Socioeconomic disadvantage is associated with greater mortality after high-risk emergency general surgery

Abstract

BACKGROUND:Socioeconomic disadvantage is associated with worse outcomes after elective surgery, but the effect on emergency general surgery (EGS) remains unclear. We examined the association of socioeconomic disadvantage and outcomes after EGS procedures and investigated whether admission to hospitals with comprehensive clinical and social resources mitigated this effect. METHODS:Adults undergoing 1 of the 10 most burdensome high-and low-risk EGS procedures were identified in six 2014 State Inpatient Databases. Socioeconomic disadvantage was assessed using Area Deprivation Index (ADI) of patient residence. Multivariable logistic regression models adjusting for patient and hospital factors were used to evaluate the association between ADI quartile (high >75 percentile vs. low <25 percentile), and 30-day readmission, in-hospital mortality, and discharge disposition. Effect modification between ADI and (a) level 1 trauma center and (b) safety-net hospital status was tested. RESULTS:A total of 103,749 patients were analyzed: 72,711 low-risk (70.1%) and 31,038 high-risk procedures (29.9%). Patients from neighborhoods with high socioeconomic disadvantage had a higher proportion with ≥3 comorbidities (41.9% vs. 32.0%), minority race/ ethnicity (66.3% vs. 42.4%), and Medicaid (28.8% vs. 14.7%) and were less likely to be treated at level 1 trauma centers (18.3% vs. 27.7%; p < 0.001 for all). Adjusting for competing factors, high socioeconomic disadvantage was associated with increased inhospital mortality after high-risk procedures (odd ratio, 1.30; 95% confidence interval, 1.01-1.66; p = 0.04) and higher odds of non-home discharge (odd ratio, 1.15; 95% confidence interval, 1.02-1.30; p = 0.03) for low-risk procedures. Socioeconomic disadvantage was not associated with 30-day readmission for either procedure group. Level 1 trauma status and safety-net hospital did not meaningfully mitigate effect of ADI for any outcome. CONCLUSION:Socioeconomic disadvantage is associated with increased mortality after high-risk procedures and higher odds of non-home discharge after low-risk procedures. This effect was not mitigated by either level 1 trauma or safety-net hospitals. Interventions that specifically address the needs of socially vulnerable communities will be required to significantly improve EGS outcomes for this population.

Emergency General Surgery Procedures in Older Adults: Where You Live Matters!

“…Furthermore, care at a tertiary care facility did not mitigate the disparities stemming from socioeconomic disadvantage. 3 Socioeconomic differences in the built environment have been documented and suggest that lower income residents may be exposed to less activity-supportive environments and reduced access to healthy foods leading to lower levels of physical activity and an increased risk of adverse health conditions, including cardiovascular diseases, hypertension, obesity, type II diabetes, depression, and malignancy. [19][20][21] The SES and its associated built environment influence not only health care access but also the quality of health care provided.…”

“…Prior research has demonstrated that patients from areas of greater socioeconomic disadvantage may present more severely ill, with more advanced disease or poorly controlled comorbidities, which contributes to worse postoperative outcomes. 3 Dugravot et al, in a review of the long-standing Whitehall II cohort study, demonstrated that social inequalities play a causative role in the development of multimorbidity, frailty, and disability. In a surgical patient, this additional comorbid burden adds to their operative risk, particularly during emergency procedures.…”

“…Socioeconomic status is one of the most extensively studied components of SDOH and has been linked to increased mortality, major complications, longer lengths of hospital stay, and higher rates of failure to rescue following major surgery. 3 Zip code, a representative of both SES and the associated neighborhood/built environment, has been shown to influence an individual’s life expectancy.…”

Performance of quick sequential organ failure assessment and modified age disease adjusted qadSOFA for the prediction of outcomes in emergency general surgery patients

“…1 The detected mortality rate of 4.3% in the current study is comparable to the literature with the highest mortality rate for patients suffering from MI (26.2%). [1][2][3][4][5][6][25][26][27] In the daily clinical routine, it is of highest importance to predict outcomes at a very early stage of surgical decision making. Especially in times of reduced hospital and ICU resources, increasing frailty of EGS patients and different patients' or relatives' treatment expectations and goals, predictive scores may facilitate decision making in a timely manner.…”

“… 1 The detected mortality rate of 4.3% in the current study is comparable to the literature with the highest mortality rate for patients suffering from MI (26.2%). 1 – 6 , 25 – 27 …”