Impact of hospital quality on surgical outcomes in patients with high social vulnerability: Association of textbook outcomes and social vulnerability by hospital quality

Abstract

BackgroundWe sought to define the impact of high- versus low-quality hospitals on the risk of adverse outcomes among patients undergoing hepatopancreatic surgery relative to social vulnerability. Social vulnerability is an important factor associated with risk of adverse postoperative outcomes. MethodsPatients from 2013 to 2017 were identified from the Medicare Inpatient Standard Analytic File. Hospital quality was determined by calculating risk-adjusted probability to achieve a textbook outcome. The Social Vulnerability Index was used to categorize patients. Risk-adjusted probability of mortality, morbidity, and textbook outcome was examined across varying social vulnerability indices stratified by low-, average-, and high-quality hospitals. ResultsAmong 27,000 patients who underwent a pancreatectomy (67%) or hepatectomy (33%%), median patient age was 72 years, 48% were female, and 89% were White; mean Social Vulnerability Index was 49. Risk-adjusted 90-day mortality (odds ratio: 1.32, 95% CI: 1.20–1.59, P = .004) and postoperative complications (odds ratio: 1.12, 95% confidence interval: 1.00–1.24, P = .044) were both higher among beneficiaries from the highest social vulnerability counties versus the lowest counties. At low-quality hospitals, patients from the highest vulnerability counties had 70% higher odds of mortality (odds ratio: 1.70, 95% confidence interval: 1.16–2.48, P = .007), 31% higher odds of overall morbidity odds ratio: 1.31, 95% confidence interval: 1.05–2.63, P = .013), and 19% lower odds of achieving a textbook outcome (odds ratio: 0.81, 95% confidence interval: 0.66–0.99, P = .035)—all of which were markedly worse compared with outcomes achieved at high-quality hospitals. ConclusionAmong patients with increased social vulnerability, outcomes were considerably better at high-quality hospitals. Referral of socially vulnerable patients to high-quality hospitals represents an important opportunity to ensure optimal outcomes after complex surgery.