Patient Social Vulnerability and Hospital Community Racial/Ethnic Integration: Do All Patients Undergoing Pancreatectomy Receive the Same Care Across Hospitals?

The Role of Delirium on Short- and Long-Term Postoperative Outcomes Following Major Gastrointestinal Surgery for Cancer

INTRODUCTION

The growing burden of an aging population has raised concerns about demands on healthcare systems and resources, particularly in the context of surgical and cancer care. Delirium can affect treatment outcomes and patient recovery. We sought to determine the prevalence of postoperative delirium among patients undergoing digestive tract surgery for malignant indications and to analyze the role of delirium on surgical outcomes.

METHODS

Medicare claims data were queried to identify patients diagnosed with esophageal, gastric, hepatobiliary, pancreatic, and colorectal cancers between 2018 and 2021. Postoperative delirium, occurring within 30 days of operation, was identified via International Classification of Diseases, 10th edition codes. Clinical outcomes of interested included "ideal" textbook outcome (TO), characterized as the absence of complications, an extended hospital stay, readmission within 90 days, or mortality within 90 days. Discharge disposition, intensive care unit (ICU) utilization, and expenditures also were examined.

RESULTS

Among 115,654 cancer patients (esophageal: n = 1854, 1.6%; gastric: n = 4690, 4.1%; hepatobiliary: n = 6873, 5.9%; pancreatic: n = 8912, 7.7%; colorectal: n = 93,325, 90.7%), 2831 (2.4%) were diagnosed with delirium within 30 days after surgery. On multivariable analysis, patients with delirium were less likely to achieve TO (OR 0.27 [95% CI 0.25-0.30]). In particular, patients who experienced delirium had higher odds of complications (OR 3.00 [2.76-3.25]), prolonged length of stay (OR 3.46 [3.18-3.76]), 90-day readmission (OR 1.96 [1.81-2.12]), and 90-day mortality (OR 2.78 [2.51-3.08]). Furthermore, patients with delirium had higher ICU utilization (OR 2.85 [2.62-3.11]). Upon discharge, patients with delirium had a decreased likelihood of being sent home (OR 0.40 [0.36-0.46]) and instead were more likely to be transferred to a skilled nursing facility (OR 2.17 [1.94-2.44]). Due to increased utilization of hospital resources, patients with delirium incurred in-hospital expenditures that were 55.4% higher (no delirium: $16,284 vs. delirium: $28,742) and 90-day expenditures that were 100.7% higher (no delirium: $2564 vs. delirium: $8226) (both p < 0.001). Notably, 3-year postoperative survival was adversely affected by delirium (no delirium: 55.5% vs. delirium: 37.3%), even after adjusting risk for confounding factors (HR 1.79 [1.70-1.90]; p < 0.001).

CONCLUSIONS

Postoperative delirium occurred in one in 50 patients undergoing surgical resection of a digestive tract cancer. Delirium was linked to a reduced likelihood of achieving an optimal postoperative outcome, increased ICU utilization, higher expenditures, and a worse long-term prognosis. Initiatives to prevent delirium are vital to improve postoperative outcomes among cancer surgery patients.

Association between social determinants of health and delayed postoperative adjuvant therapy among patients undergoing resection of pancreatic cancer

BACKGROUND AND OBJECTIVES

Pancreatic cancer (PDAC) requires a multimodality approach. We sought to define the association between social determinants of health (SDOH) and delayed or nonreceipt of adjuvant chemotherapy (aCT) among patients undergoing PDAC resection.

METHODS

Data on patients who underwent PDAC resection between 2014 and 2020 were identified from Medicare Standard Analytic Files and merged with the county-level social vulnerability index (SVI). Mediation analysis defined the association between SVI subthemes and aCT receipt.

RESULTS

Among 24 078 patients, 47.7% received timely aCT, 17.7% received delayed aCT, and 34.6% did not receive any aCT. High SVI was associated with delay (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.10-1.34) and nonreceipt of aCT (OR 1.30, 95% CI 1.20-1.41) (both p < 0.05). 73.1% of the variation in timely aCT receipt was directly attributable to SVI, whereas 26.9% of the effect was due to indirect mediators including hospital volume (6.4%), length-of-stay (7.9%) and postoperative complications (12.6%). Socioeconomic status (delayed aCT: OR 1.25, 95% CI 1.13-1.38; nonreceipt aCT: OR 1.25, 95% CI 1.15-1.36) and household composition and disability (delayed aCT: OR 1.30, 95% CI 1.17-1.43; nonreceipt aCT: OR 1.19, 95% CI 1.09-1.29) were associated with receipt of aCT (both p < 0.001).

CONCLUSIONS

Most of the disparities in receipt of aCT after PDAC surgery are driven by underlying SDOH such as SVI.

