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Impact of Residential Racial Integration on Postoperative Outcomes Among Medicare Beneficiaries Undergoing Resection for Cancer

  • Global Health Services Research
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Introduction

While social determinants of health may adversely affect various populations, the impact of residential segregation on surgical outcomes remains poorly defined.

Objective

The objective of the current study was to examine the association between residential segregation and the likelihood to achieve a textbook outcome (TO) following cancer surgery.

Methods

The Medicare 100% Standard Analytic Files were reviewed to identify Medicare beneficiaries who underwent resection of lung, esophageal, colon, or rectal cancer between 2013 and 2017. Shannon’s integration index, a measure of residential segregation, was calculated at the county level and its impact on composite TO [no complications, no prolonged length of stay (LOS), no 90-day readmission, and no 90-day mortality] was examined.

Results

Among 200,509 patients who underwent cancer resection, the overall incidence of TO was 56.0%. The unadjusted likelihood of achieving a TO was lower among patients in low integration areas [low integration: n = 19,978 (55.0%) vs. high integration: n = 18,953 (59.3%); p < 0.001]. On multivariable analysis, patients residing in low integration areas had higher odds of complications [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.03–1.11], extended LOS (OR 1.13, 95% CI 1.09–1.18), and 90-day mortality (OR 1.29, 95% CI 1.22–1.38) and, in turn, lower odds of achieving a TO (OR 0.87, 95% CI 0.84–0.90) versus patients from highly integrated communities.

Conclusion

Patients who resided in counties with a lower integration index were less likely to have an optimal TO following resection of cancer compared with patients who resided in more integrated counties. The data highlight the importance of increasing residential racial diversity and integration as a means to improve patient outcomes.

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References

  1. Chetty R, Stepner M, Abraham S, et al. The association between income and life expectancy in the United States, 2001–2014. JAMA. 2016;315(16):1750–66.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Graham GN. Why your ZIP code matters more than your genetic code: promoting healthy outcomes from mother to child. Breastfeed Med. 2016;11:396–7.

    Article  PubMed  Google Scholar 

  3. Meyer OL, Castro-Schilo L, Aguilar-Gaxiola S. Determinants of mental health and self-rated health: a model of socioeconomic status, neighborhood safety, and physical activity. Am J Public Health. 2014;104(9):1734–41.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Puckrein GA, Egan BM, Howard G. Social and medical determinants of cardiometabolic health: the big picture. Ethn Dis. 2015;25(4):521–4.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Bennett KM, Scarborough JE, Pappas TN, et al. Patient socioeconomic status is an independent predictor of operative mortality. Ann Surg 2010; 252(3):552–7; discussion 557–8.

  6. Semega J, Kollar M, Shrider EA, Creamer JF. Income and poverty in the United States: 2019. Current Population Reports. Washington DC: United States Census Buruea; 2020. pp. 60–270.

  7. Rangrass G, Ghaferi AA, Dimick JB. Explaining racial disparities in outcomes after cardiac surgery: the role of hospital quality. JAMA Surg. 2014;149(3):223–7.

    Article  PubMed  Google Scholar 

  8. Nathan H, Frederick W, Choti MA, et al. Racial disparity in surgical mortality after major hepatectomy. J Am Coll Surg. 2008;207(3):312–9.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Popescu I, Duffy E, Mendelsohn J, et al. Racial residential segregation, socioeconomic disparities, and the White-Black survival gap. PLoS One. 2018;13(2):e0193222.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  10. Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep. 2001;116(5):404–16.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Landrine H, Corral I, Lee JGL, et al. Residential Segregation and Racial Cancer Disparities: A Systematic Review. J Racial Ethn Health Disparities. 2017;4(6):1195–205.

    Article  PubMed  Google Scholar 

  12. Kershaw KN, Pender AE. Racial/ethnic residential segregation, obesity, and diabetes mellitus. Curr Diab Rep. 2016;16(11):108.

    Article  PubMed  Google Scholar 

  13. Diaz A, Chavarin D, Paredes AZ, et al. Association of neighborhood characteristics with utilization of high-volume hospitals among patients undergoing high-risk cancer surgery. Ann Surg Oncol. 2021;28(2):617–31.

    Article  PubMed  Google Scholar 

  14. Lucas FL, Stukel TA, Morris AM, et al. Race and surgical mortality in the United States. Ann Surg. 2006;243(2):281–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Allen JG, Weiss ES, Arnaoutakis GJ, et al. The impact of race on survival after heart transplantation: an analysis of more than 20,000 patients. Ann Thorac Surg 2010; 89(6):1956–63; discussion 1963–4.

  16. Trivedi AN, Sequist TD, Ayanian JZ. Impact of hospital volume on racial disparities in cardiovascular procedure mortality. J Am Coll Cardiol. 2006;47(2):417–24.

