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January 7, 2020/Diabetes & Endocrinology

Surgical Outcomes Linked to Geographic Measures of Socioeconomic Status and Deprivation

Odds of mortality increase as geographic distress increases, study finds

Patient in wheelchair, black woman

There is a consistent and fairly robust association between surgical outcomes and geographic measures of socioeconomic status and deprivation, according to new research. Previously, an association between outcomes and socioeconomic status has been established across a variety of settings. The new findings are notable, according to co-author Jesse Schold, PhD, a researcher with Cleveland Clinic’s Department of Quantitative Health Sciences, because of the strength and consistency of the association.


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“The association is strong across the board, regardless of acuity level or the specific geographic area,” says Dr. Schold. “While we don’t know the specific mechanisms of the effect at this time, the association is consistent enough that it requires further study and consideration for other policy and interventional work.”

In the study, researchers analyzed the hospital discharges of more than 1.5 million patients following major surgery in seven states. Specifically, the team was interested in the impact of geographic risk on inpatient mortality, length of stay, hospital costs, discharge status and 30-day all-cause readmission.

The odds of inpatient mortality increased as geographic distress increased, after adjusting for patient, hospital and discharge factors. This was true regardless of geographic location, median household income, percent living in poverty and life expectancy estimates.

“The effect is similar in magnitude to many other, traditional clinical co-morbidity effects,” Dr. Schold explains. “This suggests that socioeconomic status and deprivation need to be considered in the development of plans of care and risk assessment, and potentially for risk stratification, in much the same way as we think about clinical risk factors.”

Risk adjustments for socioeconomic status

Adjusting for social risks is important for two key reasons, according to Dr. Schold:

  • Social risks may vary by the institutions that treat these populations.
  • Accounting for those differences may attenuate reluctance to treat patients that carry higher levels of social burden.

“I think it’s important to be transparent and adjust for these differences in risk. Otherwise, providers who have a higher prevalence of patients with these risk factors may look worse on paper when, really, the outcomes may be independent of the quality of care they provide,” says Dr. Schold.


“In the current quality measurement landscape, which includes public-facing quality rating and ranking programs as well as direct impacts on reimbursement, there is not sufficient accounting for these social determinants of health, which clearly impact outcomes that matter for our patients,” states Aaron Hamilton, MD, MBA, Interim Chief Quality Officer at Cleveland Clinic. “In order to best serve our patients and deliver exceptional outcomes, we must understand and address these impacts. This research brings us one step closer to executing on that mandate.”

Population health

This study also has implications on population health, both in terms of developing interventions to help address risks related to socioeconomic status and deprivation, and also how we partner with community partners to facilitate optimal care for patients with these additional challenges.

“Ultimately,” explains Dr. Schold, “the biggest implication is how we can think about treating patients with these various risk factors that aren’t traditionally clinical. There’s this new concept of personalized population health, where, for example, we need to think about not just treating obese patients versus non-obese patients differently in terms of managing their surgical risks, but need to acknowledge that patients come with certain social burdens and develop interventions to treat those appropriately. There’s a lot more work to be done about how to consider these differences in care management.”

At Cleveland Clinic, this work is already underway. “Traditionally, health systems have viewed our responsibility to end where our doors were, and that has changed,” says Adam Myers, MD, MHCM, Chief of Population Health at Cleveland Clinic and Director of Cleveland Clinic Community Care. “One of the first steps in changing that approach starts with simply asking about our patient’s socioeconomic needs. We are now beginning to systematically query patients about food insecurity, homelessness, safety, transportation and other social determinants of health. This can now be entered into the electronic medical record as a reference for care and as a way to connect patients with the services they need to address their needs. In time, we will become as proficient at helping with these needs as we are with traditional medical treatments.”


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