Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio.
National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
Ann Surg. 2021 Dec 1;274(6):881-891. doi: 10.1097/SLA.0000000000004691.
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.
我们旨在描述患者县级脆弱性与术后结果之间的关联。
尽管已经研究了人口统计学、临床和医院水平因素对手术后结果的影响，但对于患者居住的社区对手术结果的影响知之甚少。
在 2016 年至 2017 年的医疗保险数据库中确定了接受结肠切除术、冠状动脉旁路移植术（CABG）、肺切除术或下肢关节置换术（LEJR）的个体，并与疾病控制中心社会脆弱性指数（SVI）数据集在受益人居住水平上进行合并。利用逻辑回归模型估计术后并发症、死亡率、再入院和支出的概率。
在接受结肠切除术（n = 88778，29.6%）、CABG（n = 109564，36.6%）、肺切除术（n = 30401，10.1%）或 LEJR（n = 70840，23.6%）的 299583 名医疗保险受益人中。平均 SVI 得分为 50.2（标准差：（25.2）；少数民族患者更有可能居住在高度脆弱的社区（低 SVI：n = 3531，5.8%vs 高 SVI：n = 7895，13.3%；P < 0.001）。在控制竞争风险因素后，与低 SVI 县相比，高 SVI 县患者的严重并发症风险调整后概率在结肠切除术（OR 1.1，95%置信区间[CI] 1.1-1.2）或 CABG（OR 1.2，95%CI 1.1-1.3）后增加了 10%至 20%，但 SVI 与肺切除术（OR 1.2，95%CI 1.0-1.3）或 LEJR（OR 1.0，95%CI 0.93-1.2）后严重并发症风险无关联。与低 SVI 县的患者相比，高 SVI 县的结肠切除术（OR 1.1，95%CI 1.1-1.3）、CABG（OR 1.4，95%CI 1.2-1.5）和肺切除术（OR 1.4，95%CI 1.1-1.8）术后 30 天死亡率的风险调整后概率逐渐升高，但 LEJR 则不然（OR 0.95，95%CI 0.72-1.2）。接受结肠切除术、CABG 或肺切除术且居住在高度社会脆弱性县的黑人和/或少数民族患者，与居住在低度社会脆弱性县的黑人和/或少数民族患者相比，严重并发症的发生几率增加了 28%至 68%，30 天死亡率的发生几率增加了 58%至 60%，且比白人患者的风险明显更高（均 P > 0.05）。
居住在脆弱社区的患者，其脆弱性特征表现为高 SVI，一般术后结果较差。社会脆弱性的影响在黑人和/或少数民族患者中最为明显，而不是白人患者。确保公平的手术结果需要同时关注患者和社区特定因素。