    Article  PubMed  Google Scholar 

  17. Godley PA, Schenck AP, Amamoo MA, et al. Racial differences in mortality among Medicare recipients after treatment for localized prostate cancer. J Natl Cancer Inst. 2003;95(22):1702–10.

    Article  PubMed  Google Scholar 

  18. Mehta R, Paredes AZ, Tsilimigras DI, et al. Influence of hospital teaching status on the chance to achieve a textbook outcome after hepatopancreatic surgery for cancer among Medicare beneficiaries. Surgery. 2020;168(1):92–100.

    Article  PubMed  Google Scholar 

  19. Tsilimigras DI, Mehta R, Merath K, et al. Hospital variation in Textbook Outcomes following curative-intent resection of hepatocellular carcinoma: an international multi-institutional analysis. HPB (Oxford). 2020;22(9):1305–13.

    Article  Google Scholar 

  20. Heidsma CM, Hyer M, Tsilimigras DI, et al. Incidence and impact of Textbook Outcome among patients undergoing resection of pancreatic neuroendocrine tumors: results of the US Neuroendocrine Tumor Study Group. J Surg Oncol. 2020;121(8):1201–8.

    Article  PubMed  Google Scholar 

  21. Shwartz M, Restuccia JD, Rosen AK. Composite measures of health care provider performance: a description of approaches. Milbank Q. 2015;93(4):788–825.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Kolfschoten NE, Kievit J, Gooiker GA, et al. Focusing on desired outcomes of care after colon cancer resections; hospital variations in ‘textbook outcome.’ Eur J Surg Oncol. 2013;39(2):156–63.

    Article  CAS  PubMed  Google Scholar 

  23. Shannon C. A mathematical theory of communication. Bell Syst Techn J. 1948;27(379–423):623–56.

    Article  Google Scholar 

  24. Reardon S, O’Sullivan D. Measures of spatial segregation. Sociol Methodol. 2004;34:121–62.

    Article  Google Scholar 

  25. Schilling M. Measuring diversity in the United States. Math Horizons. 2002;9(4):29–30.

    Article  Google Scholar 

  26. Morris EK, Caruso T, Buscot F, et al. Choosing and using diversity indices: insights for ecological applications from the German Biodiversity Exploratories. Ecol Evol. 2014;4(18):3514–24.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Centers for Medicare and Medicaid Services Limited Data Set (LDS) Files 06/30/2020 11:06 AM. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/Data-Disclosures-Data-Agreements/DUA_-_NewLDS. Accessed 23 Feb 2021.

  28. Manson S, Schroeder J, Van Riper D et al. IPUMS National Historical Geographic Information System: Version 15.0.

  29. Bureau USC. Housing patterns. Appendix B: measures of residential segregation. Available at: https://www.census.gov/topics/housing/housing-patterns/guidance/appendix-b.html. Accessed 29 Oct 2020.

  30. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.

    Article  CAS  Google Scholar 

  31. Quan H, Li B, Couris CM, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173(6):676–82.

    Article  PubMed  Google Scholar 

  32. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43(11):1130–9.

    Article  Google Scholar 

  33. Agency for Toxic Substances and Disease Registry. CDC Social Vulnerability Index September 15, 2020, Available at: https://www.atsdr.cdc.gov/placeandhealth/svi/index.html. Accessed 27 Nov 2020.

  34. Merath K, Chen Q, Bagante F, et al. Textbook outcomes among medicare patients undergoing hepatopancreatic surgery. Ann Surg. 2020;271(6):1116–23.

    Article  PubMed  Google Scholar 

  35. Iezzoni LI, Daley J, Heeren T, et al. Identifying complications of care using administrative data. Med Care. 1994;32(7):700–15.

    Article  CAS  PubMed  Google Scholar 

  36. Arcaya MC, Tucker-Seeley RD, Kim R, et al. Research on neighborhood effects on health in the United States: a systematic review of study characteristics. Soc Sci Med. 2016;168:16–29.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Oakes JM, Andrade KE, Biyoow IM, et al. Twenty years of neighborhood effect research: an assessment. Curr Epidemiol Rep. 2015;2(1):80–7.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Oakes JM. Commentary: advancing neighbourhood-effects research–selection, inferential support, and structural confounding. Int J Epidemiol. 2006;35(3):643–7.

    Article  PubMed  Google Scholar 

  39. Diez Roux AV. Investigating neighborhood and area effects on health. Am J Public Health. 2001;91(11):1783–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Diez Roux AV, Mair C. Neighborhoods and health. Ann N Y Acad Sci. 2010;1186:125–45.

