Moazzam Zorays, Alaimo Laura, Lima Henrique A, Endo Yutaka, Pawlik Timothy M
Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. Electronic address: http://www.twitter.com/ZoraysM.
Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. Electronic address: http://www.twitter.com/LauraAlaimo5.
Surgery. 2023 May;173(5):1192-1198. doi: 10.1016/j.surg.2023.01.012. Epub 2023 Feb 25.
BACKGROUND: The impact of upward economic mobility and race/ethnicity on achieving quality metrics such as textbook outcomes remains ill-defined. As such, we sought to define the impact of race and county-level upward economic mobility on the ability to achieve a textbook outcome among patients undergoing hepatic and pancreatic surgery. METHODS: Patients who underwent hepatic or pancreatic procedures between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The primary outcomes of interest were textbook outcome and its components. RESULTS: Among 35,403 patients, 17,923 (50.6%) patients were classified as living in a low upward economic mobility county, whereas 17,480 (49.4%) lived in a high upward economic mobility county. Furthermore, 32,981 (93.1%) patients were White, and 2,422 (6.8%) were Black. Overall, a textbook outcome was achieved in 45.6% of patients (n = 16,139), with textbook outcome most likely in patients from a high upward economic mobility county compared with a low upward economic mobility county (low: 44.6% vs high: 46.6%, P < .001). On multivariable analysis, patients in a low upward economic mobility county had 6% lower odds of achieving a textbook outcome compared with a high upward economic mobility county (odds ratio 0.94, 95% confidence interval 0.90-0.98). Furthermore, Black patients were less likely to achieve a textbook outcome (odds ratio 0.91, 95% confidence interval 0.84-0.99) and had 17% and 15% higher odds of developing a complication (odds ratio 1.17, 95% confidence interval 1.07-1.28) and extended length of stay (odds ratio 1.15, 95% confidence interval 1.05-1.27), respectively. Within races, White patients in a high upward economic mobility county had 7% higher odds of achieving a textbook outcome compared with White patients in a low upward economic mobility county (odds ratio 1.07, 95% confidence interval 1.02-1.12), although no such effect was observed in Black patients (odds ratio 0.94, 95% confidence interval 0.77-1.15). Furthermore, Black patients in a high upward economic mobility county had similar odds of achieving a textbook outcome compared with White patients in a low upward economic mobility county (odds ratio 0.92, 95% confidence interval 0.77-1.09). CONCLUSION: These results highlight the differential impact of upward economic mobility and race on postoperative outcomes. Due to the health care implications of socioeconomic status, future policy initiatives should target economic mobility as a means to ensure greater health care equity.
背景：向上的经济流动性以及种族/民族对实现诸如教科书式结局等质量指标的影响仍不明确。因此，我们试图确定种族和县级向上的经济流动性对接受肝脏和胰腺手术患者实现教科书式结局能力的影响。 方法：从医疗保险标准分析文件中识别出2013年至2017年间接受肝脏或胰腺手术的患者。感兴趣的主要结局是教科书式结局及其组成部分。 结果：在35403例患者中，17923例（50.6%）患者被归类为生活在经济向上流动性低的县，而17480例（49.4%）生活在经济向上流动性高的县。此外，32981例（93.1%）患者为白人，2422例（6.8%）为黑人。总体而言，45.6%的患者（n = 16139）实现了教科书式结局，与经济向上流动性低的县的患者相比，经济向上流动性高的县的患者最有可能实现教科书式结局（低：44.6% 对高：46.6%，P <.001）。在多变量分析中，与经济向上流动性高的县的患者相比，经济向上流动性低的县的患者实现教科书式结局的几率低6%（优势比0.94，95%置信区间0.90 - 0.98）。此外，黑人患者实现教科书式结局的可能性较小（优势比0.91，95%置信区间0.84 - 0.99），发生并发症的几率高17%（优势比1.17，95%置信区间1.07 - 1.28），住院时间延长的几率高15%（优势比1.15，95%置信区间1.05 - 1.27）。在种族内部，与经济向上流动性低的县的白人患者相比，经济向上流动性高的县的白人患者实现教科书式结局的几率高7%（优势比1.07，95%置信区间1.02 - 1.12），尽管在黑人患者中未观察到这种效应（优势比0.94，95%置信区间0.77 - 1.15）。此外，与经济向上流动性低的县的白人患者相比，经济向上流动性高的县的黑人患者实现教科书式结局的几率相似（优势比0.92，95%置信区间0.77 - 1.09）。 结论：这些结果凸显了向上的经济流动性和种族对术后结局的不同影响。鉴于社会经济地位对医疗保健的影响，未来的政策举措应将经济流动性作为确保更大医疗保健公平性的一种手段。
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