Association of social vulnerability with the use of high-volume and Magnet recognition hospitals for hepatopancreatic cancer surgery.Surgery. 2021 08; 170(2):571-578.S
In an effort to improve perioperative and oncologic outcomes, there have been multiple quality improvement initiatives, including regionalization of high-risk procedures and hospital accreditation designations from independent organizations. These initiatives may, however, hinder access to high-quality surgical care for certain patients living in areas with high social vulnerability who may be disproportionally affected, leading to disparities in access and worse postoperative outcomes.
Medicare beneficiaries who underwent liver or pancreas resection for cancer were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals were designated as high-volume based on Leapfrog criteria. The Centers for Disease Control and Prevention's social vulnerability index database was used to abstract social vulnerability index information based on each beneficiary's county of residence at the time of operation. The probability that a patient received care at a high-volume hospital stratified by the social vulnerability of the patient's county of residence was examined. Risk-adjusted postoperative outcomes were compared across low, average, and high levels of vulnerability at both low- and high-volume hospitals.
Among 16,978 Medicare beneficiaries who underwent a pancreatectomy (n = 13,393, 78%) or a liver resection (n = 3,594, 21.2%) for cancer, the mean age was 73.3 years (standard deviation: 5.8), nearly half the cohort was female (n = 7,819, 46%), and the overwhelming majority were White (n = 15,034, 88.5%). Mean social vulnerability index was 49.8 (standard deviation 24.8) and mean Charlson comorbidity index was 4.8 (standard deviation: 3). Overall, 8,251 (48.6%) of patients had their operations at a high-volume hospital, and 3,802 patients had their operations at a hospital with Magnet recognition. Age and sex were similar within the low-, average-, and high-social vulnerability index cohorts (P > .05); however, race differed across social vulnerability index groups. White patients made up 93% (n = 3,241) of the low social vulnerability index compared with 83.9% (n = 2,706) of the high-social vulnerability index group, whereas non-Whites made up 7% (n = 244) of the low-social vulnerability index group compared with 16.1% (n = 556) of the high-social vulnerability index group (P < .001). The risk-adjusted overall probability of having surgery at a high-volume hospital decreased as social vulnerability increased (odds ratio: 0.98, 95% confidence interval: 0.97-0.99). Risk-adjusted probability of postoperative complications increased with social vulnerability index; however, among patients with high social vulnerability, risk of postoperative complications was lower at high-volume hospitals compared with low-volume hospitals. In contrast, there was no difference in postoperative complications between hospitals with and without Magnet recognition across social vulnerability index.
Patients residing in communities characterized by a high social vulnerability index were less likely to undergo high-risk cancer surgery at a high-volume hospital. Although postoperative complications and mortality increased as social vulnerability index increased, some of the risk appeared to be mitigated by having surgery at a high-volume hospital. These data highlight the importance of access to high-quality surgical care, especially among patients who may already be more vulnerable.