    Article  PubMed  Google Scholar 

  41. Schwarz D. What’s the Connection Between Residential Segregation and Health? 2018. Available at: https://www.rwjf.org/en/blog/2016/03/what_s_the_connectio.html. Accessed 27 Nov 2020.

  42. Woo B, Kravitz-Wirtz N, Sass V, et al. Residential segregation and racial/ethnic disparities in ambient air pollution. Race Soc Probl. 2019;11(1):60–7.

    Article  PubMed  Google Scholar 

  43. Mayne SL, Hicken MT, Merkin SS, et al. Neighbourhood racial/ethnic residential segregation and cardiometabolic risk: the multiethnic study of atherosclerosis. J Epidemiol Commun Health. 2019;73(1):26–33.

    Article  Google Scholar 

  44. Yu CY, Woo A, Hawkins C, et al. The Impacts of residential segregation on obesity. J Phys Act Health. 2018;15(11):834–9.

    Article  PubMed  Google Scholar 

  45. Mayne SL, Yellayi D, Pool LR, et al. Racial residential segregation and hypertensive disorder of pregnancy among women in Chicago: analysis of electronic health record data. Am J Hypertens. 2018;31(11):1221–7.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Williams AD, Wallace M, Nobles C, et al. Racial residential segregation and racial disparities in stillbirth in the United States. Health Place. 2018;51:208–16.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Mehtsun WT, Figueroa JF, Zheng J, et al. Racial disparities in surgical mortality: the gap appears to have narrowed. Health Aff (Millwood). 2017;36(6):1057–64.

    Article  Google Scholar 

  48. Health in all policies: Helsinki statement. Framework for country action 2013. Available at: https://www.who.int/publications/i/item/9789241506908. Accessed 25 Feb 2021.

  49. Hayanga AJ, Zeliadt SB, Backhus LM. Residential segregation and lung cancer mortality in the United States. JAMA Surg. 2013;148(1):37–42.

    Article  PubMed  Google Scholar 

  50. Haas JS, Earle CC, Orav JE, et al. Racial segregation and disparities in cancer stage for seniors. J Gen Intern Med. 2008;23(5):699–705.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Sarrazin MV, Campbell M, Rosenthal GE. Racial differences in hospital use after acute myocardial infarction: Does residential segregation play a role? Health Aff (Millwood). 2009;28(2):w368–78.

    Article  Google Scholar 

  52. Dimick J, Ruhter J, Sarrazin MV, et al. Black patients more likely than whites to undergo surgery at low-quality hospitals in segregated regions. Health Aff (Millwood). 2013;32(6):1046–53.

    Article  Google Scholar 

  53. Higgins RS. Truth and consequences: it’s not a game anymore. JAMA Surg. 2014;149(3):228.

    Article  PubMed  Google Scholar 

  54. Azap RA, Paredes AZ, Diaz A, et al. The association of neighborhood social vulnerability with surgical textbook outcomes among patients undergoing hepatopancreatic surgery. Surgery. 2020;168(5):868–75.

    Article  PubMed  Google Scholar 

  55. Timberlake JM, Ignatov MD. Residential Segregation May 10, 2017, 2014. Available at: https://www.oxfordbibliographies.com/view/document/obo-9780199756384/obo-9780199756384-0116.xml. Accessed 27 Nov 2020.

  56. Thornton RL, Glover CM, Cene CW, et al. Evaluating strategies for reducing health disparities by addressing the social determinants of health. Health Aff (Millwood). 2016;35(8):1416–23.

    Article  Google Scholar 

  57. Morrill R. On the measure of spatial segregation. Geogr Res Forum. 1991;11:25–36.

    Google Scholar 

  58. Wong D. Spatial dependency of segregation indices. Can Geogr. 1997;41(2):128–36.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA

    Alessandro Paro MD, Djhenne Dalmacy MS, J. Madison Hyer MS , Diamantis I. Tsilimigras MD, Adrian Diaz MD  & Timothy M. Pawlik MD, MPH, MTS, PhD

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  1. Alessandro Paro MD
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  2. Djhenne Dalmacy MS
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  3. J. Madison Hyer MS
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  4. Diamantis I. Tsilimigras MD
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  5. Adrian Diaz MD
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Correspondence to Timothy M. Pawlik MD, MPH, MTS, PhD.

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Alessandro Paro, Djhenne Dalmacy, J. Madison Hyer, Diamantis I. Tsilimigras, Adrian Diaz, and Timothy M. Pawlik have no conflicts of interest to report.

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Paro, A., Dalmacy, D., Madison Hyer, J. et al. Impact of Residential Racial Integration on Postoperative Outcomes Among Medicare Beneficiaries Undergoing Resection for Cancer. Ann Surg Oncol 28, 7566–7574 (2021). https://doi.org/10.1245/s10434-021-10034-w

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