The Ohio State University, Department of Surgery, Columbus, OH.
University of Michigan, IHPI Clinician Scholars Program, Ann Arbor, MI.
Ann Surg. 2021 Dec 1;274(6):985-991. doi: 10.1097/SLA.0000000000005195.
To evaluate the association of historical racist housing policies and modern-day healthcare outcomes.
In 1933 the United States Government Home Owners Loan Corporation (HOLC) used racial composition of neighborhoods to determine creditworthiness and labeled them "Best", "Still Desirable", "Definitely Declining", and "Hazardous." Although efforts have been made to reverse these racist policies that structurally disadvantage those living in exposed neighborhoods, the lasting legacy on modern day healthcare outcomes is uncertain.
We performed a cross-sectional retrospective review of 212,179 Medicare beneficiaries' living in 171,930 unique neighborhoods historically labeled by the HOLC who underwent 1 of 5 of common surgical procedures - coronary artery bypass, appendectomy, colectomy, cholecystectomy, and hernia repair - between 2012 and 2018. We compared 30-day mortality, complications, and readmissions across HOLC grade and Area Deprivation Index (ADI) of each neighborhood. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods ADI; a modern day measure of neighborhood disadvantage that includes education, employment, housing-quality, and poverty measures.
Overall, 212,179 Medicare beneficiaries (mean age, 71.2 years; 54.2% women) resided in 171,930 unique neighborhoods historically graded by the HOLC. Outcomes worsened in a stepwise fashion across HOLC neighborhoods. Overall, 30-day postoperative mortality was 5.4% in "Best" neighborhoods, 5.8% in "Still Desirable", 6.1% in "Definitely Declining", and 6.4% in "Hazardous" (Best vs Hazardous Odds Ration: 1.23, 95% CI: 1.13-1.24, P < 0.001). The same stepwise pattern was seen from "Best" to "Hazardous" neighborhoods for complications (30.5% vs 32.2%; OR: 1.12 [95% CI: 1.07-1.17]; P < 0.001) and Readmissions (16.3% vs 17.1%; OR: 1.06 [95% CI: 1.01-1.11]; P = 0.023). After controlling for modern day deprivation using ADI, the patterns persisted with "Hazardous" neighborhoods having higher mortality (OR: 1.17 [95% CI: 1.08-1.27]; P < 0.001) and complications (OR: 1.07 [95% CI: 1.02-1.12]; P = 0.003), but not for readmissions (OR: 1.02 [95% CI: 0.97-1.07]; P = 0.546).
Patients residing in neighborhoods previously "redlined" or labeled "Hazardous" were more likely to experience worse outcomes after inpatient hospitalization compared to those living in "Best" neighborhoods, even after taking into account modern day measures of neighborhood disadvantage.
评估历史上的种族主义住房政策与现代医疗保健结果之间的关联。
1933 年，美国政府房主贷款公司（HOLC）利用社区的种族构成来确定信用度，并将其标记为“最佳”、“仍然理想”、“明显下降”和“危险”。尽管已经做出努力来扭转这些对居住在暴露社区的人结构上不利的种族主义政策，但对现代医疗保健结果的持久影响尚不确定。
我们对 212179 名接受过五种常见手术之一的 Medicare 受益人的回顾性横断面研究——冠状动脉旁路移植术、阑尾切除术、结肠切除术、胆囊切除术和疝修补术——他们居住在 171930 个历史上由 HOLC 标记的独特社区中，这些手术在 2012 年至 2018 年期间进行。我们比较了 HOLC 等级和每个社区的贫困指标（教育、就业、住房质量和贫困）衡量的现代社区贫困程度的每个社区的区域贫困指数（ADI）的 30 天死亡率、并发症和再入院率。使用多变量逻辑回归模型对结果进行风险调整，该模型考虑了患者因素（年龄、性别、Elixhauser 合并症）、入院类型（择期、紧急、紧急）、手术类型以及每个社区的 ADI。
共有 212179 名 Medicare 受益人（平均年龄 71.2 岁；54.2%为女性）居住在 171930 个历史上由 HOLC 分级的独特社区中。HOLC 社区的结果呈逐步恶化趋势。总体而言，“最佳”社区术后 30 天死亡率为 5.4%，“仍然理想”社区为 5.8%，“明显下降”社区为 6.1%，“危险”社区为 6.4%（最佳与危险的比值比：1.23，95%CI：1.13-1.24，P <0.001）。从“最佳”到“危险”社区，并发症（30.5% vs 32.2%；OR：1.12 [95%CI：1.07-1.17]；P <0.001）和再入院（16.3% vs 17.1%；OR：1.06 [95%CI：1.01-1.11]；P = 0.023）也呈现出相同的逐步模式。在用 ADI 控制现代贫困因素后，这种模式仍然存在，“危险”社区的死亡率更高（OR：1.17 [95%CI：1.08-1.27]；P <0.001）和并发症（OR：1.07 [95%CI：1.02-1.12]；P = 0.003），但再入院率没有（OR：1.02 [95%CI：0.97-1.07]；P = 0.546）。
与居住在“最佳”社区的患者相比，以前被“划线”或标记为“危险”的社区的患者在住院后更有可能出现不良结果，即使考虑到现代社区贫困的衡量标准。
