Abstract
Background:
While the Social Vulnerability Index (SVI) was created to identify vulnerable populations after unexpected natural disasters, its ability to identify similar groups of patients undergoing unexpected emergency surgical procedure is unknown. We sought to examine the association between SVI and outcomes after emergency general surgery.
Methods:
Cross-sectional review of 887,193 Medicare beneficiaries who underwent one of four common emergency general surgery procedures(appendectomy, cholecystectomy, colectomy, and ventral hernia repair) performed in the urgent or emergent setting between 2014 and 2018. This data was merged with the SVI at the census track level of residence. Risk-adjusted outcomes(thirty-day mortality, serious complications, readmission) were evaluated using a logistic regression model accounting for age, gender, comorbidities, year, procedure type and hospital characteristics between high and low social vulnerability quintiles and within the four SVI subthemes (socioeconomic status; household composition and disability; minority status and language; housing type and transportation).
Results:
Compared to beneficiaries with low social vulnerability, Medicare beneficiaries living in areas of high social vulnerability experienced higher rates of thirty-day mortality (8.56% vs 8.08%; adjusted odds ratio [OR], 1.07; p<0.001), serious complications (20.71% vs 18.40%; OR, 1.17; p<0.001), and readmissions (16.09% vs 15.03%; OR, 1.08; p<0.001). This pattern of differential outcomes was present in subgroup analysis of all four SVI subthemes but greatest in the socioeconomic status and household composition and disability subthemes.
Conclusions:
National efforts to support patients with high social vulnerability from natural disasters may be well aligned with efforts to identify communities that are particularly vulnerable to worse postoperative outcomes after emergency general surgery. Policies targeting structural barriers related to household composition and socioeconomic status may help alleviate these disparities.
Keywords: Social Vulnerability, Emergency General Surgery, Disparities
Precis
A study of Medicare beneficiaries undergoing 4 emergency general surgery procedures (appendectomy, cholecystectomy, colectomy, ventral hernia repair) in the urgent/emergent setting demonstrated an association of worse outcomes with higher social vulnerability, specifically those disadvantaged in housing/disability and socioeconomic status.
Introduction:
The Social Vulnerability Index was developed by the Centers for Disease Control as a predictive fatality tool after a natural disaster1. The index uses 15 different social factors divided into four subthemes (socioeconomic status; household composition and disability; minority status and language; housing type and transportation) to measure a community’s ability to recover from unplanned hazardous events2. Specifically, socioeconomic status is derived from unemployment rate, education level, and income; household composition and disability is derived from prevalence of minors, elderly and people with disabilities; minority status and language is derived from language barriers and racial distribution; lastly, housing type and transportation is derived from lack of vehicle access and overcrowded communities. This resulting score ranging from 0 (lowest vulnerability) to 1 (highest vulnerability) has been used to assist local officials in identifying locations of the most socially vulnerable populations3. There is broad consensus that communities with high social vulnerability have increased rates of mortality and morbidity and are less likely to recover from natural disasters1,3–5.
While the relationship between the Social Vulnerability Index and elective general surgical procedures has been demonstrated, the relationship for emergency general surgery procedures is less clear. Emergency general surgery, another form of unplanned healthcare, encompasses a broad array of acute, resource-intensive surgical diseases that require urgent evaluation and possible emergency operation. Hence, patients undergoing surgery for these conditions may be impacted by the social vulnerability of their communities and abilities to provide unplanned care6,7. Emergency general surgery conditions also place a large and increasing burden on the health care system with more than 2 million hospital admissions in the United States each year and estimated $28.4 billion in costs8–10. Recent concerns have been raised that patients in higher vulnerability communities are more likely to undergo emergency general surgery and have worse outcomes11,12. However, to date, this has been evaluated only in a single procedure or single health system study. Additionally, although numerous studies have shown a relationship between worse surgical outcomes and higher social vulnerability, few studies have identified areas of intervention12–17.
The objective of the current study was to explore the association between social vulnerability and outcomes of four common emergency general surgery procedures performed in the urgent and emergent setting among Medicare beneficiaries. By comparing the risk-adjusted rates of surgical outcomes between different levels of vulnerability and among the four subthemes, we were not only able to better understand this relationship but also identify more granular areas for intervention.
Methods
Data source and Study Population
Data from the 100% capture Medicare Provider Analysis and Review (MEDPAR) file between 2014 and 201818 were used for this cross-sectional retrospective cohort study. Hospital characteristics were obtained from the American Hospital Association Annual Survey. Each admission was linked to a hospital by a unique hospital identifier located in the MEDPAR file. This study was approved by the University of Michigan Investigation Review Board and deemed exempt due to use of secondary data.
