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High Social Vulnerability Linked to Adverse Cancer Surgery Outcomes, Study Finds

Analysis  |  By Christopher Cheney  
   February 08, 2021

Many patients from socially vulnerable communities lack essential resources to achieve optimal surgical outcomes, researcher says.

Cancer surgery patients who live in socially vulnerable communities have a higher likelihood of adverse outcomes than other patients, a recent research article says.

Social determinants of health are widely recognized as a key component of healthcare inequities. "Social determinants of health such as poverty, unequal access to healthcare, lack of education, stigma, and racism are underlying, contributing factors of health inequities," the Centers for Disease Control and Prevention (CDC) says.

The recent research article, which was published by the Journal of the American College of Surgeons, is based on data collected from more than 200,000 cancer surgery patients.

The study evaluated the relationship between "textbook outcomes" and social vulnerability, which was measured using the CDC's Social Vulnerability Index (SVI). A textbook outcome was defined as the absence of complications, extended length of stay, readmission, and mortality. The SVI features 15 variables drawn from U.S. Census data, including poverty, vehicle access, and the quality of housing.

The study includes three key data points.

  • Patients with a high SVI ranking were more likely to experience complications than patients with a low SVI ranking: 24.0% of high-SVI patients experienced complications vs. 21.5% of low-SVI patients.
  • Patients with a high SVI ranking were more likely to experience 90-day mortality than patients with a low SVI ranking: 8.4% of high-SVI patients experienced 90-day mortality vs. 7.0% of low-SVI patients.
  • Race was also associated with adverse outcomes. White patients with a high SVI ranking had 10% lower odds of having textbook outcomes. Non-white patients with a high SVI ranking had 22% lower odds of having textbook outcomes.

"Collectively, the data strongly suggested that cancer patients from areas characterized by high social vulnerability were at higher risk of adverse postoperative outcomes independent of other measured variables," the study's co-authors wrote.

Interpreting and assessing the data

The corresponding author of the study told HealthLeaders the data features three findings.

"First, we found that patients who were black or Hispanic were disproportionately represented in high socially vulnerable communities. Second, even if you did not look at race and ethnicity, if you resided in a community that was very vulnerable, then you had a very much higher risk of having worse outcomes postoperatively. Third, if you happened to be a minority and living in a socially vulnerable neighborhood, it had an additive effect. So, those patients were in double jeopardy for having lower odds for an optimal outcome after surgery," said Timothy Pawlik, MD, PhD, MPH, surgeon-in-chief at The Ohio State University Wexner Medical Center, and chair at the Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio.

Patients with a high SVI ranking lack critical resources to lower the odds of adverse surgical outcomes, he said.

"The SVI is basically reflective of how rich the resources are in a community. If you have bad transportation, it is hard for you to get to your clinic appointment or to get to the hospital in a timely manner. If you have substandard housing, it is going to make it much more challenging after you get discharged from a complex operation to have as good a recovery compared to a patient who is discharged home to a much more affluent setting that has many more resources. For socioeconomic status, if you are discharged home into a community that is more economically deprived, it is more difficult to get the resources that you need such as food, transportation, and assistance to recover from your surgery."

Impact of race on outcomes

The study's data reflect systemic racial inequalities in the country, Pawlik said.

"We know that patients who are black or Hispanic have worse healthcare outcomes than their white counterparts, even after you control for insurance status and disease stage. The data that we present in this paper shows that even if you control for social vulnerability, black and Hispanic patients still did worse. If black and Hispanic patients are also in a socially deprived or vulnerable neighborhood, it is even more difficult for them to overcome barriers."

Addressing social vulnerability

Physicians and hospitals can take actions to address social vulnerability at the patient level, Pawlik said.

"There are good screening tools that are available to do this work. If we can identify that a patient comes from a socially vulnerable community or environment, then we can mobilize resources in the hospital such as social work, patient care managers, and patient navigators to interact with patients to get them the resources that they may need around housing, food insecurity, and transportation."

At the community level, healthcare organizations need to support efforts to build healthy neighborhoods, he said. "We need to look beyond the doors of our hospital and begin to look at systematic change in the environments in which our patients live. We need to create healthy communities because that will ultimately help us achieve better outcomes in perioperative care."

Photo credit: Florida Chuck

Related: Social Determinants of Health: Lead or Partner?

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Cancer surgery patients from more socially vulnerable communities were more likely to experience complications than patients from less socially vulnerable communities, according to a new study.

Cancer surgery patients from more socially vulnerable communities were more likely to experience 90-day mortality than patients from less socially vulnerable communities, the study found.

Black and Hispanic cancer surgery patients had worse outcomes than white patients, the study found.

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