O.P. Chatzipanagiotou1, D.I. Tsilimigras1, S. Woldesenbet1, G. Catalano1,2, T.M. Pawlik1 1Ohio State University, Department Of Surgery, Columbus, OH, USA 2University of Verona, Department Of Surgery, Verona, ITALY, Italy
Introduction: Poor infrastructure in degraded areas may hinder access to healthcare and lack of socioeconomic resources can prevent patients from remaining at home post-discharge. Days at home (DAH) has increasingly been used in clinical trials as a quality assurance metric. We sought to assess the association between Area Deprivation Index (ADI) and DAH within 90 days (DAH-90) after a complex operative procedure, as well as define the association of DAH with surgical costs and mortality risk.
Methods: Patients who underwent an elective operation for colorectal or hepatopancreatobiliary cancer between 2016 and 2020 were identified from the Medicare Standard Analytic Files. DAH-90 was calculated using a 90-day observational window after surgery, subtracting days spent at the inpatient setting, emergency department, other outpatient visits, skilled nursing facilities, and hospice. DAH-90 was categorized as low (≤ 20%), medium (20-80%), and high (≥ 80%). County-level ADI was calculated using a weighted average of ADI percentiles for each census block within a county ranging from 0 to 1. Multinomial multivariable logistic regression was used to assess the association between ADI and DAH-90. Moreover, the impact of DAH-90 on 1-year expenditures and 1-year mortality was evaluated.
Results: Among 72,452 patients who underwent surgery, median patient age was 75 (IQR 71, 81) years and a slight majority had a CCI >2 (54.3%). In adjusted multinomial logistic regression, a +0.2 increase in ADI was associated with 15% lower odds of achieving high DAH-90 [adjusted Odds Ratio (aOR) 0.850; 95% Confidence Interval (CI) 0.822-0.878], and 4% lower odds of achieving medium DAH-90 (aOR 0.960; 95%CI 0.937,0.983) compared with low DAH-90. Moreover, for +0.4, +0.6, +0.8, and +1.0 increases in ADI, there was 27.6%, 38.7%, 47.9%, and 55.7% lower likelihood of being in the high versus low DAH-90 category, respectively. Of note, adjusted linear regression demonstrated that high DAH-90 (mean difference -56,064$; 95%CI -56,978$, -55,149$) and medium DAH-90 (mean difference -39,665$ IQR -40,320$, -39,011$) were associated with markedly decreased 1-year total expenditures, as well as lower 1-year mortality compared with patients who spent less days at home following surgery (high DAH-90: aOR 0.059; 95%CI 0.052,0.067; medium DAH-90: aOR 0.138; 95%CI 0.132,0.145) (Figure).
Conclusion: Increasing area deprivation was associated with higher likelihood of spending more days away from home after a complex cancer surgical procedure. Patients spending less days at home were far more likely to die within 1-year and experienced higher healthcare costs. Major surgical procedures may result in a high number of days away from home, especially among vulnerable patients.