A Comparison of Area-Level Socioeconomic Status Indices in Colorectal Cancer Care

INTRODUCTION

There are multiple measures of area socioeconomic status (SES) and there is little evidence on the comparative performance of these measures. We hypothesized adding area SES measures improves model ability to predict guideline concordant care and overall survival compared to models with standard clinical and demographic data alone.

MATERIALS AND METHODS

We included patients with colorectal cancer from 2006 to 2015 from the North Carolina Cancer Registry merged with insurance claims data. The primary area SES study variables were the Social Deprivation Index, Distressed Communities Index, Area Deprivation Index, and Social Vulnerability Index. We used multivariable logistic modeling and Cox proportional hazards modeling to assess the adjusted association of each indicator, with guideline concordant care and overall survival, respectively. Model performance of the SES measures was compared to a base model using likelihood ratio testing and area under the curve (AUC) assessments to compare SES indicator models with each other.

RESULTS

We found that the Area Deprivation Index, Social Vulnerability Index and Social Deprivation Index, but not Distressed Communities Index, were significantly associated with receiving guideline concordant care and significantly improved model fit over the base model on likelihood ratio testing. All models had similar AUCs. With respect to overall survival, we found that all indices were independently and significantly associated with survival and had significantly improved model fit over the base model on likelihood ratio testing. AUC analysis again showed all area SES measures had comparable performance for overall survival at 5 y.

CONCLUSIONS

This analysis demonstrates the importance of including these measures in risk adjustment models. However, of the commonly available measures, no one measure stood out as superior to others.

S-144 lack of association between glycated hemoglobin and adverse outcomes in diabetic patients undergoing ventral hernia repair: an ACHQC study

INTRODUCTION

Elevated preoperative glycated hemoglobin (HbA1c) is believed to predict complications in diabetic patients undergoing ventral hernia repair (VHR). Our objective was to assess the association between HbA1c and outcomes of VHR in diabetic patients.

METHODS

We conducted a retrospective cohort study using the Abdominal Core Health Quality Collaborative (ACHQC) database. We included adult diabetic patients who underwent elective VHR with an available HbA1c result. The patients were divided into two groups (HbA1c < 8% and HbA1c ≥ 8%). Patient demographics, comorbidities, hernia characteristics, operative details, and surgical outcomes were compared. Multivariable logistic regression analysis of complications was performed. Cox proportional hazard regression was used to assess probability of composite recurrence at different HbA1c levels.

RESULTS

2167 patients met the inclusion criteria (HbA1c < 8% = 1,776 and HbA1c ≥ 8% = 391). Median age was 61 years and median body mass index was 34 kg/m². 75% had an American Society of Anesthesiology class of 3. The median HbA1c was 6.5% in the HbA1c < 8% group versus 8.7% in the HbA1c ≥ 8% group. 73% were incisional hernias, 34% were recurrent, and median hernia width was 6 cm. Open approach was used in 63% and myofascial release was performed in 46%. Median follow-up was 27 days. There were no clinically significant differences in the rates of overall 30-day complications, wound complications, reoperation, readmission, mortality, length of stay and quality of life and pain scores between the two groups. Regression analyses did not identify an association between HbA1c and the rates of complications, surgical site infection or composite recurrence across the spectrum of HbA1c values.

CONCLUSION

Our study finds no evidence of an association between HbA1c and operative outcomes in diabetic patients undergoing elective VHR.

Social and environmental determinants of health among children with long-term movement impairment

The healthcare research community increasingly recognizes the need to address social (SDOH) and environmental determinants of health (EDOH) to optimize health and healthcare. This is particularly relevant to disability and functioning and to those with child onset conditions that impair mobility and impact functioning and participation. Using the World Health Organization (WHO)'s International Classification of Functioning, Disability, and Health (ICF) as a comprehensive framework, this paper aims to discuss our understanding of the relationships between social and EDOH and outcomes among people with impaired mobility that impacts functioning. This paper offers suggestions for future developments and guidance to use SDOH and EDOH in research and clinical practice.