Geospatial analysis of cyanobacterial exposure and liver cancer in the contiguous United States

BACKGROUND AND AIMS

Cyanobacteria are commonly found in water bodies and their production of hepatotoxins can contribute to liver damage. However, the population health effects of cyanobacteria exposure (CE) are unknown. Our objectives were to determine the effect of chronic exposure to cyanobacteria through proximity to water bodies with high cyanobacteria counts on the incidence and mortality of liver cancers, as well as to identify location-based risk factors.

APPROACH AND RESULTS

Across the contiguous United States, regions with high cyanobacteria counts in water bodies were identified using satellite remote sensing data. The data were geospatially mapped to county boundaries, and disease mortality and incidence rates were analyzed. Distinctive spatial clusters of CE and mortality related to liver diseases or cancer were identified. There was a highly significant spatial association between CE, liver disease, and liver cancer but not between CE and all cancers. Hot spots of CE and mortality were identified along the Gulf of Mexico, eastern Texas, Louisiana, and Florida, and cold spots across the Appalachians. The social vulnerability index was identified as a major location-based determinant by logistic regression, with counties in the fourth or fifth quintiles having the highest prevalence of hot spots of CE and mortality from liver cancer.

CONCLUSIONS

These findings emphasize the importance of environmental exposure to cyanobacteria as a location-based determinant of mortality from liver cancer. Public health initiatives addressing CE may be considered to reduce mortality, particularly in areas of high social vulnerability.

Associations Between Social Vulnerability Indicators and Pediatric Tonsillectomy Outcomes

OBJECTIVE

To investigate the impact of neighborhood-level social vulnerability on pediatric tonsillectomy outcomes.

METHODS

This single-center retrospective cohort study included tonsillectomies performed on children aged 1 to 18 between August 2019 and August 2020. Geographic information systems were used to geocode addresses, and spatial overlays were used to assign census-tract level social vulnerability index (SVI) scores to each patient. For categorical variables, two-sided Pearson chi-square tests were used, whereas for continuous variables, paired t-tests, means, and standard deviations were calculated. SVI and its four subthemes were investigated using binomial logistic regressions to determine their impact on post-T&A complications and readmissions.

RESULTS

The study included 397 patients, with 52 having complications (13.1%) and 33 (8.3%) requiring readmissions due to their complications. Controlling for age, gender, race, insurance status, surgical indication, comorbidities, obesity, and obstructive sleep apnea, postoperative complications were associated with high overall SVI (odds ratio [OR] 5.086, 95% confidence interval [CI] 1.128-22.938), high socioeconomic vulnerability (SVI theme 1, OR 6.003, 95% CI 1.270-28.385), and high house composition vulnerability (SVI theme 2, OR 6.340, 95% CI 1.275-31.525). Readmissions were also associated with high overall SVI (10.149, 95% CI 1.293-79.647) and high housing/transportation vulnerability (SVI theme 4, OR 5.657, 95% CI 1.089-29.396).

CONCLUSION

Social vulnerability at the neighborhood level is linked to poorer surgical outcomes in otherwise healthy children, suggesting a target for community-based interventions. Because of the increased risk, it may have implications for preoperative decision-making, treatment plans, and clinic follow-ups.

LEVEL OF EVIDENCE: 3

Laryngoscope, 134:954-962, 2024.

Social vulnerability and new mobility disability among adults with polymerase chain reaction (PCR)-confirmed SARS-CoV-2: Michigan COVID-19 Recovery Surveillance Study

OBJECTIVE

Understanding the relationship between social factors and persistent COVID-19 health outcomes, such as onset of a disability after a SARS-CoV-2 (the virus that causes COVID-19) infection, is an increasingly important public health issue. The purpose of this paper is to examine associations between social vulnerability and new onset of a mobility disability post-COVID-19 diagnosis.

METHODS

We used data from the Michigan COVID-19 Recovery Surveillance Study, a population-based probability survey of adults with PCR-confirmed SARS-CoV-2 infection in Michigan between January 2020-May 2022 (n = 4295). We used the Minority Health Social Vulnerability Index (MHSVI), with high county-level social vulnerability defined at or above the 75th percentile. Mobility disability was defined as new difficulty walking or climbing stairs. We regressed mobility disability on the overall MHSVI, as well as sub-themes of the index (socioeconomic status, household composition/disability, minority and language, housing type, healthcare access, and medical vulnerability), using multivariable logistic regression, adjusting for age, race, sex, education, employment, and income.

RESULTS

Living in a county with high (vs. low) social vulnerability was associated with 1.38 times higher odds (95% confidence interval [CI]:1.18-1.61) of reporting a new mobility disability after a COVID-19 diagnosis after adjustment. Similar results were observed for the socioeconomic status and household composition/disability sub-themes. In contrast, residents of highly racially diverse counties had lower odds (odds ratio 0.74, 95% CI: 0.61, 0.89) of reporting a new mobility disability compared to low diversity counties.

