Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH.
Royal College of Surgeons, Dublin, Ireland.
J Am Coll Surg. 2021 Apr;232(4):351-359. doi: 10.1016/j.jamcollsurg.2020.11.024. Epub 2021 Jan 25.
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.
社区层面因素对手术结果的影响尚未得到充分研究。我们旨在描述医疗保险受益人接受癌症手术的情况下，相对于社会脆弱性，“教科书结果”（TO）的差异。
使用医疗保险数据库确定了 2013 年至 2017 年间接受肺癌、食管癌、结肠癌或直肠癌手术的个体，该数据库与疾病预防控制中心的社会脆弱性指数（SVI）合并。TO 定义为无并发症、延长住院时间、再入院和死亡率的手术病例。使用混合效应逻辑回归评估 SVI 与 TO 之间的关联。
在 203800 名患者中（结肠癌，n=113929；肺癌，n=70642；直肠癌，n=14849；食管癌，n=4380），中位年龄为 75 岁（四分位距为 70 至 80 岁），绝大多数患者为白人（n=184989[90.8%]）。TO 的总发生率为 56.1%（n=114393）。并发症发生率（低 SVI：21.5%比高 SVI：24.0%）和 90 天死亡率（低 SVI：7.0%比高 SVI：8.4%）在来自高度脆弱社区的患者中更高（均，p<0.05）。相反，高 SVI 患者比低 SVI 患者获得 TO 的可能性低（优势比 0.83；95%CI，0.78 至 0.87）。尽管高 SVI 白人患者获得 TO 的可能性低 10%（95%CI，0.87 至 0.93），但高 SVI 非白人患者获得术后 TO 的可能性低 22%（95%CI，0.71 至 0.85）。与低 SVI 白人患者相比，高 SVI 少数民族患者的住院时间延长的可能性增加了 47%，并发症的可能性增加了 40%，90 天死亡率的可能性增加了 23%（均，p<0.05）。
只有大约一半的医疗保险受益人达到了复合最佳 TO 质量指标。社会脆弱性与 TO 获得率降低以及几种常见肿瘤手术后不良手术结果的风险增加相关。高 SVI 的影响在少数民族患者中最为显著。
