Persistence of Poverty and its Impact on Surgical Care and Postoperative Outcomes

Abstract

Objective: We sought to characterize the association between prolonged county-level poverty with postoperative outcomes. Background: The impact of long-standing poverty on surgical outcomes remains ill-defined. Methods: Patients who underwent lung resection, colectomy, coronary artery bypass graft, or lower extremity joint replacement were identified from Medicare Standard Analytical Files Database (2015–2017) and merged with data from the American Community Survey and the United States Department of Agriculture. Patients were categorized according to the duration of high poverty status from 1980 to 2015 [ie, never high poverty (NHP), persistent poverty (PP)]. Logistic regression was used to characterize the association between the duration of poverty and postoperative outcomes. Principal component and generalized structural equation modeling were used to assess the effect of mediators in the achievement of Textbook Outcomes (TO). Results: Overall, 335,595 patients underwent lung resection (10.1%), colectomy (29.4%), coronary artery bypass graft (36.4%), or lower extremity joint replacement (24.2%). While 80.3% of patients lived in NHP, 4.4% resided in PP counties. Compared with NHP, patients residing in PP were at increased risk of serious postoperative complications [odds ratio (OR)=1.10, 95% CI: 1.05–1.15], 30-day readmission (OR=1.09, 95% CI: 1.01–1.16), 30-day mortality (OR=1.08, 95% CI: 1.00–1.17), and higher expenditures (mean difference, $1010.0, 95% CI: 643.7–1376.4) (all P<0.05). Notably, PP was associated with lower odds of achieving TO (OR=0.93, 95% CI: 0.90–0.97, P<0.001); 65% of this effect was mediated by other social determinant factors. Minority patients were less likely to achieve TO (OR=0.81, 95% CI: 0.79–0.84, P<0.001), and the disparity persisted across all poverty categories. Conclusions: County-level poverty duration was associated with adverse postoperative outcomes and higher expenditures. These effects were mediated by various socioeconomic factors and were most pronounced among minority patients.