Outcomes Vary Significantly Using a Tiered Approach to Define Success After Total Knee Arthroplasty

BACKGROUND

Patient-reported outcome measures (PROM) allow assessment of clinical outcomes following primary total knee arthroplasty (TKA). The purpose of this study is to use progressively more stringent definitions of success to examine clinical outcomes of primary TKA at 1 year postoperatively and to determine which demographic variables were associated with achieving clinical success.

METHODS

The American Joint Replacement Registry was queried from 2012 to 2020 for primary TKA. Patients who completed the following PROMs preoperatively and 1 year postoperatively were included: Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), and KOOS for Joint Replacement (KOOS JR). Mean PROM scores were determined for each visit and between-visit changes were evaluated using paired t-tests. Rates of achievement of minimal clinically important difference (MCID) by distribution-based and anchor-based criteria, Patient Acceptable Symptom State, and substantial clinical benefit were calculated. Logistic regression was used to evaluate the association between demographic variables and odds of clinical success.

RESULTS

In total, 12,341 TKAs were included. Mean improvement in PROM scores were as follows: KOOS JR, 29; WOMAC-Pain, 33; and WOMAC-Function, 31 (P < .0001 for all). Rates of achievement of each metric were the following: distribution-based MCID, 84%-87%; anchor-based MCID, 46%-79%; Patient Acceptable Symptom State, 54%-82%; and substantial clinical benefit, 68%-81%. Patient age and gender were the most influential demographic factors on achievement of clinical success.

CONCLUSION

Clinical outcomes at 1 year following TKA vary significantly when using a tiered approach to define success. A tiered approach to interpretation of PROMs should be considered for future research and clinical assessment.

Neighborhood deprivation and Medicare expenditures for common surgical procedures

INTRODUCTION

The Center of Medicare and Medicaid Services valued based payments for inpatient surgical hospitalizations are adjusted for clinical but not social risk factors. While research has shown that social risk is associated with worse surgical patient outcomes, it is unknown if inpatient surgical episode Medicare payments are affected by social risk factors.

METHODS

Retrospective review of Medicare beneficiaries, age 65-99, undergoing appendectomy, colectomy, hernia repair, or cholecystectomy between 2014 and 2018. Neighborhood deprivation measured by Area Deprivation Index for beneficiary census tract. We evaluated Medicare payments for a total episode of surgical care comprised of index hospitalization, physician fees, post-acute care, and readmission by beneficiary neighborhood deprivation.

RESULTS

A total of 809,059 patients (Women, 56.0%) and mean (SD) age of 75.7 (7.4 years were included. A total of 145,351 beneficiaries lived in the least deprived neighborhoods and 134,188 who lived in the most deprived neighborhoods. Total surgical episode spending was $2654 higher among beneficiaries from the most deprived neighborhoods compared to those from the least after risk adjustment for clinical and hospital factors. These differences were driven in part by higher rates of readmissions (12.9% vs 10.8%, P < 0.001) and post-acute care (67.8% vs. 61.2%, P < 0.001) among beneficiaries living in the most deprived neighborhoods.

CONCLUSION

These findings suggest that value-based payment models with inclusion of social risk adjustment may be needed for surgical cohorts. Moreover, efforts focused on investing in deprived communities may be aligned with surgical quality improvement.

Does Adding a Measure of Social Vulnerability to a Surgical Risk Calculator Improve Its Performance?

BACKGROUND

Emerging literature suggests that measures of social vulnerability should be incorporated into surgical risk calculators. The Social Vulnerability Index (SVI) is a measure designed by the CDC that encompasses 15 socioeconomic and demographic variables at the census tract level. We examined whether adding the SVI into a parsimonious surgical risk calculator would improve model performance.

STUDY DESIGN

The eight-variable Surgical Risk Preoperative Assessment System (SURPAS), developed using the entire American College of Surgeons (ACS) NSQIP database, was applied to local ACS-NSQIP data from 2012 to 2018 to predict 12 postoperative outcomes. Patient addresses were geocoded and used to estimate the SVI, which was then added to the model as a ninth predictor variable. Brier scores and c-indices were compared for the models with and without the SVI.

RESULTS

The analysis included 31,222 patients from five hospitals. Brier scores were identical for eight outcomes and improved by only one to two points in the fourth decimal place for four outcomes with addition of the SVI. Similarly, c-indices were not significantly different (p values ranged from 0.15 to 0.96). Of note, the SVI was associated with most of the eight SURPAS predictor variables, suggesting that SURPAS may already indirectly capture this important risk factor.

