Social Determinants of Health in Surgery Overview

Introduction

Health outcomes are mediated by the intersection of socioeconomic and environmental factors with healthcare. Although life expectancy and disease outcomes have improved over time, it is important to note these improvements have not been equal across all populations, with significant disparities observed across race, ethnicity, and socioeconomic status. ^, The World Health Organization defines social determinants of health as the “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”

Multiple factors drive disparities in health outcomes; variation in life expectancy has been thought to be modulated by the superimposition of socioeconomic and race/ethnicity with behavioral and metabolic risk factors as well as by differences in access to care. Together, these forces insidiously erect barriers to preventative care and screening and compromise the quality of medical care and availability of treatment options. Additionally, social determinants of health have been implicated in surgical outcomes with lower socioeconomic status, underinsurance, race and ethnicity, education, and geography influencing outcomes. This textbook will develop a framework for understanding social determinants of health and elucidate how they underpin disparities in surgical outcomes as well as describe interventions to improve outcomes and research strategies for measuring progress.

Access to Care

Access to care has been implicated as a critical modulator of healthcare disparities. Preventative care and health screening are associated with a lower frequency of emergent diagnosis and surgery, which are, in turn, associated with reduced morbidity and mortality. ^, In a study of patients presenting for evaluation by the acute case surgery service at a level 1 trauma hospital, Hambright et al. found that adherence to preventative screenings and interventions, including mammography, colonoscopy, and pneumococcal vaccinations, was only 57%. When patients had a primary care doctor, the adherence rate was 60% versus 27% when patients did not have a primary care doctor. Education beyond high school has been associated with increased adherence to preventative screenings. Multiple studies have demonstrated that access to preventative screening and adherence to preventative screening recommendations are also impacted by race and ethnicity, with rates of screening colonoscopy higher in non-Hispanic populations rather than Hispanic populations. These data have inspired targeted interventions by primary care programs, with some programs reporting significant improvements.

Reduced access to care results in barriers to screening, delays in diagnostic workup, and is associated with more advanced disease and worse oncologic outcomes. Income and insurance status are linked to screening, with low-income and underinsured patients being less likely to receive screening and having a greater likelihood of late-stage diagnosis. ^, Quality of screening is also impacted by socioeconomic status, education, and race and ethnicity, with studies of breast cancer screening demonstrating that digital mammography and supplemental breast ultrasound use lower among disadvantaged groups. ^, Notably, when African American women undergo screening, they are more likely to be done at lower resourced and nonaccredited facilities and have longer intervals between mammograms and follow-up imaging. These trends have been implicated in the findings that regional disease is present in approximately 33% of African American women compared with 25% of Caucasian American women.

Lack of access to preventative care is implicated in the diagnosis and treatment of gallbladder disease. ^, Treatment of cholecystitis in the emergency setting, rather than in the elective setting, is associated with increased morbidity and mortality. ^, Moreover, insurance status and race have also been implicated in access to cholecystectomy, with Medicaid insurance being associated with a lower rate of surgery being performed at the index hospitalization for acute cholecystitis as well as a reduced rate of laparoscopic surgery when surgery was performed.

Safety net hospitals disproportionately care for patients from disadvantaged backgrounds who are most affected by the social risk factors of poverty, food insecurity, and unstable housing. As a result, these hospitals serve a significant number of uninsured patients and patients on Medicaid. While studies evaluating surgical outcomes in safety net hospitals have demonstrated mixed results, with similar mortality rates in major vascular operations but increased morbidity and mortality following ventral hernia repairs, colectomies, and Whipple operations. ^, In a study of nonfederally funded California hospitals, hospitals with higher rates of Medicaid-insured and uninsured patients had a higher rate of patients with perforated appendicitis as well as a lower rate of laparoscopic surgery, again demonstrating the higher disease acuity associated with being underinsured and not being able to access care in a timely fashion. What does appear to be clear is that access to care does not fully explain disparities in surgical outcomes. Factors including geographic location, physician communication, discrimination, and logistical challenges have also been implicated in these disparities.