Despite insurance coverage, people living in poor neighborhoods have worse surgical outcomes: study

Patients living in poor neighborhoods are more likely to have worse post-surgical outcomes even if they’ve got insurance coverage, according to a study published Feb. 7 in JAMA Surgery.

Paula K. Shireman, M.D., a professor at Texas A&M University School of Medicine and the study’s corresponding author, told Fierce Healthcare in an email, that the study “suggests that the most impactful way to improve outcomes in patients with low socioeconomic status is to focus on preventive care to decrease rates of [preoperative acute serious conditions (PASC)] and urgent/emergent surgeries.”

Shireman and fellow researchers affiliated with various teaching hospitals measured textbook outcomes (TO)—meaning outcomes less likely to result in death, complications or readmissions. They also looked at the area deprivation index (ADI), which the Centers for Disease Control and Prevention defines as a “multidimensional evaluation of a region’s socioeconomic conditions, which have been linked to health outcomes.”

Paula K Shireman, M.D. (Texas A&M University)

Researchers looked at data collected from 2013 to 2019 by the National Surgical Quality Improvement Program (NSQIP) for 29,924 patients, of which 14,306 patients had private insurance and 15,618 had Medicare.

“This study found that patients living in highly deprived neighborhoods had lower or worse odds of TO and higher presentation acuity despite having private insurance or Medicare,” the study states. “These findings suggest that insurance coverage expansion alone is insufficient to overcome healthcare disparities, possibly due to persistent barriers to preventive care and other complex causes of health inequities.”

That’s not to say that the researchers discount the crucial role healthcare coverage plays in keeping individuals healthy; they describe it as “an important first step.” They hope their findings prod payers and other healthcare systems to use ADI to spot high-risk patients even if those individuals don't have insurance coverage.

“Self-insured employers and health plans could use the Area Deprivation Index and/or other social risk factors such as employees with incomes near the poverty line to offer additional assistance,” Shireman told Fierce Healthcare. “For example, encourage patients to have a primary care provider, waive copays for low SES patients, develop policies for employees to access health care without losing hourly wages. We think there would be a positive return on investment, especially for self-insured employers, in substituting preventive for emergency care and less disruption of their workforce due to unexpected sick leave.”

Researchers say they were able to get better data on PASCs by using the NSQIP. “Patients living in deprived neighborhoods had increased odds of presenting with PASC, and having PASC was associated with worse outcomes,” the study states. “Most administrative databases cannot accurately differentiate between acute preoperative conditions from postoperative complications.”

They cite as an example pneumonia, which can be either a reason for going to the hospital or a result of surgery. “Using administrative data that do not account for differences in PASC may lead to reduced resources for hospitals caring for vulnerable patient populations with higher rates of PASC.”

The study’s authors argue that NSQIP data should include vigorous data about social determinants of health to further improve risk management.

Researchers also looked at urgent or emergency care status of patients and found that patients living in highly deprived neighborhoods were more prone to having to have such care than patients not living in such areas.

They note that while the Centers for Medicare & Medicaid Services has toyed with the idea of adding ADI to risk adjustment, those proposals have yet to generate much traction.

However, that shouldn’t prevent hospital systems from using their data about outcomes and insurance to gain insight into the ADI of patients they serve.

“Nationally, improving risk adjustment for presentation acuity and adding measures such as the ADI to risk adjustment can be an important step to improve … accounting for differences in populations served by healthcare systems and resource availability within local communities,” the study states.

Shireman says that “from a healthcare policy perspective, the higher presentation acuity associated with patients living in highly deprived neighborhoods suggests that healthcare systems/providers caring for patients with low SES may have worse outcomes due to higher presentation acuity rather than lower quality of care within the hospital setting."

“Penalizing safety-net hospitals for increased readmissions and other ‘quality of care’ indicators reduces resources to providers caring for our most vulnerable patients,” Shireman said.