CONCLUSIONS

Mitigating the effects of social vulnerabilities requires additional resources and attention to support affected individuals.

Social Vulnerability and Emergency General Surgery among Medicare Beneficiaries

BACKGROUND

Although the Social Vulnerability Index (SVI) was created to identify vulnerable populations after unexpected natural disasters, its ability to identify similar groups of patients undergoing unexpected emergency surgical procedures is unknown. We sought to examine the association between SVI and outcomes after emergency general surgery.

STUDY DESIGN

This study is a cross-sectional review of 887,193 Medicare beneficiaries who underwent 1 of 4 common emergency general surgery procedures (appendectomy, cholecystectomy, colectomy, and ventral hernia repair) performed in the urgent or emergent setting between 2014 and 2018. These data were merged with the SVI at the census-track level of residence. Risk-adjusted outcomes (30-day mortality, serious complications, readmission) were evaluated using a logistic regression model accounting for age, sex, comorbidity, year, procedure type, and hospital characteristics between high and low social vulnerability quintiles and within the 4 SVI subthemes (socioeconomic status; household composition and disability; minority status and language; and housing type and transportation).

RESULTS

Compared with beneficiaries with low social vulnerability, Medicare beneficiaries living in areas of high social vulnerability experienced higher rates of 30-day mortality (8.56% vs 8.08%; adjusted odds ratio 1.07; p < 0.001), serious complications (20.71% vs 18.40%; adjusted odds ratio 1.17; p < 0.001), and readmissions (16.09% vs 15.03%; adjusted odds ratio 1.08; p < 0.001). This pattern of differential outcomes was present in subgroup analysis of all 4 SVI subthemes but was greatest in the socioeconomic status and household composition and disability subthemes.

CONCLUSIONS

National efforts to support patients with high social vulnerability from natural disasters may be well aligned with efforts to identify communities that are particularly vulnerable to worse postoperative outcomes after emergency general surgery. Policies targeting structural barriers related to household composition and socioeconomic status may help alleviate these disparities.

Social vulnerability index (SVI) and poor postoperative outcomes in children undergoing surgery in California

INTRODUCTION

Area-based social determinants of health (SDoH) associated with disparities in children's surgical outcomes are not well understood, though some may be risk factors modifiable by public health interventions.

METHODS

This retrospective cohort study investigated the effect of high social vulnerability index (SVI), defined as ≥90th percentile, on postoperative outcomes in children classified as ASA 1-2 who underwent surgery at a large institution participating in the National Surgical Quality Improvement Program (2015-2021). Primary outcome was serious postoperative complications, defined as postoperative death, unplanned re-operation, or readmission at 30 days after surgery.

RESULTS

Among 3278 pediatric surgical procedures, 12.1% had SVI in the ≥90th percentile. Controlling for age, sex, racialization, insurance status, and language preference, serious postoperative complications were associated with high overall SVI (odds ratio [OR] 1.58, 95% confidence interval [CI] 1.02-2.44) and high socioeconomic vulnerability (SVI theme 1, OR 1.75, 95% CI 1.03-2.98).

CONCLUSION

Neighborhood-level socioeconomic vulnerability is associated with worse surgical outcomes in apparently healthy children, which could serve as a target for community-based intervention.

Pancreatogenic Diabetes after Partial Pancreatectomy: A Common and Understudied Cause of Morbidity

BACKGROUND

Partial pancreatic resection is a known risk factor for new-onset pancreatogenic diabetes mellitus (P-DM). The long-term incidence of P-DM and its clinical impact after partial pancreatic resection remains unknown. The primary objective of this study is to determine the long-term incidence of P-DM and its clinical impact after partial pancreatic resection.

STUDY DESIGN

The Medicare 100% Standard Analytic File (2013 to 2017) was queried for all patients who underwent partial pancreatic resection (pancreaticoduodenectomy, distal pancreatectomy). The primary outcome was the development of postoperative P-DM after surgery.

RESULTS

Among 4,255 patients who underwent a pancreaticoduodenectomy or distal pancreatectomy, with a median follow-up of 10.8 months, the incidence of P-DM was 20.3% (n=863) and occurred at a median of 3.6 months after surgery. For patients with at least a 3-year follow-up, 32.2% of patients developed P-DM. Risk factors for developing P-DM included male sex (odds ratio [OR] 1.32, 95% CI 1.13 to 1.54), undergoing a distal pancreatectomy (OR 1.98, 95% CI 1.68 to 2.35), having a malignant diagnosis (OR 1.65, 95% CI 1.34 to 2.04), a family history of diabetes (OR 2.06, 95% CI 1.43 to 2.97; all p < 0.001), and being classified as prediabetic in the preoperative setting (OR 1.57, 95% CI 1.18 to 2.08; p = 0.002). Patients who developed P-DM were more commonly readmitted within 90 days of surgery and had higher postoperative healthcare expenditures in the year after surgery ($24,440 US dollars vs $16,130 US dollars; both p < 0.001) vs patients without P-DM.