Patients between 65- and 99-years old undergoing four common emergency general surgical procedures were included in this study. Using procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS), we chose to study four common emergency general surgery procedures: appendectomy, cholecystectomy, colectomy, and ventral hernia repair. To reflect those consistent with emergency general surgery, we focused on only procedures that were done in the urgent or emergent setting. This cohort represent some of the most common emergency general surgery procedures and account for a large proportion of both mortality/morbidity and cost burdens19. Information on patient age, demographic features, geographic location, and comorbidities were collected. A full table of the ICD codes used for this study can be found in the in the Supplemental Digital Content (Supplemental Digital Content 1). For each beneficiary, the nine-digit zip code was used to determine their individual census tract which was subsequently linked to a specific Social Vulnerability Index score. Patients transferred prior to receiving a surgical procedure were included and categorized by the social vulnerability of their home communities, and not that of the hospital where they received care.
The exposure of interest was the Social Vulnerability Index, which is publicly available at the county and census-tract level from the Centers for Disease Control20. In this study, the Index was evaluated as a categorial variable where patients were stratified based on ordinal quintiles, with the lowest quintile (score of 0.2 or lower) designed as lowest vulnerability and highest quintile (score of 0.8 or greater) designated as highest vulnerability. The range of Social Vulnerability Scores range from 0 to 1. We chose to evaluate the Index as quintiles for ease of presentation and based on previous surgical work studying Social Vulnerability Index.21–24 We intentionally chose to merge the Social Vulnerability Index data for each beneficiary at the census track level of residence to provide the most specificity in identifying associations3,25.
Outcome Variables:
The primary outcome was rate of thirty-day mortality of beneficiaries undergoing emergency general surgical procedures. Mortality in the hospital was determined by vital status at time of discharge or within thirty days of discharge from the index operation, and not after the index operation. To examine the association between emergency general surgery and social vulnerability, we limited the acuity of each procedure to those done only in the urgent or emergent setting through the admission status coded in the Medicare inpatient file for each of the four procedures. Patients with multiple qualifying procedures during the same admission were classified based on the index procedure.
Secondary outcomes included any complications, serious complications, and readmissions. Complications were identified using the International Classification of Diseases (ICD), Version 926,27 and 1028 codes, previously described and validated in studies using the MEDPAR file29,30. Serious complications were defined as having at least one complication and a length of stay higher than the 75th percentile for the specific procedure that was performed previously in the administrative claims database to improve specificity31. Readmissions were defined as any inpatient admission within thirty days of discharge to any facility for which Medicare was charged32,33. This criterion has been applied in multiple previous studies using MEDPAR to study surgical complications29,30.
Analysis
The overall goal of this analysis was to identify rates of postoperative outcomes in communities with different levels of social vulnerability at the census tract level. Patient characteristics of those living in communities with the highest and lowest socially vulnerability who underwent emergency general surgical procedures were first compared using T- and Chi-square tests as appropriate. Hospital characteristics were compared also using T-tests. Next, a multivariable logistic regression model accounting for patient age, sex, race, comorbidities (as described by Elixhauser34), and procedure (i.e., appendectomy, cholecystectomy, colectomy, and ventral hernia repair) was used to examine the association of social vulnerability and surgical outcomes for all procedures combined. In our sensitivity analyses, we also analyzed each of the four emergency general surgical procedures separately. To identify areas for intervention, we also examined this association for each of the four subthemes (socioeconomic status; household composition and disability; minority status and language; housing type and transportation) of the Social Vulnerability Index.
To account for hospital characteristics, hospital bed size, teaching status and staffing ratios were included in the model. To adjust for clustering within hospitals, robust standard errors were used for all models. Additionally, secular trends were adjusted for by including the year of operation as a categorical variable. Finally, to understand the relationship between a beneficiary’s community and location of care, we also determined the patient’s travel distance. This was calculated using the Google Maps Application Programming Interface through the statistical software SAS, which measures the distance from the centroid of a beneficiary’s zip code to the centroid of a hospital’s zip code.
All P values reported were 2-sided with 0.05 as the threshold for significance. Statistical analyses were performed using STATA version MP 16.1 (STATA Corp).
Study Results
Patient Characteristics
Among 887,193 Medicare beneficiaries who underwent one of four emergency general surgery procedures: appendectomy (n=102,509, 11.6%), cholecystectomy (n=406,994, 45.9%), colectomy (n=249,753, 28.2%), ventral hernia repair (n=127,940, 14.4%), mean age was 76.0 years (standard deviation SD: 7.6); roughly one-half were male (n=404,222, 45.6%) and the majority had two or more Elixhauser comorbidities (n=732,350, 82.5%). Compared to patients living in the lowest vulnerable communities (n=171,625, 19.3%), patients in the highest vulnerable communities (n=154,957, 17.5%) were slightly younger (75.4 vs 76.3, p<0.001) and had higher comorbidity burden (% of patients with ≥2 Elixhauser comorbidities; 85.6% vs 79.6%, p<0.001). Of the four procedures, cholecystectomy was the most common procedure across all levels of social vulnerability comprising 45.0% of emergency general surgical procedures performed in the lowest social vulnerability quintile and 46.8% of those performed in the highest social vulnerability quintile (Table 1). These patterns stayed consistent throughout the five social vulnerability quintiles (Supplemental Digital Content 2).
