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Community level socioeconomic status association with surgical outcomes and resource utilisation in a regional cohort: a prospective registry analysis
  1. J Hunter Mehaffey1,
  2. Robert B Hawkins1,
  3. Eric J Charles1,
  4. Florence E Turrentine1,
  5. Brian Kaplan2,
  6. Sandy Fogel3,
  7. Charles Harris3,
  8. David Reines4,
  9. Jorge Posadas5,
  10. Gorav Ailawadi1,
  11. John B Hanks1,
  12. Peter T Hallowell1,
  13. R Scott Jones1
  1. 1 Surgery, University of Virginia, Charlottesville, Virginia, USA
  2. 2 Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
  3. 3 Department of Surgery, Carilion Clinic, Roanoke, Virginia, USA
  4. 4 Department of Surgery, Inova Mount Vernon Hospital, Alexandria, Virginia, USA
  5. 5 Department of Surgery, Winchester Medical Center, Winchester, Virginia, USA
  1. Correspondence to Dr J Hunter Mehaffey, Surgery, University of Virginia, Charlottesville, VA 22903, USA; jhm9t{at}


Background Socioeconomic status affects surgical outcomes, however these factors are not included in clinical quality improvement data and risk models. We performed a prospective registry analysis to determine if the Distressed Communities Index (DCI), a composite socioeconomic ranking by zip code, could predict risk-adjusted surgical outcomes and resource utilisation.

Methods All patients undergoing surgery (n=44,451) in a regional quality improvement database (American College of Surgeons-National Surgical Quality Improvement Program ACS-NSQIP) were paired with DCI, ranging from 0–100 (low to high distress) and accounting for unemployment, education level, poverty rate, median income, business growth and housing vacancies. The top quartile of distress was compared to the remainder of the cohort and a mixed effects modeling evaluated ACS-NSQIP risk-adjusted association between DCI and the primary outcomes of surgical complications and resource utilisation.

Results A total of 9369 (21.1%) patients came from severely distressed communities (DCI >75), who had higher rates of most medical comorbidities as well as transfer status (8.4% vs 4.8%, p<0.0001) resulting in higher ACS-NSQIP predicted risk of any complication (8.0% vs 7.1%, p<0.0001). Patients from severely distressed communities had increased 30-day mortality (1.8% vs 1.4%, p=0.01), postoperative complications (9.8% vs 8.5%, p<0.0001), hospital readmission (7.7 vs 6.8, p<0.0001) and resource utilisation. DCI was independently associated with postoperative complications (OR 1.07, 95% CI 1.04 to 1.10, p<0.0001) as well as resource utilisation after adjusting for ACS-NSQIP predicted risk

Conclusion Increasing Distressed Communities Index is associated with increased postoperative complications and resource utilisation even after ACS-NSQIP risk adjustment. These findings demonstrate a disparity in surgical outcomes based on community level socioeconomic factors, highlighting the continued need for public health innovation and policy initiatives.

  • health policy
  • healthcare quality improvement
  • patient safety
  • surgery
  • quality improvement

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  • Funding This study was supported by National Heart, Lung, and Blood Institute (T32HL00784).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.