Independent Associations of Neighborhood Deprivation and Patient-Level Social Determinants of Health With Textbook Outcomes After Inpatient Surgery

Abstract

Objective: Assess associations of social determinants of health (SDoH) using area deprivation index (ADI), race/ethnicity and insurance type with textbook outcomes (TO). Background: Individual- and contextual-level SDoH affect health outcomes, but only one SDoH level is usually included. Methods: Three healthcare system cohort study using National Surgical Quality Improvement Program (2013–2019) linked with ADI risk-adjusted for frailty, case status, and operative stress examining TO/TO components (unplanned reoperations, complications, mortality, emergency department/observation stays, and readmissions). Results: Cohort (34,251 cases) mean age 58.3 [SD = 16.0], 54.8% females, 14.1% Hispanics, 11.6% Non-Hispanic Blacks, 21.6% with ADI >85, and 81.8% TO. Racial and ethnic minorities, non-private insurance, and ADI >85 patients had increased odds of urgent/emergent surgeries (adjusted odds ratios [aORs] range: 1.17–2.83, all P < 0.001). Non-Hispanic Black patients, ADI >85 and non-Private insurances had lower TO odds (aORs range: 0.55–0.93, all P < 0.04), but ADI >85 lost significance after including case status. Urgent/emergent versus elective had lower TO odds (aOR = 0.51, P < 0.001). ADI >85 patients had higher complication and mortality odds. Estimated reduction in TO probability was 9.9% (95% confidence interval [CI] = 7.2%–12.6%) for urgent/emergent cases, 7.0% (95% CI = 4.6%–9.3%) for Medicaid, and 1.6% (95% CI = 0.2%–3.0%) for non-Hispanic Black patients. TO probability difference for lowest-risk (White-Private-ADI <85-elective) to highest-risk (Black-Medicaid-ADI >85-urgent/emergent) was 29.8% for very frail patients. Conclusion: Multilevel SDoH had independent effects on TO, predominately affecting outcomes through increased rates/odds of urgent/emergent surgeries driving complications and worse outcomes. Lowest-risk versus highest-risk scenarios demonstrated the magnitude of intersecting SDoH variables. Combination of insurance type and ADI should be used to identify high-risk patients to redesign care pathways to improve outcomes. Risk adjustment including contextual neighborhood deprivation and patient-level SDoH could reduce unintended consequences of value-based programs.