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ASSOCIATION OF HOSPITAL QUALITY AND SOCIAL DETERMINANTS OF HEALTH WITH SHORT-TERM SURGICAL OUTCOMES AMONG MEDICARE BENEFICIARY PATIENTS UNDERGOING ELECTIVE CANCER SURGERY
Abolfazl Salari
*, Mengyuan Ruan, Terhas Weldelase, Jiping Wang, Joel S. Weissman, George Molina
Brigham and Women's Hospital, Boston, MA
INTRODUCTION Patient- and community-level sociodemographic factors have been found to be associated with access to cancer care and outcomes. Where patients receive care also has an impact on the quality of care they receive. The objective of this study was to evaluate whether the association of Social Determinants of Health (SDoH) with short-term surgical outcomes persists after controlling for quality of care of the hospital where care is received.
METHODSThis retrospective study evaluated 30-day mortality and 30-day readmission among Medicare beneficiary patients (age ? 65) who underwent selected elective cancer surgery between 2016-2018. We used two measures of SDoH: 1) county-level Social Vulnerability Index (SVI), measured on a scale from 0 (least vulnerable) to 1 (most vulnerable); and 2) zip-code Distressed Communities Index (DCI), which categorized patients into five groups: prosperous, comfortable, mid-tier, at risk, and distressed. The CMS Overall Hospital Star Rating ranged from 1 (worst) to 5 (best). Short-term outcomes were evaluated using separate multivariable logistic regression models that sequentially adjusted for comorbidities and each SDoH (Model 1 and 3) and then the Hospital Star Rating (Model 2 and 4). An ordinal logistic regression model was used to evaluate the association between each SDoH factor and Hospital Star Rating.
RESULTSAmong 16,869 patients that met inclusion criteria, 12.5%, 14.8%, 24.1%, and 48.6% underwent esophagectomy, gastrectomy, liver resection, or pancreatectomy, respectively. In Models 1 and 3 (without Hospital Star Rating adjustment), the "At Risk" DCI group and higher SVI were associated with higher 30-day mortality, and SVI was associated with higher odds of 30-day readmission (OR 1.17, 95% CI 1.01-1.36, p=0.03). Models 2 and 4 demonstrated that higher Hospital Star Rating was consistently associated with lower odds of 30-day mortality and readmission. The two SDoH factors (SVI and DCI) were no longer significant after adjusting for Hospital Star Rating (models 2 & 4). Additionally, patients from distressed communities (p < 0.05 for all DCI groups) or from more socially vulnerable counties (p <0.001) had lower odds of receiving surgery at hospitals with higher Hospital Star Rating.
CONCLUSIONSThe lack of significant associations between DCI/SVI and 30-day mortality and readmission following elective cancer surgery after adjusting for hospital quality suggests that the quality of the hospital where patients undergo surgery appears to have a greater impact than community-level SDoH after elective cancer surgery. In addition, patients from more distressed communities and socially vulnerable counties were less likely to receive surgery at higher rated hospitals. These findings underscore the importance of addressing social vulnerabilities and ensuring equitable access to high-quality surgical care.
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