Race and Medicine

Race and Medicine

Disclosures: The authors report no relevant financial disclosures.
February 06, 2021
4 min read

Social vulnerability linked to poorer outcomes after cancer surgery

Disclosures: The authors report no relevant financial disclosures.
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Only about half of Medicare beneficiaries who underwent surgery for cancer achieved optimal outcomes, according to study results published in Journal of the American College of Surgeons.

Social vulnerability appeared associated with poorer outcomes, and this association appeared most pronounced among “non-white” patients.

Timothy Pawlik, MD, PhD, MPH, Urban Meyer III and Shelley Meyer chair for cancer research at The Ohio State University Comprehensive Cancer Center

“The key take-home message is that health care providers need to conceive of health care and the needs of their patients beyond the hospital and clinic,” study author Timothy Pawlik, MD, PhD, MPH, Urban Meyer III and Shelley Meyer chair for cancer research at The Ohio State University Comprehensive Cancer Center — Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, told Healio. “Determinants of health in the community must get addressed if we are to achieve the best outcomes for our patients.

“The data also highlight that these community factors are not borne equally by all,” added Pawlik, who serves as surgeon-in-chief at Ohio State Wexner Medical Center and chair of the department of surgery at Ohio State College of Medicine. “Minority patients are subject to more risk [for] bad outcomes based solely on their race and where they live. ... Policymakers need to consider ways to improve neighborhoods and address social vulnerability in the community as a means to improve health care.”

The relationship between community-level factors and outcomes after surgery has not been studied extensively.

Pawlik and colleagues sought to assess differences in chances of “textbook outcomes” after complex surgery relative to the characteristics of the county and neighborhood in which patients lived. They defined textbook outcomes as the absence of complications, extended length-of-stay, readmission and mortality.

“We hypothesized that patients who lived in communities that were very socially vulnerable would have worse outcomes following surgery compared with patients from neighborhoods with low vulnerability,” Pawlik said. “In essence, we were interested in examining how much social determinants — rather than disease determinants — impacted outcomes after cancer surgery.”

Pawlik and colleagues used the 2016-2017 Medicare database — which merged with CDC’s social vulnerability index (SVI) — to identify Medicare beneficiaries who underwent surgery for four common cancers between 2013 and 2017.

The analysis included 203,800 patients (median age, 75 years; interquartile range, 70-80; 90.8% white).

More than half (55.9%; n = 113,929) of the cohort underwent surgery for colon cancer and about one-third (34.6%; n = 70,642) had surgery for lung cancer. About 7.2% of patients (n = 14,849) underwent surgery for rectal cancer and 2.1% (n = 4,380) had surgery for esophageal cancer.

Results showed 56.1% of patients achieved textbook outcomes.

“The ability to achieve this optimal outcome following surgery was strongly associated with not only disease factors, but also community-level factors that were specific to where the patient lived,” Pawlik said. “In particular, among patients who lived in neighborhoods or communities that were very socially vulnerable — ie, had low socioeconomic status, poor housing, poor transportation, etc — the chance of an optimal outcome after surgery was much lower.”

Patients who lived in high SVI neighborhoods were significantly more likely than those who lived in low SVI neighborhoods to experience complications (24% vs. 21.5%; P < .05) or die within 90 days (8.4% vs. 7%; P < .05).

Patients in the high SVI group were significantly less likely to achieve textbook outcomes (OR = 0.83; 95% CI, 0.78-0.87). In that subgroup, white patients had a 10% (OR = 0.9; 95% CI, 0.87-0.93) lower likelihood of achieving postoperative textbook outcomes, whereas “non-white” patients had a 22% (OR = 0.78; 95% CI, 0.71-0.85) lower likelihood of achieving textbook outcomes.

Pawlik offered potential explanations for the results.

“Patients in high social vulnerability neighborhoods have less access to quality housing [and] transportation, as well as less economic resources,” he said. “As such, either coming to the hospital or being discharged from the hospital into neighborhoods with less resources disadvantages patients relative to their health.

“Substandard housing and poor transplantation limit an individual’s ability to seek timely medical care,” he added. “Of note, [although] minority patients represented only a subset of patients in the study, minority individuals were disproportionately more likely to reside in a high socially vulnerable county.”

The proportion of racial minorities was higher among the high SVI group (14%) than the average (8.6%) or low (5.7%) SVI groups.

Compared with white patients in the low SVI subgroup, “non-white” patients in the high SVI group had a 47% higher likelihood of an extended length of stay, a 40% higher likelihood of a complication and a 23% higher likelihood of dying within 90 days (P < .05 for all).

“The relative impact of SVI and race/ethnicity was most notable when comparing outcomes of white patients from low socially vulnerable areas with those of Black/minority patients from high socially vulnerable neighborhoods,” Pawlik said. “In fact, Black/minority patients from high socially vulnerable neighborhoods had much lower odds of achieving textbook outcomes [than] a white patient from a low socially vulnerable county.”

These findings mirror the health care disparities that have been “unmasked” during the COVID-19 pandemic, Pawlik said.

“These data emphasize the intersection between race/ethnicity and vulnerability, and how minority patients living in high socially vulnerable areas might be susceptible to a ‘double hit’ disparity of worse outcomes,” Pawlik said.

The SVI is comprised of 15 variables related to socioeconomic status, household composition and disability, minority status, language, housing and transportation.

Pawlik and colleagues hope to conduct more research to determine which specific elements of social vulnerability are driving outcomes.

“Social determinants of health — and, in particular, the communities in which patients live — are strong drivers of patient outcomes,” Pawlik told Healio. “Black and Hispanic patients disproportionately live in high socially vulnerable counties and are at highest risk [for] adverse outcome due to adverse social determinants of health.

“Providers need to screen for these factors and provide patients the necessary services to deal with these challenges, while policymakers need to more systematically address the factors driving vulnerability in our communities,” he added. “Only through recognition and purposeful actions to address social vulnerability in our communities — especially those in which Black and Hispanic patients live — will we be able to improve health care outcomes and address disparities in care.”