CONCLUSION

The eight-variable SURPAS prediction model was not significantly improved by adding the SVI, showing that this parsimonious tool functions well without including a measure of social vulnerability.

Effect of Socioeconomic Distress on Risk-Adjusted Mortality After Valve Surgery for Infective Endocarditis

Infective endocarditis affects patients of all socioeconomic status. We hypothesized that the Distressed Communities Index (DCI), a comprehensive assessment of socioeconomic status, would be associated with risk-adjusted mortality for patients with endocarditis. All patients with endocarditis (2001-2017) in a regional Society of Thoracic Surgeons database were analyzed. DCI scores range from 0 (no socioeconomic distress) to 100 (severe distress) and account for unemployment, poverty rate, median income, housing vacancies, education level, and business growth by zip code. The most distressed patients (top quartile, DCI > 75) were compared to all other patients. Hierarchical logistic regression modeled the association between DCI and mortality. A total of 2,075 patients were included (median age 55 years, 65.2% urgent/emergent cases, 42.7% self-pay). Major morbidity was 32.8% and operative mortality was 9.5%. Tricuspid/pulmonic valve endocarditis was present in 12.5% of cases, with significantly worse mean DCI compared to patients with left-sided endocarditis (median 55.3, IQR 20.3-77.6 vs 46.8, IQR 17.3-74.2, P = 0.016). High socioeconomic distress (DCI > 75) was associated with higher rates of major morbidity, operative mortality, increased length of stay, and higher total cost. After risk-adjustment, DCI was independently predictive of higher operative mortality for patients with endocarditis (OR 1.24 per DCI quartile increase, 95% CI 1.06-1.45, P < 0.001). Increasing DCI, an indicator of poor socioeconomic status, independently predicts increased risk-adjusted mortality and resource utilization for patients with endocarditis. Accounting for socioeconomic status allows for more accurate risk prediction and resource allocation for patients with endocarditis.

Estimating uncertainty in a socioeconomic index derived from the American community survey

Socioeconomic indexes are widely used in public health to facilitate neighborhood-scale analyses. Although they are calculated with high levels of precision, they are rarely reported with accompanying measures of uncertainty (e.g., 90% confidence intervals). Here we use the variance replicate tables that accompany the United States Census Bureau's American Community Survey to report confidence intervals around the Yost Index, a socioeconomic index comprising seven variables that is frequently used in cancer surveillance. The Yost Index is reported as a percentile score from 1 (most affluent) to 100 (most deprived). We find that the average uncertainty for a census tract in the United States is plus or minus 8 percentiles, with the uncertainty a function of the value of the index itself. Scores at the extremes of the distribution are more precise and scores near the center are less precise. Less-affluent tracts have greater uncertainty than corresponding more-affluent tracts. Fewer than 50 census tracts of 72,793 nationally have unusual distributions of socioeconomic conditions that render the index uninformative. We demonstrate that the uncertainty in a census-based socioeconomic index is calculable and can be incorporated into any analysis using such an index.

Sociodemographic disparities in fetal surgery for myelomeningocele: a single-center retrospective review

OBJECTIVE

Fetal surgery for myelomeningocele has become an established treatment that offers less risk of requiring a ventricular shunt and improved functional outcomes for patients. An increasing body of literature has suggested that social determinants of health have a profound influence on health outcomes. The authors sought to determine the socioeconomic and racial and ethnic backgrounds of patients who were treated with fetal surgery versus those who underwent postnatal repair.

METHODS

Demographic data, the method of myelomeningocele repair, insurance status, and zip code data for patients entered into the National Spina Bifida Patient Registry (NSBPR) from Children's Wisconsin were collected. The zip code was used to determine the Distressed Communities Index (DCI) score, a composite socioeconomic ranking with scores ranging from 0 (no distress) to 100 (severe distress). The zip code was also used to determine the median household income for each patient based on the US Census Bureau 2013-2017 American Community Survey 5-year estimates.