Table 1:
Patient and Hospital Characteristics
| Characteristic | Total (n = 887,193) | Lowest social vulnerability* (n = 171,625) | Highest social vulnerability† (n = 154,957) | p Value |
|---|---|---|---|---|
| Demographic characteristic | ||||
| Age, y, mean (SD) | 76.0 (7.6) | 76.3 (7.6) | 75.4 (7.6) | <0.001 |
| Sex, m, n (%) | 404,222 (45.6) | 81,762 (47.6) | 66,908 (43.2) | <0.001 |
| Race, n (%) | ||||
| White | 751,276 (84.7) | 161,469 (94.1) | 99,745 (64.4) | <0.001 |
| Black | 76,717 (8.6) | 4,315 (2.5) | 33,288 (21.5) | <0.001 |
| Asian | 15,254 (1.7) | 2,143 (1.2) | 3,654 (2.4) | <0.001 |
| Hispanic | 23,685 (2.7) | 892 (0.5) | 12,450 (8.0) | <0.001 |
| Native American | 4,805 (0.5) | 225 (0.1) | 2,218 (1.4) | <0.001 |
| Other | 15,456 (1.7) | 2,581 (1.5) | 3,602 (2.3) | <0.001 |
| Comorbidity, n (%) | ||||
| Hypertension | 665,699 (75.0) | 124,420 (72.5) | 121,493 (78.4) | <0.001 |
| Fluid and electrolyte disorder | 389,237 (43.9) | 72,767 (42.4) | 70,624 (45.6) | <0.001 |
| Diabetes | 263,826 (29.7) | 41,687 (24.3) | 57,201 (36.9) | <0.001 |
| Chronic pulmonary disease | 189,796 (21.4) | 31,719 (18.5) | 34,963 (22.6) | <0.001 |
| Deficiency anemia | 177,970 (20.1) | 31,025 (18.1) | 36,504 (23.6) | <0.001 |
| Obesity | 157,328 (17.7) | 27,257 (15.9) | 30,406 (19.6) | <0.001 |
| Hypothyroidism | 156,962 (17.7) | 32,243 (18.8) | 23,914 (15.4) | <0.001 |
| Renal failure | 152,478 (17.2) | 26,505 (15.4) | 30,057 (19.4) | <0.001 |
| Congestive heart failure | 136,228 (15.4) | 23,341 (13.6) | 25,511 (16.5) | <0.001 |
| Weight loss | 126,465 (14.3) | 23,278 (13.6) | 23,391 (15.1) | <0.001 |
| Peripheral vascular disease | 91,334 (10.3) | 16,651 (9.7) | 16,240 (10.5) | <0.001 |
| Depression | 90,142 (10.2) | 17,937 (10.5) | 13,866 (8.9) | <0.001 |
| Other neurological disorder | 71,844 (8.1) | 13,642 (7.9) | 12,626 (8.1) | 0.036 |
| Coagulopthy | 68,863 (7.8) | 13,184 (7.7) | 12,567 (8.1) | <0.001 |
| Valvular disease | 67,344 (7.6) | 14,679 (8.6) | 9,488 (6.1) | <0.001 |
| Liver disease | 53,876 (6.1) | 9,926 (5.8) | 10,474 (6.8) | <0.001 |
| Metastatic cancer | 47,090 (5.3) | 8,944 (5.2) | 8,227 (5.3) | 0.21 |
| Solid tumor | 32,097 (3.6) | 6,113 (3.6) | 5,692 (3.7) | 0.088 |
| Rheumatoid arthritis | 30,851 (3.5) | 6,395 (3.7) | 4,827 (3.1) | <0.001 |
| Psychoses | 18,542 (2.1) | 3,166 (1.8) | 3,768 (2.4) | <0.001 |
| Elixhauser comorbidity, n (%) | ||||
| 0 | 43,581 (4.9) | 10,299 (6.0) | 5,906 (3.8) | <0.001 |
| 1 | 111,262 (12.5) | 24,749 (14.4) | 16,427 (10.6) | <0.001 |
| ≥2 | 732,350 (82.5) | 136,577 (79.6) | 132,624 (85.6) | <0.001 |
| Discharge location, n (%) | ||||
| Home | 598,763 (67.5) | 120,208 (70.0) | 102,512 (66.2) | <0.001 |
| Skilled nursing facility | 216,085 (24.4) | 39,655 (23.1) | 38,748 (25.0) | <0.001 |
| Transferred | 10,216 (1.2) | 1,595 (0.9) | 1,870 (1.2) | <0.001 |
| Other | 47,691 (5.4) | 7,603 (4.4) | 9,237 (6.0) | <0.001 |
| Hospice | 14,438 (1.6) | 2,564 (1.5) | 2,590 (1.7) | <0.001 |
| Home rurality, n (%) | ||||
| Rural | 13,560 (1.5) | 1,153 (0.7) | 4,699 (3.0) | <0.001 |
| Urban cluster (suburban) | 93,604 (10.6) | 9,198 (5.4) | 18,969 (12.2) | <0.001 |
