County-level Social Vulnerability is Associated With Worse Surgical Outcomes Especially Among Minority Patients.

We sought to characterize the association between patient county-level vulnerability with postoperative outcomes. Although the impact of demographic-, clinical- and hospital-level factors on outcomes following surgery have been examined, little is known about the effect of a patient's community of residence on surgical outcomes. Individuals who underwent colon resection, coronary artery bypass graft (CABG), lung resection, or lower extremity joint replacement (LEJR) were identified in the 2016 to 2017 Medicare database, which was merged with Center for Disease Control social vulnerability index (SVI) dataset at the beneficiary level of residence. Logistic regression models were utilized to estimate the probability of postoperative complications, mortality, readmission, and expenditures. Among 299,583 Medicare beneficiary beneficiaries who underwent a colectomy (n = 88,778, 29.6%), CABG (n = 109,564, 36.6%), lung resection (n = 30,401, 10.1%), or LEJR (n = 70,840, 23.6%).Mean SVI score was 50.2 (standard deviation: (25.2); minority patients were more likely to reside in highly vulnerable communities (low SVI: n = 3531, 5.8% vs high SVI: n = 7895, 13.3%; P < 0.001). After controlling for competing risk factors, the risk-adjusted probability of a serious complication among patients from a high versus low SVI county was 10% to 20% higher following colectomy [odds ratio (OR) 1.1 95% confidence intervals (CI) 1.1-1.2] or CABG (OR 1.2 95%CI 1.1-1.3), yet there no association of SVI with risk of serious complications following lung resection (OR 1.2 95%CI 1.0-1.3) or LEJR (OR 1.0 95%CI 0.93-1.2). The risk-adjusted probability of 30-day mortality was incrementally higher among patients from high SVI counties following colectomy (OR 1.1 95%CI 1.1-1.3), CABG (OR 1.4, 95%CI 1.2-1.5), and lung resection (OR 1.4 (95%CI 1.1-1.8), yet not LEJR (OR 0.95 95%CI 0.72-1.2). Black/minority patients undergoing a colectomy, CABG, or lung resection who lived in highly socially vulnerable counties had an estimate 28% to 68% increased odds of a serious complication and a 58% to 60% increased odds of 30-day mortality compared with a Black/minority patient from a low socially vulnerable county, as well as a markedly higher risk than White patients (all P > 0.05). Patients residing in vulnerable communities characterized by a high SVI generally had worse postoperative outcomes. The impact of social vulnerability was most pronounced among Black/minority patients, rather than White individuals. Efforts to ensure equitable surgical outcomes need to focus on both patient-level, as well as community-specific factors.

Diaz A ，Hyer JM ，Barmash E ，Azap R ，Paredes AZ ，Pawlik TM ... -  《-》

High Social Vulnerability and "Textbook Outcomes" after Cancer Operation.

The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in "textbook outcomes" (TO) relative to social vulnerability among Medicare beneficiaries who underwent operations for cancer. Individuals who underwent operations for lung, esophageal, colon, or rectal cancer between 2013 and 2017 were identified using the Medicare database, which was merged with the CDC's Social Vulnerability Index (SVI). TO was defined as surgical episodes with the absence of complications, extended length of stay, readmission, and mortality. The association of SVI and TO was assessed using mixed-effects logistic regression. Among 203,800 patients (colon, n = 113,929; lung, n = 70,642; rectal, n = 14,849; and esophageal, n = 4,380), median age was 75 years (interquartile range 70 to 80 years) and the overwhelming majority of patients was White (n = 184,989 [90.8%]). The overall incidence of TO was 56.1% (n = 114,393). The incidence of complications (low SVI: 21.5% vs high SVI: 24.0%) and 90-day mortality (low SVI: 7.0% vs high SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both, p < 0.05). In turn, there were lower odds of achieving TO among high-vs low-SVI patients (odds ratio 0.83; 95% CI, 0.78 to 0.87). Although high-SVI White patients had 10% lower odds (95% CI, 0.87 to 0.93) of achieving TO, high-SVI non-White patients were at 22% lower odds (95% CI, 0.71 to 0.85) of postoperative TO. Compared with low-SVI White patients, high-SVI minority patients had 47% increased odds of an extended length of stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality (all, p < 0.05). Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncologic procedures. The effect of high SVI was most pronounced among minority patients.

Hyer JM ，Tsilimigras DI ，Diaz A ，Mirdad RS ，Azap RA ，Cloyd J ，Dillhoff M ，Ejaz A ，Tsung A ，Pawlik TM ... -  《-》

Impact of Race/Ethnicity and County-Level Vulnerability on Receipt of Surgery Among Older Medicare Beneficiaries With the Diagnosis of Early Pancreatic Cancer.