CONCLUSIONS

Approximately 1 in 5 Medicare beneficiaries who undergo a pancreatic resection develop P-DM after pancreatic resection. Appropriate screening and improved patient education should be conducted for these patients, in particular, for those with identified risk factors.

State-Level Social Vulnerability Index and Healthcare Access: The Behavioral Risk Factor Surveillance System Survey

INTRODUCTION

Access to health care is affected by social determinants of health. The social vulnerability index encompasses multiple social determinants of health simultaneously and may therefore be associated with healthcare access.

METHODS

Cross-sectional data were used from the 2016‒2019 Behavioral Risk Factor Surveillance System, a nationally representative U.S. telephone-based survey of adults aged ≥18 years. State-level social vulnerability index was derived using county-level social vulnerability index estimates from the Centers for Disease Control and Prevention Agency for Toxic Substances and Disease Registry. Analyses were performed in October 2021. Social vulnerability index was ranked according to percentiles, which were divided into tertiles: Tertile 1 (0.10-0.32), Tertile 2 (0.33-0.53), and Tertile 3 (0.54-0.90).

RESULTS

In multivariable-adjusted models comparing U.S. states in Tertile 3 with those in Tertile 1 of social vulnerability index, there was a higher prevalence of absence of healthcare coverage (OR=1.39 [95% CI=1.22, 1.58]), absence of primary care provider (OR=1.34 [95% CI=1.22, 1.48]), >1-year duration since last routine checkup (OR=1.18 [95% CI=1.10, 1.27]), inability to see a doctor because of cost (OR=1.38 [95% CI=1.23, 1.54]), and the composite variable of any difficulty in accessing healthcare (OR=1.15 [95% CI=1.08, 1.22]).

CONCLUSIONS

State-level social vulnerability is associated with several measures related to healthcare access. These results can help to identify targeted interventions to improve access to health care in U.S. states with high social vulnerability index burden.

Social Vulnerability Subtheme Analysis Improves Perioperative Risk Stratification in Hepatopancreatic Surgery

BACKGROUND

There has been increased interest in understanding how social determinants of health (SDH) may affect care both in the medical and surgical setting. We sought to define the impact of various aspects of social vulnerability on the ability of patients to achieve a "textbook outcome" (TO) following hepatopancreatic surgery.

METHODS

Medicare beneficiaries who underwent hepatopancreatic resection between 2013 and 2017 were identified using the Medicare database. Social vulnerability was defined using the Centers for Disease Control Social Vulnerability Index (SVI), which is comprised of four subthemes: socioeconomic (SE), household composition and disability (HCD), minority status and language (MSL), and housing type and transportation (HTT). TO was defined as the composite endpoint: absence of 90-day mortality or readmission, absence of an extended length of stay (LOS), and no complications during the index admission. Cluster analysis was used to identify vulnerability cohorts, and multivariable logistic regression was utilized to assess the impact of these SVI subthemes on the likelihood to achieve a textbook outcome.

RESULTS

Among 37,707 Medicare beneficiaries, 64.9% (n = 24,462) of patients underwent pancreatic resection while 35.1% (n = 13,245) underwent hepatic resection. Median patient age was 72 years (IQR: 68-77), just over one-half were male (51.9%; n = 19,558), and the median CCI was 3 (IQR: 2-8). Cluster analysis revealed five distinct SVI profiles with wide variability in the distribution of SVI subthemes, ranging from 15 (profile 1 IQR: 7-26) to 83 (profile 5 IQR: 66-93). The five profiles were grouped into 3 categories based on median composite SVI: "low vulnerability" (profile 1), "average vulnerability" (profiles 2 and 3), or "high vulnerability" (profiles 4 and 5). The rate of TO ranged from 44.6% in profile 5 (n = 4022) to 49.2% in profile 1 (n = 4836). Multivariable analyses comparing patients categorized into the two average SVI profiles revealed that despite having similar composite SVI scores, the risk of adverse postoperative outcomes was not similar. Specifically, patients from profile 5 had lower odds of achieving a TO (OR 0.89, 95%CI: 0.83-0.95) and higher odds of 90-day mortality (OR 1.29, 95%CI: 1.15-1.44) versus patients in profile 4.

CONCLUSION

Distinct profiles of SVI subtheme characteristics were independently associated with postoperative outcomes among Medicare beneficiaries undergoing HP surgery, even among patients with similar overall composite SVI scores.