| Urban area | 780,029 (87.9) | 161,274 (94.0) | 131,289 (84.7) | <0.001 |
| Emergency general surgical procedure, n (%) | ||||
| Appendectomy | 102,506 (11.6) | 22,583 (13.2) | 15,842 (10.2) | <0.001 |
| Cholecystectomy | 406,994 (45.9) | 77,310 (45.0) | 72,568 (46.8) | <0.001 |
| Colectomy | 249,753 (28.2) | 47,971 (28.0) | 42,939 (27.7) | 0.13 |
| Ventral hernia repair | 127,940 (14.4) | 23,761 (13.8) | 23,608 (15.2) | <0.001 |
| Hospital size, n (%) | ||||
| Has fewer than 250 beds | 343,813 (38.8) | 62,179 (36.2) | 56,335 (36.4) | 0.46 |
| Has between 250 and 499 beds | 328,410 (37.0) | 66,657 (38.8) | 57,797 (37.3) | <0.001 |
| Has 500 or more beds | 214,970 (24.2) | 42,789 (24.9) | 40,825 (26.3) | <0.001 |
| Hospital region, n (%) | ||||
| Northeast | 149,593 (16.9) | 39,282 (22.9) | 18,181 (11.7) | <0.001 |
| Midwest | 192,462 (21.7) | 47,437 (27.6) | 20,011 (12.9) | <0.001 |
| South | 364,746 (41.1) | 54,500 (31.8) | 76,481 (49.4) | <0.001 |
| West | 180,392 (20.3) | 30,406 (17.7) | 40,284 (26.0) | <0.001 |
| Teaching hospital, n (%) | 628,684 (70.9) | 128,315 (74.8) | 109,932 (70.9) | <0.001 |
| Patient to nurse ratio, n (%) | 8.8 (3.3) | 8.9 (3.0) | 8.4 (3.8) | <0.001 |
| Travel distance, mi, median (IQR) | 11.1 (4.8–23.8) | 10.6 (5.4–19.3) | 9.3 (3.7–23.1) | <0.001 |
| Rural | 10.3 (5.1–24.0) | 9.8 (5.5–19.7) | 9.4 (4.7–24.2) | 0.82 |
| Urban cluster (suburban) | 22.6 (5.2–44.8) | 19.5 (8.8–33.7) | 28.4 (1.8–53.8) | <0.001 |
| Urban area | 10.4 (4.8–21.4) | 10.3 (5.3–18.5) | 8.5 (3.6–18.7) | <0.001 |
| Travel time, min, median (IQR) | 20.0 (12.0–33.0) | 19.0 (12.0–29.0) | 18.0 (10.0–33.0) | <0.001 |
| Travel time, n (%) | ||||
| <30 min | 623,936 (70.3) | 130,987 (76.3) | 111,678 (72.1) | <0.001 |
| 30–60 min | 165,986 (18.7) | 26,796 (15.6) | 25,940 (16.7) | <0.001 |
| >60 min | 97,271 (11.0) | 13,842 (8.1) | 17,339 (11.2) | <0.001 |
Sources: Medicare Claims, 2014–2018; American Hospital Association Annual Survey, 2014–2018. Social Vulnerability Index, 2018
Lowest census-tract vulnerability is defined as the lowest quintile by the Social Vulnerability Index, score of 0 to 0.2.
Highest census-tract vulnerability is defined as the highest quintile by the Social Vulnerability Index, score of 0.81 to 1.
IQR, interquartile range.
Association of Social Vulnerability on Travel Time and Distance
Medicare beneficiaries living in areas of higher social vulnerability on average were more likely to travel for a shorter time and for shorter distances to a hospital. The medial travel time and distance for all cohorts were 20.0 minutes (Interquartile Range [IQR], 12.0–33.0) and 11.1 miles (IQR, 4.8–23.8) respectively. Beneficiaries living in communities with the highest social vulnerability traveled on average for 18.0 minutes (IQR, 10.0–33.0) and 9.3 miles (IQR, 3.7–23.1) while beneficiaries living in communities with the lowest social vulnerability traveled on average for 19.0 minutes (IQR, 12.0–29.0) and 10.6 miles (IQR, 5.4–19.3). Though interestingly, out of the 97,271 beneficiaries who traveled >60 minutes, 17,339 (18.8%) were from communities with highest vulnerability while only 13,842 (14.2%) were from communities with lowest vulnerability (Table 1).