Patients can experience barriers and disparities to access high-quality cancer care. This study sought to characterize receipt of surgery and chemotherapy among Medicare beneficiaries with a diagnosis of early-stage pancreatic adenocarcinoma cancer (PDAC) relative to race/ethnicity and social vulnerability. The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients with a diagnosis of early-stage (stage 1 or 2) PDAC between 2004 and 2016. Data were merged with the CDC's Social Vulnerability Index (SVI) at the beneficiary's county of residence. Multivariable, mixed-effects logistic regression was used to assess the association of SVI with resection. Among 15,931 older Medicare beneficiaries with early-stage PDAC (median age, 77 years; interquartile range [IQR], 71-82 years), the majority was White (n = 12,737, 80.0 %), whereas a smaller subset was Black or Latino (n = 3194, 20.0 %) A minority of patients was more likely to live in highly vulnerable communities (low SVI: white [90.5 %] vs minority [9.5 %] vs high SVI: white [71.9 %] vs minority [28.1 %]; p < 0.001). Use of resection for early-stage PDAC was lowest among the patients who resided in high-SVI areas (low [38.0 %] vs average [34.3 %] vs high [31.9 %]; p < 0.001). The minority patients were less likely to undergo resection than the White patients (no resection: white [64.1 %] vs minority [70.7 %]; p < 0.001). The median SVI was higher among the patients who underwent resection (57.6; IQR, 36.0-81.0) than among those who did not (60.4; IQR, 41.9-84.3), and increased SVI resulted in a decline in the likelihood of resection (SVI trend: OR, 0.98; 95 % confidence interval [CI], 0.97-1.00), especially among the minority patients. Minority patients from high-SVI counties had markedly lower odds of preoperative chemotherapy than minority patients from a low-SVI neighborhood (OR, 0.62; 95 % CI, 0.52-0.73). Older Medicare beneficiaries with early-stage PDAC residing in counties with higher social vulnerability had lower odds of undergoing pancreatic resection, which was more pronounced among minority versus older White Medicare beneficiaries.

Azap RA ，Diaz A ，Hyer JM ，Tsilimigras DI ，Mirdad RS ，Ejaz A ，Pawlik TM ... -  《-》

Association of County-Level Social Vulnerability with Elective Versus Non-elective Colorectal Surgery.

Diaz A ，Barmash E ，Azap R ，Paredes AZ ，Hyer JM ，Pawlik TM ... -  《-》

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

The objective of the current study was to characterize the role of patient social vulnerability relative to hospital racial/ethnic integration on postoperative outcomes among patients undergoing pancreatectomy. The interplay between patient- and community-level factors on outcomes after complex surgery has not been well-examined. Medicare beneficiaries who underwent a pancreatectomy between 2013 and 2017 were identified utilizing 100% Medicare inpatient files. P-SVI was determined using the Centers for Disease Control and Prevention criteria, whereas H-REI was estimated using Shannon Diversity Index. Impact of P-SVI and H-REI on "TO" [ie, no surgical complication/extended length-of-stay (LOS)/90-day mortality/90-day readmission] was assessed. Among 24,500 beneficiaries who underwent pancreatectomy, 12,890 (52.6%) were male and median age was 72 years (Interquartile range: 68-77); 10,619 (43.3%) patients achieved a TO. The most common adverse postoperative outcome was 90-day readmission (n = 8,066, 32.9%), whereas the least common was 90-day mortality (n = 2282, 9.3%). Complications and extended LOS occurred in 30.4% (n = 7450) and 23.3% (n = 5699) of the cohort, respectively. Patients from an above average SVI county who underwent surgery at a below average REI hospital had 18% lower odds [95% confidence interval (CI): 0.74-0.95] of achieving a TO compared with patients from a below average SVI county who underwent surgery at a hospital with above average REI. Of note, patients from the highest SVI areas who underwent pancreatectomy at hospitals with the lowest REI had 30% lower odds (95% CI: 0.54-0.91) of achieving a TO compared with patients from very low SVI areas who underwent surgery at a hospital with high REI. Further comparisons of these 2 patient groups indicated 76% increased odds of 90-day mortality (95% CI: 1.10-2.82) and 50% increased odds of an extended LOS (95% CI: 1.07-2.11). Patients with high social vulnerability who underwent pancreatectomy in hospitals located in communities with low racial/ethnic integration had the lowest chance to achieve an "optimal" TO. A focus on both patient- and community-level factors is needed to ensure optimal and equitable patient outcomes.

Hyer JM ，Tsilimigras DI ，Diaz A ，Dalmacy D ，Paro A ，Pawlik TM ... -  《-》