COLUMBUS, Ohio - Older minority cancer patients with poor social determinants of health are significantly more likely to experience negative surgical outcomes compared to white patients with similar risk factors, according to a new study published by researchers at The Ohio State University Comprehensive Cancer Center - Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC - James).
A new retrospective analysis of more than 200,000 patients conducted by researchers with the OSUCCC - James suggests that minority patients living in high socially vulnerable neighborhoods had a 40% increased risk of a complication and 23% increased risk of 90-day mortality compared with white patients for neighborhoods with low social vulnerability. The U.S. Centers for Disease Control (CDC) defines social vulnerability as "potential negative effects on communities caused by external stresses on human health."
Study results were published online ahead of print in the Journal of the American College of Surgeons Jan. 25, 2021, and were highlighted in the 2020 Southern Surgical Association Program.
"This study speaks to how health care and health outcomes extend beyond the doors of the hospital and even beyond the specifics of the disease the patient may have. Ultimately, the resources in the patient's community may be as important to a patient's health as what goes on in the hospital," said Timothy Pawlik, MD, senior author of the study and holder of the Urban Meyer III and Shelley Meyer Chair for Cancer Research at the OSUCCC - James. Pawlik serves as surgeon-in-chief at the Ohio State Wexner Medical Center and as chair of the Department of Surgery in the Ohio State College of Medicine.
"This issue is not new, but the data strongly suggests we could significantly improve surgical outcomes by intentionally integrating vulnerability assessments into our national standard of care models. By doing so, we could help identify the most vulnerable among us - upfront - and provide additional supports as patients move through treatment and recovery," Pawlik added. "The data emphasize how efforts to improve outcomes for cancer patients need to extend beyond the hospital and address systemic health-related disparities within the communities in which patients live."
Study Method and Results
For this retrospective study, researchers used a novel risk stratification tool called the social vulnerability index (SVI), a composite measure of 15 social and economic factors. Although the CDC created the SVI using census data to identify communities needing greater support during disasters, researchers recently have applied it to medical studies.
Researchers identified 203,800 patients age 65 or older from the 2016-2017 Medicare inpatient claims files who underwent an operation for one of three common cancers--lung, colon and rectal--or for cancer of the esophagus between 2013-2017. The investigators merged the Medicare information with the CDC's SVI for each patient's county of residence. The SVI includes county-level data such as unemployment rates, racial distribution, prevalence of people with disabilities, vehicle access and overcrowded community living. A high SVI score indicates greater social vulnerability.
Researchers found that minority patients with high SVI scores had a 47% increased chance of an extended length-of-stay, 40% increased odds of a surgical complication and 23% increased odds of 90-day mortality. When comparing white to non-white patients with a similar social vulnerability risk factor score, non-white patients fared worse in overall recovery.
Additionally, researchers noted that older patients who underwent a cancer operation and resided in areas with high social vulnerability were less likely to achieve a "textbook outcome" as a result of their procedures. A "textbook outcome" means that these patients did not have in-hospital complications, an extended hospitalization or a readmission within three months, and that they were alive 90 days after surgery.
Differences Noted by Race
As social vulnerability increased, the outcomes differences by race became more pronounced, Pawlik said.
"Especially for Black and Hispanic individuals, the impact of residing in a socially vulnerable community was much more pronounced," he added. "They had much greater risk of having adverse outcomes than white patients."
Even when the researchers matched patients' characteristics, such as age and cancer type, they found that Blacks and Hispanic patients from high-SVI counties had 26% lower odds of receiving a textbook outcome compared to whites from a low-SVI county.
In general, the differences in textbook outcomes were driven by complications and prolonged hospitalization, according to Pawlik.
"Patients from socially vulnerable communities had the most difficulty achieving a postoperative course without a complication, and they were the most likely to have an extended length of stay. These patients are in double and triple jeopardy," Pawlik said. "Our data clearly showed a disparity in health, as defined by textbook outcome, with poorer outcomes if a patient was a minority, or from a highly socially vulnerable community or, in particular, both."
Recommendations Based on Findings
Pawlik cautioned that, because the SVI is population-based, it is not a useful tool to calculate risk at the individual level. Instead, he says, health care providers should ask about patients' home situations and address their potential lack of resources/support as a routine step in standard of care across all health care systems.
"Make sure patients have the necessary support in the community they are going back into, with access to such things as food, basic services, transportation, home health care and wound care," Pawlik said. "Strong, individualized discharge planning and partnering with community leaders to ensure a smoother transition from the hospital back into the community are key."
Collaborators in this study include J. Madison Hyer, MS, Diamantis I. Tsilimigras, MD, Adrian Diaz, MD, Rosevine A. Azap, Jordan Cloyd, MD, FACS, Mary Dillhoff, MD, FACS, Aslam Ejaz, MD, FACS, and Allan Tsung, MD, FACS, all from The Ohio State University; and Rayyan S. Mirdad of the Royal College of Surgeons, Dublin, Ireland.
Journal of the American College of Surgeons