Patient-Level Social Determinants of Health Risk Factors and Short-Term Outcomes After Major Thoracic and Abdominal Surgery Across a Statewide Academic Healthcare System
Kurt Schultz Doctor of Medicine1, *Emily Y. Park BA1, *Julianna Mastrorilli BS2, Ira L. Leeds MD, MBA, ScM1
1Surgery, Yale School of Medicine, New Haven, CT; 2Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
Background: Early evidence supports an association between social determinants of health (SDOH) and surgical outcomes. Historically, though, these studies have lacked patient-level SDOH granularity and diversity of surgical disease. The aim of this study was to use routine, bedside questionnaires to assess the association of patient-level SDOH risk factors with postoperative complications after major thoracic and abdominal surgery. Study Design: This was a retrospective study of patients who underwent major thoracic and abdominal surgery at the second largest hospital system in the United States from January 1, 2022 to June 30, 2023. SDOH risk factors were collected by bedside nursing staff via a standardized electronic medical record (EMR)-based screening instrument. This SDOH data was linked with National Surgical Quality Improvement Program (NSQIP) institutional quality reporting data. The explanatory variable was “any SDOH risk factor,” defined as having ? one SDOH risk factor (i.e., housing instability, transportation needs, food insecurity, and financial resource strain). The primary outcome was any 30-day NSQIP-defined complication, and secondary outcomes were the length of stay (LOS), discharge disposition, and 30-day readmission. Categorical variables were compared by Chi-squared tests and continuous variables by Wilcoxon rank-sum tests. Results: 1,196 patients met the inclusion criteria. For the four SDOH risk factors, 1.8% (n=22) of patients had medium- or high-risk housing situations, 0.9% (n=11) of patients had unmet transportation needs, 3.2% (n=38) of patients had food insecurity, and 3.4% (n=41) of patients had medium or high financial resource strain. 6.1% (n=73) of patients had any SDOH risk factor. There were no differences in short-term outcomes between patients with and without any SDOH risk for major thoracic surgery. For major abdominal surgery, short-term outcomes were significantly different between the two groups (Table 1). On multivariable logistic regression, patients with any SDOH risk factor had approximately two times the odds of having any 30-day complication after major abdominal surgery compared to patients with no SDOH risk factors (OR, 2.10; 95% CI, 1.03-4.29; p=0.042). Conclusions: Patients who screen positive for at least one SDOH risk factor have a higher likelihood of worse short-term outcomes after major abdominal surgery, but not after major thoracic surgery, compared to those with no SDOH risk factors. The type of complications which occur after major abdominal surgery might be more dependent on the social determinants of health compared to the type of complications which occur after major thoracic surgery. Future studies should investigate if more comprehensive screening modalities improve the quality of data collection and enhance the identification of vulnerable populations undergoing major surgery.
Short-term outcomes for patients with at least one social determinants of health risk factor compared to patients with no social determinants of health risk factors following major abdominal surgery across a large academic healthcare system.
| No social risk (n=796) | Any social risk (n=44) | p-value* | |
| 30-day Postoperative Complicationsa, n (%) | 122 (15.3%) | 12 (27.3%) | 0.035 |
| 30-day Major Complications, n (%) | 108 (13.6%) | 9 (20.5%) | 0.20 |
| Any Significant 30-day Postoperative Eventb, n (%) | 155 (19.5%) | 15 (34.1%) | 0.019 |
| Number of Any 30-day Postoperative Complications, n (%) | 0.20 | ||
| 0 | 641 (80.5%) | 29 (65.9%) | |
| 1 | 83 (10.4%) | 7 (15.9%) | |
| 2 | 43 (5.4%) | 5 (11.4%) | |
| 3 | 16 (2.0%) | 3 (6.8%) | |
| 4+ | 13 (1.7%) | 0 (0.0%) | |
| Hospital Length of Stay, median (IQR) | 4.0 (3.0, 7.0) | 5.0 (4.0, 8.0) | 0.034 |
| Hospital Discharge Disposition, n (%) | 0.003 | ||
| Home/Permanent Residence | 727 (91.3%) | 34 (77.3%) | |
| Other Facility | 58 (7.3%) | 8 (18.2%) | |
| Expired | 5 (0.6%) | 0 (0.0%) | |
| Missing | 6 (0.8%) | 2 (4.5%) | |
| Unplanned 30-day Readmissions, n (%) | 71 (8.9%) | 4 (9.1%) | 0.97 |
*Chi-squared tests for categorical variables; Wilcoxon rank-sum test for continuous variables. aAny 30-day NSQIP-defined postoperative complication; bDefined as a return to the operating room, any 30-day complication, or 30-day readmission.
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