Impact of Social Vulnerability on Surgical Outcomes
When analyzing all emergency general surgical procedures, compared to beneficiaries from the lowest socially vulnerable communities, patients from the highest socially vulnerable communities experienced higher rates of thirty-day mortality (8.08% vs 8.56%; OR, 1.07; 95% confidence interval [CI], 1.07–1.08; p<0.001), any complications (34.11% vs 37.24%; OR, 1.18; 95% CI, 1.18–1.18; p<0.001), serious complications (18.40% vs 20.71%; OR, 1.17; 95% CI, 1.17–1.18; p<0.001), and readmission (15.03% vs 16.09%; OR, 1.08; 95% CI, 1.08–1.09; p<0.001). This pattern was consistent throughout the different quintiles of social vulnerability (Table 2) and when we added dual-eligibility status in the risk-adjusted model (Supplemental Digital Content 3).
Table 2:
Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Social Vulnerability Quintiles
| Outcomes | Risk-adjusted rate* (95% CI), % | Odds ratio (95% CI) | p Value† |
|---|---|---|---|
| Mortality, 30-d | |||
| Lowest vulnerability‡ | 8.08 (7.97 to 8.19) | Ref | - |
| Below average vulnerability§ | 8.26 (8.15 to 8.37) | 1.03 (1.03 to 1.03) | <0.001 |
| Average vulnerability∥ | 8.35 (8.24 to 8.46) | 1.05 (1.05 to 1.05) | <0.001 |
| Above average vulnerability¶ | 8.51 (8.40 to 8.62) | 1.07 (1.07 to 1.07) | <0.001 |
| Highest vulnerability# | 8.56 (8.45 to 8.68) | 1.07 (1.07 to 1.08) | <0.001 |
| Any complication | |||
| Lowest vulnerability | 34.11 (33.90 to 34.32) | Ref | - |
| Below average vulnerability | 34.87 (34.67 to 35.08) | 1.04 (1.04 to 1.04) | <0.001 |
| Average vulnerability | 35.56 (35.35 to 35.77) | 1.08 (1.08 to 1.08) | <0.001 |
| Above average vulnerability | 36.35 (36.14 to 36.55) | 1.13 (1.12 to 1.13) | <0.001 |
| Highest vulnerability | 37.24 (37.02 to 37.45) | 1.18 (1.18 to 1.18) | <0.001 |
| Serious complication | |||
| Lowest vulnerability | 18.40 (18.20 to 18.59) | Ref | - |
| Below average vulnerability | 18.85 (18.65 to 19.04) | 1.03 (1.03 to 1.03) | <0.001 |
| Average vulnerability | 19.30 (19.10 to 19.49) | 1.07 (1.06 to 1.07) | <0.001 |
| Above average vulnerability | 19.97 (19.77 to 20.17) | 1.12 (1.11 to 1.12) | <0.001 |
| Highest vulnerability | 20.71 (20.51 to 20.92) | 1.17 (1.17 to 1.18) | <0.001 |
| Reoperation | |||
| Lowest vulnerability | 11.98 (11.85 to 12.11) | Ref | - |
| Below average vulnerability | 12.07 (11.95 to 12.20) | 1.00 (1.00 to 1.00) | 0.001 |
| Average vulnerability | 12.11 (11.98 to 12.24) | 1.00 (1.00 to 1.00) | 0.57 |
| Above average vulnerability | 12.31 (12.18 to 12.44) | 1.02 (1.01 to 1.02) | <0.001 |
| Highest vulnerability | 12.49 (12.36 to 12.62) | 1.02 (1.02 to 1.03) | <0.001 |
| Readmission | |||
| Lowest vulnerability | 15.03 (14.89 to 15.16) | Ref | - |
| Below average vulnerability | 15.32 (15.19 to 15.45) | 1.02 (1.02 to 1.02) | <0.001 |
| Average vulnerability | 15.57 (15.44 to 15.71) | 1.04 (1.04 to 1.05) | <0.001 |
| Above average vulnerability | 15.82 (15.68 to 15.95) | 1.06 (1.06 to 1.07) | <0.001 |
| Highest vulnerability | 16.09 (15.95 to 16.23) | 1.08 (1.08 to 1.09) | <0.001 |
Data Sources: Medicare Claims, 2014–2018; Social Vulnerability Index, 2018
Emergency general surgical procedures include appendectomy, cholecystectomy, colectomy and ventral hernia repair
Model was adjusted for age, sex, year of procedure, patient to nurse ratio, hospital teaching status and Elixhauser comorbidity
p Value is referring to the odds ratio.
Lowest census-tract social vulnerability is defined as the lowest quintile by Social Vulnerability Index with score of 0 to 0.2.
Below average census-tract social vulnerability is defined as the quintile by Social Vulnerability Index with score of 0.21–0.40.
Average census-tract social vulnerability is defined as the quintile by Social Vulnerability Index with score of 0.41–0.60.
Above average census-tract social vulnerability is defined as the quintile by Social Vulnerability Index with score of 0.61 to 0.80.
Highest census-tract social vulnerability is defined as the highest quintile by Social Vulnerability Index with score of 0.81 to 1.
