County-Level Social Vulnerability Is Associated With Worse Surgical Outcomes Especially Among Minority Patients

Adrian Diaz, MD, MPH; J. Madison Hyer, MS; Elizabeth Barmash, BS; Rosevine Azap, BS; Anghela Z. Paredes, MD, MS; Timothy M. Pawlik, MD, MPH, PhD


Annals of Surgery. 2021;274(6):881-891. 

In This Article

Abstract and Introduction


Objective: We sought to characterize the association between patient county-level vulnerability with postoperative outcomes.

Summary Background Data: Although the impact of demographic-, clinical- and hospital-level factors on outcomes following surgery have been examined, little is known about the effect of a patient's community of residence on surgical outcomes.

Methods: Individuals who underwent colon resection, coronary artery bypass graft (CABG), lung resection, or lower extremity joint replacement (LEJR) were identified in the 2016 to 2017 Medicare database, which was merged with Center for Disease Control social vulnerability index (SVI) dataset at the beneficiary level of residence. Logistic regression models were utilized to estimate the probability of postoperative complications, mortality, readmission, and expenditures.

Results: Among 299,583 Medicare beneficiary beneficiaries who underwent a colectomy (n = 88,778, 29.6%), CABG (n = 109,564, 36.6%), lung resection (n = 30,401, 10.1%), or LEJR (n = 70,840, 23.6%).

Mean SVI score was 50.2 (standard deviation: (25.2); minority patients were more likely to reside in highly vulnerable communities (low SVI: n = 3531, 5.8% vs high SVI: n = 7895, 13.3%; P < 0.001). After controlling for competing risk factors, the risk-adjusted probability of a serious complication among patients from a high versus low SVI county was 10% to 20% higher following colectomy [odds ratio (OR) 1.1 95% confidence intervals (CI) 1.1–1.2] or CABG (OR 1.2 95%CI 1.1–1.3), yet there no association of SVI with risk of serious complications following lung resection (OR 1.2 95%CI 1.0–1.3) or LEJR (OR 1.0 95%CI 0.93–1.2). The risk-adjusted probability of 30-day mortality was incrementally higher among patients from high SVI counties following colectomy (OR 1.1 95%CI 1.1–1.3), CABG (OR 1.4, 95%CI 1.2–1.5), and lung resection (OR 1.4 (95%CI 1.1–1.8), yet not LEJR (OR 0.95 95%CI 0.72–1.2). Black/minority patients undergoing a colectomy, CABG, or lung resection who lived in highly socially vulnerable counties had an estimate 28% to 68% increased odds of a serious complication and a 58% to 60% increased odds of 30-day mortality compared with a Black/minority patient from a low socially vulnerable county, as well as a markedly higher risk than White patients (all P > 0.05).

Conclusions: Patients residing in vulnerable communities characterized by a high SVI generally had worse postoperative outcomes. The impact of social vulnerability was most pronounced among Black/minority patients, rather than White individuals. Efforts to ensure equitable surgical outcomes need to focus on both patient-level, as well as community-specific factors.


Patient-level characteristics such as age, sex, and race have been extensively studied as predictors of surgical outcomes.[1–5] Furthermore, factors such as insurance type, health literacy, cost, and geographic access, have similarly been examined in the context of surgical outcomes.[6–11] There is an emerging belief, however, that a person's community may play an equally – if not more – important role in achieving optimal health.[12–14] For example, neighborhoods are highly correlated with housing quality, municipal services, public transportation, and commuting patterns, as well as educational and employment opportunities.[15–18] Because these factors can influence baseline health as well as access to health care,[19,20] patient-related outcomes may be adversely affected by where an individual lives. To this end, the World Health Organization's (WHO's) Commission on the Social Determinants of Health released a report in 2008 that highlighted the critical role of Social Determinants of Health (SDOH) in propagating societal health inequities and advocated for policy changes to promote the eradication of these inequities.[21] SDOH have been defined as various facets of an individual's life that can influence their health and well-being, including economic stability, neighborhood and physical environment, education, and food.[22–24]

Some health policymakers have advocated for screening of SDOH as a means to foster achievement of the triple aim of better health, improved health care delivery, and reduced costs – given that social and environmental factors may contribute up to one-half of the modifiable factors that influence health.[25,26] Policies aimed at addressing SDOH have largely focused, however, on facilitating healthy behaviors, as well as improving access and financing of health care services.[27,28] In particular, most efforts on screening and addressing SDOH have been relegated to patients seen by primary care providers or specialty physicians focused on chronic conditions.[20] Although an operation represents a more discrete "episode of care" compared with management of chronic health conditions, a patient's daily lived environment still may have important implications for surgical outcomes.

Understanding the association between access to surgery, postoperative outcomes and the characteristics of the neighborhood of residence may be important to patients, surgeons, and policymakers. Despite emerging interest in the impact of neighborhood characteristics relative to health care outcomes, little is known as to whether surgical outcomes are affected by the communities in which patients live. The Center for Disease Control (CDC) recently proposed a social vulnerability index (SVI) comprised of a variety of neighborhood variables.[29] Tools such as the SVI may help target populations who are at particular risk due to poor SDOH. The objective of the current study was to assess the impact of patient SVI derived from their county of residence on postoperative surgical outcomes and expenditures. In particular, we hypothesized that individuals from areas with a high SVI would be at greater risk to have postoperative complications and higher expenditures compared with patients from low social vulnerability areas following a range of surgical procedures.