Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, Ohio.
Ann Surg. 2021 Sep 1;274(3):508-515. doi: 10.1097/SLA.0000000000004989.
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.
本研究旨在探讨患者社会脆弱性相对于医院种族/民族融合对接受胰腺切除术患者术后结局的影响。
患者和社区层面因素对复杂手术后结局的相互作用尚未得到充分研究。
利用 100%的医疗保险住院患者档案，确定了 2013 年至 2017 年间接受胰腺切除术的医疗保险受益人的数据。采用疾病控制和预防中心的标准确定患者社会脆弱性指数（P-SVI），采用香农多样性指数评估医院种族/民族融合度（H-REI）。评估 P-SVI 和 H-REI 对“TO”（即无手术并发症/延长住院时间（LOS）/90 天死亡率/90 天再入院）的影响。
在接受胰腺切除术的 24500 名受益人中，12890 名（52.6%）为男性，中位年龄为 72 岁（四分位间距：68-77 岁）；10619 名（43.3%）患者达到了“TO”。最常见的不良术后结果是 90 天再入院（n=8066，32.9%），而最不常见的是 90 天死亡率（n=2282，9.3%）。该队列中分别有 30.4%（n=7450）和 23.3%（n=5699）的患者发生并发症和延长 LOS。与来自低 SVI 县且在高 REI 医院接受手术的患者相比，来自 SVI 指数高于平均水平的县但在 REI 指数低于平均水平的医院接受手术的患者达到“TO”的可能性低 18%（95%可信区间：0.74-0.95）。值得注意的是，来自 SVI 指数最高地区的患者在 REI 指数最低的医院接受胰腺切除术的患者，与来自 SVI 指数非常低地区且在高 REI 医院接受手术的患者相比，达到“TO”的可能性低 30%（95%可信区间：0.54-0.91）。进一步比较这两组患者的结果表明，90 天死亡率的几率增加了 76%（95%可信区间：1.10-2.82），延长 LOS 的几率增加了 50%（95%可信区间：1.07-2.11）。
在种族/民族融合度低的社区医院接受胰腺切除术的社会脆弱性高的患者达到“最佳”TO 的机会最低。需要关注患者和社区层面的因素，以确保患者获得最佳和公平的结局。