To evaluate the outcomes of each of the four emergency general surgical procedures separately, we performed sensitivity analyses which showed similar association between higher social vulnerability and worse surgical outcomes. Compared to beneficiaries from the lowest socially vulnerable communities, patients from the highest socially vulnerable communities experienced higher rates of thirty-day mortality (3.48% vs 4.23%; OR, 1.20; 95% CI, 1.18–1.22; p<0.001) when undergoing appendectomies (Supplemental Digital Content 4), readmissions (11.92% vs 12.83%; OR, 1.08; 95% CI, 1.08–1.09; p<0.001) when undergoing cholecystectomies (Supplemental Digital Content 5), any complications (50.42% vs 53.50%; OR, 1.17; 95% CI, 1.16–1.17; p<0.001) when undergoing colectomies (Supplemental Digital Content 6), and serious complications (22.80% vs 24.84%; OR, 1.13; 95% CI, 1.12–1.14; p<0.001) when undergoing hernia repairs (Supplemental Digital Content 7). The procedure with the most significant striking differences in outcomes was appendectomy (Supplemental Digital Content 4).
Association of Social Vulnerability Subthemes on Surgical Outcomes
When evaluating the risk-adjusted rates of each outcome within the four different subthemes individually, two subthemes had the most striking disparity in outcomes. Differences in thirty-day mortality (8.25% vs 8.69%; OR, 1.09; 95% CI, 1.08–1.09; p<0.001) was greatest between lowest and highest household composition and disability vulnerabilities. Differences in any complications (34.03% vs 37.46%; OR, 1.20; 95% CI, 1.20–1.21; p<0.001), serious complications (18.33% vs 20.92%; OR, 1.20; 95% CI, 1.19–1.20; p<0.001) and readmissions (15.04% vs 16.15%; OR, 1.09; 95% CI, 1.08–1.09; p<0.001) were greatest between lowest and highest socioeconomic status vulnerabilities (Table 3). The unabridged results of each outcome by each subtheme’s vulnerability quintile can be found in the Supplemental Digital Content (Supplemental Digital Content 8: socioeconomic status; Supplemental Digital Content 9: household composition and disability; Supplemental Digital Content 10: minority status and language; and Supplemental Digital Content 11: housing type and transportation).
Table 3:
Comparison of Risk-Adjusted Outcomes for Emergency General Surgery Procedures by Social Vulnerability Subtheme Quintiles
| Outcomes | Risk-adjusted rate* (95% CI), % | Odds ratio (95% CI) | p Value§ | |
|---|---|---|---|---|
| Lowest social vulnerability† | Highest social vulnerability‡ | |||
| Mortality, 30-d | ||||
| Socioeconomic status | 8.18 (8.07–8.29) | 8.61 (8.50–8.72) | 1.06 (1.06–1.07) | <0.001 |
| Household composition and disability | 8.25 (8.13–8.36) | 8.69 (8.58–8.80) | 1.09 (1.08–1.09) | <0.001 |
| Minority status and language | 8.33 (8.22–8.44) | 8.09 (7.98–8.20) | 0.95 (0.95–0.96) | <0.001 |
| Housing type and transportation | 8.06 (7.95–8.17) | 8.61 (8.50–8.72) | 1.08 (1.08–1.08) | <0.001 |
| Any complication | ||||
| Socioeconomic status | 34.03 (33.82–34.24) | 37.46 (37.24–37.67) | 1.20 (1.20–1.21) | <0.001 |
| Household composition and disability | 34.64 (34.42–34.85) | 37.17 (36.96–37.38) | 1.15 (1.14–1.15) | <0.001 |
| Minority status and language | 35.15 (34.94–35.35) | 35.76 (35.55–35.98) | 1.03 (1.03–1.04) | <0.001 |
| Housing type and transportation | 34.52 (34.32–34.73) | 36.48 (36.27–36.69) | 1.11 (1.11–1.11) | <0.001 |
| Serious complication | ||||
| Socioeconomic status | 18.33 (18.13–18.52) | 20.92 (20.71–21.13) | 1.20 (1.19–1.20) | <0.001 |
| Household composition and disability | 18.86 (18.65–19.06) | 20.58 (20.38–20.79) | 1.13 (1.12–1.13) | <0.001 |
| Minority status and language | 18.96 (18.77–19.16) | 19.61 (19.41–19.82) | 1.05 (1.05–1.06) | <0.001 |
| Housing type and transportation | 18.67 (18.47–18.86) | 20.07 (19.87–20.28) | 1.10 (1.10–1.10) | <0.001 |
| Readmission | ||||
| Socioeconomic status | 15.04 (14.91–15.18) | 16.15 (16.01–16.29) | 1.09 (1.08–1.09) | <0.001 |
| Household composition and disability | 15.24 (15.10–15.38) | 16.08 (15.95–16.22) | 1.07 (1.06–1.07) | <0.001 |
| Minority status and language | 15.42 (15.29–15.56) | 15.58 (15.44–15.72) | 1.01 (1.01–1.02) | <0.001 |
| Housing type and transportation | 15.14 (15.01–15.27) | 15.92 (15.78–16.05) | 1.06 (1.06–1.06) | <0.001 |
Source: Medicare Claims, 2014–2018; Social Vulnerability Index, 2018
Emergency general surgery procedures include appendectomy, cholecystectomy, colectomy, and ventral hernia repair
The 4 social vulnerability subthemes are socioeconomic status (income, poverty, employment, and education), household composition and disability (age, single parenting, and disability), minority status and language (race, ethnicity, and English language proficiency) and housing type and transportation (housing structure, crowding and vehicle access).