RESULTS

A total of 205 patients were identified with zip code and insurance data. There were 23 patients in the fetal surgery group and 182 patients in the postnatal surgery group. All patients were born between 2000 and 2019. Patients in the fetal surgery group were more likely to have commercial insurance (100% vs 52.2%, p < 0.001). Fetal surgery patients were also more likely to be non-Hispanic White (95.7% vs 68.7%, p = 0.058), just missing the level of statistical significance. Patients who underwent fetal surgery tended to reside in zip codes with a higher median household income (mean $66,507 vs $59,133, p = 0.122) and less-distressed communities (mean DCI score 31.3 vs 38.5, p = 0.289); however, these differences did not reach statistical significance.

CONCLUSIONS

Patients treated with fetal surgery were more likely to have commercial insurance and have a non-Hispanic White racial and ethnic background. The preliminary data suggest that socioeconomic and racial and ethnic disparities may exist regarding access to fetal surgery, and investigation of a larger population of spina bifida patients is warranted.

The association between socioeconomic distress communities index and amputation among patients with peripheral artery disease

Background

Socioeconomic factors have been shown to be associated with amputation in peripheral artery disease (PAD); however, analyses have normally focused on insurance status, race, or median income. We sought to determine whether community-level socioeconomic distress was associated with major amputation and if that association differed by race.

Materials and methods

Community-level socioeconomic distress was measured using the distressed communities index (DCI). The DCI is a zip code level compositive socioeconomic score (0-100) that accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies. A distressed community was defined as a zip code with DCI of 40 or greater. We calculated one-year risk of major amputation by DCI score for individuals with peripheral artery disease in South Carolina, 2012-2017. Treating death as competing event, we reported Fine and Gray subdistribution hazards ratios (sdHR), adjusted for patient demographic and clinical comorbidities associated with amputation. Further analyses were completed to identify potential differences in outcomes within strata of race and DCI.

Results

Among 82,848 individuals with peripheral artery disease, the one-year incidence of amputation was 3.5% (95% CI: 3.3%, 3.6%) and was significantly greater in distressed communities than non-distressed communities (3.9%; 95% CI: 3.8%, 4.1% vs. 2.4%; 95% CI: 2.2%, 2.6%). After controlling for death and adjusting for covariates, we found an increased hazard of amputation among individuals in a distressed community (sdHR: 1.25; 95% CI: 1.14, 1.37), which persisted across racial strata. However, regardless of DCI score, Black individuals had the highest incidence of amputation.

Conclusion

Socioeconomic status is independently predictive of limb amputation after controlling for demographic characteristics and clinical comorbidities. Race continues to be an important risk factor, with Black individuals having higher incidence of amputation, even in non-distressed communities, than White individuals had in distressed communities.

Specialty-Specific Readmission Risk Models Outperform General Models in Estimating Hepatopancreatobiliary Surgery Readmission Risk

BACKGROUND

Readmissions are costly and inconvenient for patients, and occur frequently in hepatopancreatobiliary (HPB) surgery practice. Readmission prediction tools exist, but most have not been designed or tested in the HPB patient population.

METHODS

Pancreatectomy and hepatectomy operation-specific readmission models defined as subspecialty readmission risk assessments (SRRA) were developed using clinically relevant data from merged 2014-15 ACS NSQIP Participant Use Data Files and Procedure Targeted datasets. The two derived procedure-specific models were tested along with 6 other readmission models in institutional validation cohorts in patients who had pancreatectomy or hepatectomy, respectively, between 2013 and 2017. Models were compared using area under the receiver operating characteristic curves (AUC).

RESULTS

A total of 16,884 patients (9169 pancreatectomy and 7715 hepatectomy) were included in the derivation models. A total of 665 patients (383 pancreatectomy and 282 hepatectomy) were included in the validation models. Specialty-specific readmission models outperformed general models. AUC characteristics of the derived pancreatectomy and hepatectomy SRRA (pancreatectomy AUC=0.66, hepatectomy AUC=0.74), modified Readmission After Pancreatectomy (AUC=0.76), and modified Readmission Risk Score for hepatectomy (AUC=0.78) outperformed general models for readmission risk: LOS/2 + ASA integer-based score (pancreatectomy AUC=0.58, hepatectomy AUC=0.66), LACE Index (pancreatectomy AUC=0.54, hepatectomy AUC=0.62), Unplanned Readmission Nomogram (pancreatectomy AUC=0.52, hepatectomy AUC=0.55), and institutional ARIA (pancreatectomy AUC=0.46, hepatectomy AUC=0.58).

