46. Readmission between 90 days and 2 years following spinal surgery: What role do socioeconomic and community factors play?

Abstract

<h3>BACKGROUND CONTEXT</h3> Socioeconomic status (SES) underlies three prominent determinants of health inequity: access and quality of care, environmental exposure and health behavior. We analyzed how the qualities of a patient's community, their access to health care and socioeconomic status affect their risk of readmission between postoperative day (POD) 90- and 2-years postop. <h3>PURPOSE</h3> To discern how socioeconomic determinants, the qualities of a patient's community, their access to health care, and socioeconomic status, affect their risk of readmission between postoperative day (POD) 90- and 2-years post-op. <h3>STUDY DESIGN/SETTING</h3> Tertiary care facility. <h3>PATIENT SAMPLE</h3> A total of 3,079 patients undergoing spinal surgery between 2012 and 2018 were retrospectively identified from a prospectively collected database. <h3>OUTCOME MEASURES</h3> (1) Readmissions 90-180-day postoperative; (2) 180 day-2-year readmissions. <h3>METHODS</h3> Utilizing our prospectively collected institutional database, 3,079 patients undergoing spinal surgery between 2012 and 2018 were retrospectively identified. During the year that each patient underwent surgery, social and economic neighborhood determinants were calculated for each patient-specific zip code using publicly available databases. Utilizing the 2012-2018 versions of the American Community Survey (ACS), a surrogate for each patient's annual income was estimated. We characterized each patient by their age, race, sex, employment status and insurance status. An income distribution was generated for each patient by utilizing the Public Use Micro Area level (the smallest, sub-county, geographic unit). Each patient was assigned the median measurement of the income distribution specific to their demographic characteristics and zip code. Differences in socioeconomic measures when compared to nonreadmitted patients were discerned using the Kruskal–Wallis test followed by Dunn's post-hoc tests. Significance was defined as P<0.05. <h3>RESULTS</h3> Patients readmitted between POD90-180 resided in neighborhoods where families living below the federal poverty line (FPL) were 28.6% more prevalent (13.57% vs 10.55%; P=0.01). The racial distribution of those neighborhoods was 28.3% more nonwhite (39.2% vs 29.7%; P=0.02), and a significantly greater proportion of residents cited experiencing chronic physical distress (P=0.04), mental distress (P=0.01) and encountering chronic activity limitation due to infrastructural barriers (P=0.04). In addition to those same significant differences observed at POD180, patients readmitted by 2 years additionally had 15.7% lower surrogate incomes than those who were never readmitted ($42,687.76 vs $50,640.42, P=0.0027). Importantly, there were stark differences between White patients and Black/African American patients within each cohort of readmitted patients (POD180 and 2 Year). For example, at 180D, Black/African American patients had 20.9% lower surrogate income ($48,078 vs $38,007; P=0.013) and resided in neighborhoods with 8.5% higher GINI Income Inequality Index Scores (0.51 vs 0.47; P<0.0001). Those neighborhoods additionally had 159.9% higher prevalence of families residing below the FPL (23.7% vs 9.1%; P<0.0001), 53.8% lower median household value ($132,527 vs $287,137; P<0.0001), 19.6% higher obesity prevalence (10.9 vs 9.2; P<0.0001), 8.8% more patients per primary care provider (PCP) (1.36 vs 1.25; P=0.0013), and 179.5% greater proportion of nonwhite residents (66.5% vs 23.8%; P<0.0001). <h3>CONCLUSIONS</h3> Patterns of racial and ethnic segregation in urban environments have given rise to significant disparities in access and quality of care. In this retrospective study of long-term postoperative readmissions, we found patients readmitted after 90 days had lower estimated personal income and resided in neighborhoods with lower access to care, greater activity limitation, and more economic disparity, especially among Black/African American patients. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.