Model was adjusted for age, sex, year of procedure, patient to nurse ratio, hospital teaching status and Elixhauser comorbidity.
Lowest census-tract social vulnerability is defined as the lowest quintile by Social Vulnerability Index with score of 0 to 0.2.
Highest census-tract social vulnerability is defined as the highest quintile by Social Vulnerability Index with score of 0.81 to 1.
p Value is referring to the odds ratio.
Discussion
Our study evaluating the association of community social vulnerability and patient outcomes after emergency general surgery has two principle findings. First, higher social vulnerability was associated with worse overall outcomes for four emergency general surgical procedures. Second, differences in outcomes were most prominent in the socioeconomic status and household composition and disability subthemes. Taken together, policies targeting structural barriers may help alleviate these disparities. Additionally, our findings support the use of Social Vulnerability Index as a tool to identify high risk communities undergoing emergency general procedures.
Previous attempts have been made to evaluate the association between social vulnerability and outcomes of a number of surgical procedures, but evidence on emergency general surgical procedures is limited. Studies have focused on mainly oncologic procedures such as hepatopancreatic resections35–40, showing that high social vulnerability was associated with increased risk of adverse postoperative surgical outcomes. Our present study extends those findings by demonstrating similar pattern amongst a breadth of common emergency general surgical procedures. Furthermore, given the urgent or emergent nature of our studied surgical procedures, the application of Social Vulnerability Index in identifying at risk populations may be appropriate given both unplanned surgery and natural disasters create an unexpected high demand in resources. While previous research on social vulnerability and nonelective surgical procedures have been limited in scope11,12, by focusing on a subset of common emergency general surgical procedures, we show that the Index may also be relevant to other unforeseen events such as unplanned surgery.
Our subtheme analysis of outcomes with social vulnerability provides a unique lens on quality improvement strategies for emergency general surgical procedures. Since the various subthemes within the Index target social determinants of health, they facilitate policies to target areas for interventions. Efforts in this sector have been widespread, given the increase in hospital admissions for emergency general surgery and evidence showing that patients are up to eight times more likely to die than patients undergoing the same procedure electively41,42. Numerous studies have evaluated associations between worse outcomes with trainee participation43–45, racial/ethnic disparities46,47, and low-volume hospitals48,49. However, data on how exactly to intervene is limited. Our findings showed that the disparities in outcomes were most prominent in the socioeconomic status and household composition and disability. As such, our findings suggest that investments targeting unemployment, education, and child support may represent one strategy policy makers could consider in addressing surgical disparities for emergency general surgery procedures.
Additionally, housing and transportation vulnerability was also found to be associated with worse overall outcomes. Although geographic proximity was not associated with lower overall vulnerability, we found that a higher percentage of patients who traveled for over an hour for their surgical procedures came from higher socially vulnerable communities. This shows that geographic proximity alone may not be enough to improve outcomes, rather it is a complexity of social factors. Taken together, proposed policy efforts50 around desegregation, housing stability51 and transportation infrastructure may improve access and therefore mitigate disparities observed for these emergency general surgery procedures. Additionally, our findings are in support of the Ensuring Access to General Surgery Act, which will likely study and define workforce shortage areas that overlap with the highly vulnerably communities we have outlined in this project.
Lastly, several efforts have been made to improve quality of care for emergency general surgery patients along the perioperative continuum. Many have focused on the procedural and post operative phases of care by showing predictive factors associated with worse post discharge outcomes, such as transfer status52, postoperative care discontinuity53 and different risk calculator scores54–56. Our study complements those findings by identifying preoperative factors that are potentially modifiable for communities in the prehospital phase of care which may address the observed postoperative disparities. Given the proposed need for national standards regarding standardized emergency general surgery42,57, social vulnerability may be a possible quality target for the development of future standardized emergency general surgery guidelines.
The results of this study should be interpreted in the context of some limitations. First, claims data may not capture all confounding patient characteristics; this is why we chose outcomes from that coding complications projects that are least susceptible to this bias26,27. Second, the use of zip code may not provide enough granularity about the patient’s individual social vulnerability. To mitigate this effect, we used a nine-digit zip code that allows more specificity than typically seen in studies of this nature. Third, although we could not account for all hospital level factors (surgeon experience/training, volume), we performed our analysis with robust standard errors to try to account some of these differences. Additionally, given the size and variability of zip codes, travel distance measured can differ from the actual travel distance experienced by patients. The program also assumes that the mode of transportation is a vehicle and does not account for scenarios where patient did not start traveling from their home zip-code centroid. Lastly, since we studied only four emergency general surgical procedures in the Medicare population, our results may not be generalizable to the broader range of Emergency General Surgery or to non-Medicare patients. However, these four procedures are amongst the most common and represent a large patient population, and Medicare data is one of the only national datasets that allow for census-tract granularity across the country.
