Persistency of Poverty and Its Impact on Surgical Outcomes
Henrique Araujo Lima, Selamawit Woldensenbet, Zorays Moazzam, Yutaka Endo, Laura Alaimo, Chanza Shaikh, Muhammad Musaab Munir, Lovette Azap, Timothy M. Pawlik*
The Ohio State University, Columbus, OH
Objective: Socioeconomically deprived communities may experience worse outcomes following surgery. To date, the impact of long-standing county-level poverty on surgical outcomes remains ill-defined. We sought to characterize the association between persistent county-level poverty with postoperative outcomes. Methods: Patients who underwent lung resection, colon resection, coronary artery bypass graft (CABG), or lower extremity joint replacement (LEJR) were identified from the Medicare Standard Analytical Files (SAF) Database (2015-2017). SAF was merged with county-level poverty obtained from the American Community Survey and United States Department of Agriculture. High poverty was defined as ≥20% of residents in poverty. Patients were categorized as residing in areas of never high poverty (NHP), intermittent low poverty (ILP), intermittent high poverty (IHP), and persistent poverty (PP) according to duration of high poverty from 1980-2015. Logistic regression models were utilized to assess the association between duration of poverty and postoperative complications, mortality, readmission, and expenditures. Results: A total of 336,887 Medicare beneficiaries underwent a lung resection (n=33,983, 10.1%) colectomy (n=99,332, 29.5%), CABG (n=122,534, 36.4%) or LEJR (n=81,291, 24.1%). Overall, 269,778 (80.3%) patients lived in NHP counties, while 14,907 (4.4%) resided in PP counties. Compared with individuals who resided in NHP counties, patients living in PP were more likely to present at a younger median age (NHP: 73 years vs. PP: 72 years), be non-White (NHP: 8.0% vs. PP: 18.0%), and have a higher cost of care related to the surgical episode (NHP: $19,103.43 vs. PP: $23,142.74) (all p<0.001). Patients who resided in neighborhoods characterized by PP had a higher likelihood of postoperative complications (OR 1.04, 95% CI 1.00-1.09), 30-day mortality (OR 1.12, 95% CI 1.04-1.21), and 30-day readmission (OR 1.12, 95% CI 1.05-1.19) (all p<0.05) (Figure). Of note, non-White patients residing in PP counties had 41% increased odds of 30-day mortality versus non-White individuals from a NHP county. Interestingly, non-White patients living in PP areas remained at 23-28% increased odds of postoperative complications and 30-day mortality versus White patients who also resided in PP (all p<0.05). Conclusions: County-level socioeconomic environment influenced patient-level postoperative outcomes. Individuals living in PP were at higher risk of postoperative complications, mortality, readmission, and expenditures. Effects of persistent poverty were most pronounced among non-White individuals, highlighting how minority patients are at particular risk for inequitable surgical outcomes.
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