CONCLUSION

HPB readmission risk models using 30-day subspecialty-specific data outperform general readmission risk tools. Hospitals and practices aiming to decrease readmissions in HPB surgery patient populations should use specialty-specific readmission reduction strategies.

Frequency of Firearm Injuries to Head and Neck Increased During Covid-19 Pandemic

PURPOSE

During coronavirus disease-19 (COVID-19) pandemic, hospitals faced challenges which were different than previous years. The purpose this study was to report frequency of firearm injuries (FI) to head and neck during the COVID-19 pandemic.

MATERIALS AND METHODS

This cross-sectional study reviewed patients in the Trauma Registry at Grady Memorial Hospital (GMH) in Atlanta, GA. Patients were included if they sustained FI to head and neck, were listed in TR, and were treated at GMH. Patients were stratified according to date of injury into 1) before COVID-19 pandemic, (BC19) or 2) during initial 5 months of COVID-19 pandemic, (C19). Variables were patient demographics, illegal substance use, etiology, place of injury, distressed communities index, location of injury, Glasgow Coma scale on arrival, cardiopulmonary resuscitation in Emergency Department (ED), shock on admission, disposition from ED, length of stay, days on mechanical ventilation and discharge status. Descriptive, univariate, and bivariate analysis were completed. Chi square test was used for categorical variables. Statistical significance was P < .05.

RESULTS

There were 215 patients who met inclusion criteria. There were 96 patients (78 males) with a mean age of 31.5 years old during BC19. There were 119 patients (101 males) with a mean age 32.7 years old during C19. There was a 10.4% increase in FI to head and neck during COVID-19. Our data showed that alcohol use was associated with FI during C19 (P≤ .0001). FI to base of skull occurred 34.5% more often during C19 (P = .002). Cranial injuries occurred 26% more often during BC19 (P = .03). During BC19, 85.4% of the patients arrived alive to GMH, but only 16% arrived alive during C19 (P ≤ .0001).

CONCLUSIONS

There were more FI to head and neck during COVID-10 pandemic than during the previous time period.

Disparities in telemedicine utilization among surgical patients during COVID-19

Background

Telemedicine has been rapidly adopted in the wake of the COVID-19 pandemic. There is limited work surrounding demographic and socioeconomic disparities that may exist in telemedicine utilization. This study aimed to examine demographic and socioeconomic differences in surgical patient telemedicine usage during the COVID-19 pandemic.

Methods

Department of Surgery outpatients seen from July 1, 2019 to May 31, 2020 were stratified into three visit groups: pre-COVID-19 in-person, COVID-19 in-person, or COVID-19 telemedicine. Generalized linear models were used to examine associations of sex, race/ethnicity, Distressed Communities Index (DCI) scores, MyChart activation, and insurance status with telemedicine usage during the COVID-19 pandemic.

Results

14,792 patients (median age 60, female [57.0%], non-Hispanic White [76.4%]) contributed to 21,980 visits. Compared to visits before the pandemic, telemedicine visits during COVID-19 were more likely to be with patients from the least socioeconomically distressed communities (OR, 1.31; 95% CI, 1.08,1.58; P = 0.005), with an activated MyChart (OR, 1.38; 95% CI, 1.17–1.64; P < .001), and with non-government or commercial insurance (OR, 2.33; 95% CI, 1.84–2.94; P < .001). Adjusted comparison of telemedicine visits to in person visits during COVID-19 revealed telemedicine users were more likely to be female (OR, 1.38, 95% CI, 1.10–1.73; P = 0.005) and pay with non-government or commercial insurance (OR, 2.77; 95% CI, 1.85–4.16; P < .001).

Conclusions

During the first three months of the COVID-19 pandemic, telemedicine was more likely utilized by female patients and those without government or commercial insurance compared to patients who used in-person visits. Interventions using telemedicine to improve health care access might consider such differences in utilization.