Our findings have several implications regarding the use of the Social Vulnerability Index as a tool to identify vulnerable populations at risk for worse emergency general surgical outcomes. First, for providers, the Index may be a helpful tool to identify patients who need additional resources after discharge to optimize their postoperative courses, and can aid providers in using remote monitoring and specific protocols to target high-risk patients. This is in line with current efforts by electronic health records to integrate social determinants of health domains for risk stratification58. Additionally, surgeons and hospitals striving to reduce the social vulnerability of their patients can support system policy changes such as the current infrastructure bill50, which targets desegregation and transportation, and American Hospital Association’s pledge to increase housing.51 Second, policymakers interested in health equity and optimal allocation of resources may find the Index informative beyond its original intent to understand how investing in socially vulnerable communities may have positive spillover to other unplanned needs. Finally, for payers who are using outcomes of care to inform reimbursements, these findings suggest that social vulnerability should be considered as part of a risk-adjustment model59,60.
Conclusions
Among Medicare beneficiaries undergoing emergency general surgical procedures, higher social vulnerability was associated with worse overall outcomes, especially within the socioeconomic status and housing subthemes. As such, policies targeting structural barriers related to housing and transportation and socioeconomic status may help alleviate these disparities.
Supplementary Material
Supplemental Digital Content 1. ICD Codes Used to Identify Emergency General Surgical Procedures
Supplemental Digital Content 2. Patient and Hospital Characteristics by Social Vulnerability Quintiles
Supplemental Digital Content 3. Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Social Vulnerability Quintiles
Supplemental Digital Content 4. Risk-Adjusted Rates of Outcomes for only Appendectomy by Social Vulnerability Quintiles
Supplemental Digital Content 5. Risk-Adjusted Rates of Outcomes for only Cholecystectomy by Social Vulnerability Quintiles
Supplemental Digital Content 6: Risk-Adjusted Rates of Outcomes for only Colectomy by Social Vulnerability Quintiles
Supplemental Digital Content 7. Risk-Adjusted Rates of Outcomes for only Ventral Hernia Repair by Social Vulnerability Quintiles
Supplemental Digital Content 8. Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Subtheme Socioeconomic Vulnerability Quintiles
Supplemental Digital Content 9. Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Subtheme Household Composition and Disability Vulnerability Quintiles
Supplemental Digital Content 10. Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Subtheme Minority Status and Language Vulnerability Quintiles
Supplemental Digital Content 11. Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Subtheme Housing Type and Transportation Vulnerability Quintiles
Support:
Dr Zhang is supported by the National Clinician Scholars Program, and the US Department of Veterans Affairs. Dr Dimick is supported by NIH grant [1R01DK131584-01]. Dr Ibrahim is supported by the Agency for Healthcare Research and Quality grant [R01HS028606-01A1]. Drs Kunnath, Zhang, and Ibrahim are supported by NIH grant [R01AG039434].
Presented at the American College of Surgeons 108th Annual Clinical Congress, Scientific Forum, San Diego, CA, October 2022.
Footnotes
Disclosure Information: Nothing to disclose.
Disclosures outside the scope of this work: Dr Dimick is a cofounder of ArborMetrix, Inc.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Digital Content 1. ICD Codes Used to Identify Emergency General Surgical Procedures
Supplemental Digital Content 2. Patient and Hospital Characteristics by Social Vulnerability Quintiles
Supplemental Digital Content 3. Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Social Vulnerability Quintiles
Supplemental Digital Content 4. Risk-Adjusted Rates of Outcomes for only Appendectomy by Social Vulnerability Quintiles
Supplemental Digital Content 5. Risk-Adjusted Rates of Outcomes for only Cholecystectomy by Social Vulnerability Quintiles
Supplemental Digital Content 6: Risk-Adjusted Rates of Outcomes for only Colectomy by Social Vulnerability Quintiles
Supplemental Digital Content 7. Risk-Adjusted Rates of Outcomes for only Ventral Hernia Repair by Social Vulnerability Quintiles
Supplemental Digital Content 8. Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Subtheme Socioeconomic Vulnerability Quintiles
Supplemental Digital Content 9. Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Subtheme Household Composition and Disability Vulnerability Quintiles
Supplemental Digital Content 10. Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Subtheme Minority Status and Language Vulnerability Quintiles
Supplemental Digital Content 11. Risk-Adjusted Rates of Outcomes for Emergency General Surgical Procedures by Subtheme Housing Type and Transportation Vulnerability Quintiles