The relation between household income and surgical outcome in the Dutch setting of equal access to and provision of healthcare

Abstract

BackgroundThe impact of socioeconomic disparities on surgical outcome in the absence of healthcare inequality remains unclear. Therefore, we set out to determine the association between socioeconomic status (SES), reflected by household income, and overall survival after surgery in the Dutch setting of equal access and provision of care. Additionally, we aim to assess whether SES is associated with cause-specific survival and major 30-day complications.MethodsPatients undergoing surgery between March 2005 and December 2006 in a general teaching hospital in the Netherlands were prospectively included. Adjusted logistic and cox regression analyses were used to assess the independent association of SES–quantified by gross household income–with major 30-day complications and long-term postoperative survival.ResultsA total of 3929 patients were included, with a median follow-up of 6.3 years. Low household income was associated with worse survival in continuous analysis (HR: 1.05 per 10.000 euro decrease in income, 95% CI: 1.01–1.10) and in income quartile analysis (HR: 1.58, 95% CI: 1.08–2.31, first [i.e. lowest] quartile relative to the fourth quartile). Similarly, low income patients were at higher risk of cardiovascular death (HR: 1.26 per 10.000 decrease in income, 95% CI: 1.07–1.48, first income quartile: HR: 3.10, 95% CI: 1.04–9.22). Household income was not independently associated with cancer-related mortality and major 30-day complications.ConclusionsLow SES, quantified by gross household income, is associated with increased overall and cardiovascular mortality risks among surgical patients. Considering the equality of care provided by this study setting, the associated survival hazards can be attributed to patient and provider factors, rather than disparities in healthcare. Increased physician awareness of SES as a risk factor in preoperative decision-making and focus on improving established SES-related risk factors may improve surgical outcome of low SES patients.

Low Socioeconomic Status Is Associated with Worse Outcomes After Curative Surgery for Colorectal Cancer: Results from a Large, Multicenter Study

“…GHI was chosen as a surrogate marker for SES in this study, as it is a proven accurate reflection of SES-related health disparities [ 26 , 29 – 31 ]. It was not adjusted to household size, as previous studies showed this adjustment did not improve predictability of the associated health disparities [ 30 ].…”

“…Socioeconomic status was defined as gross household income (GHI), the most commonly used and accepted surrogate marker for SES [ 26 , 29 – 31 ]. GHI from the year prior to surgery was used for analyses, as the income in the year of surgery was possibly lower due to disease-related absence from work.…”

“…Great Britain and Scandinavia) [ 11 – 23 ]. The Dutch healthcare system is known for its equal healthcare access,[ 24 , 25 ] meaning that differences in outcome associated with SES can be attributed to patient and provider factors and their interaction, rather than disparities in healthcare [ 26 ]. In the current study, we aimed to explore the association between SES, as assessed by household income, and outcomes following curative resection for stage I–III colorectal cancer in the Netherlands.…”

Previous Use of Mammography as a Proxy for General Health Checks in Association with Better Outcomes after Major Surgeries

“…Fourth, research has shown that low-income women are less likely to obtain mammograms than their more affluent counterparts regardless of free services [31], and each $10,000 increment in annual household income increased mammography utilization rates by 2.5% [32]. Low socioeconomic status is associated with increased operative and cardiovascular mortality rates among surgical patients [33,34]. Of note, our analysis has accounted for patients’ income to evaluate the independent association between the use of mammography and surgical outcome.…”

The Impact of Household Economics on Short-Term Outcomes in a Posterior Fossa Tumor Population

“…In contrast, the mechanisms underlying economic disparities after access has been attained are poorly defined and not well understood. Evidence from the Netherlands, which has been credited as the most equally accessible healthcare system in the world, notes increased post-operative mortality in low SES patients [16]. Additionally, a study in three Italian cities suggested that economically disadvantaged patients were less likely to be treated in concordance with clinical guidelines and had correspondingly worse prognoses [17].…”