Care Fragmentation, Social Determinants of Health, and Postoperative Mortality in Older Veterans

Authors

Carly A Duncan
Michael A Jacobs
Yubo Gao
Michael Mader
Susanne Schmidt
Heather Davila
Katherine Hadlandsmyth
Paula K Shireman
Leslie R M Hausmann
Robert A Tessler
Andrea Strayer
Mary Vaughan Sarrazin
Daniel E Hall

Language

English

Publication Date

8-1-2024

Journal

Journal of Surgical Research

DOI

PMC11837767

PMID

38875950

PMCID

PMC11837767

PubMedCentral® Posted Date

2-19-2025

PubMedCentral® Full Text Version

Post-print

Abstract

Introduction: Veterans Affairs Surgical Quality Improvement Program (VASQIP) benchmarking algorithms helped the Veterans Health Administration (VHA) reduce postoperative mortality. Despite calls to consider social risk factors, these algorithms do not adjust for social determinants of health (SDoH) or account for services fragmented between the VHA and the private sector. This investigation examines how the addition of SDoH change model performance and quantifies associations between SDoH and 30-d postoperative mortality.

Methods: VASQIP (2013-2019) cohort study in patients ≥65 y old with 2-30-d inpatient stays. VASQIP was linked to other VHA and Medicare/Medicaid data. 30-d postoperative mortality was examined using multivariable logistic regression models, adjusting first for clinical variables, then adding SDoH.

Results: In adjusted analyses of 93,644 inpatient cases (97.7% male, 79.7% non-Hispanic White), higher proportions of non-veterans affairs care (adjusted odds ratio [aOR] = 1.02, 95% CI = 1.01-1.04) and living in highly deprived areas (aOR = 1.15, 95% CI = 1.02-1.29) were associated with increased postoperative mortality. Black race (aOR = 0.77, CI = 0.68-0.88) and rurality (aOR = 0.87, CI = 0.79-0.96) were associated with lower postoperative mortality. Adding SDoH to models with only clinical variables did not improve discrimination (c = 0.836 versus c = 0.835).

Conclusions: Postoperative mortality is worse among Veterans receiving more health care outside the VA and living in highly deprived neighborhoods. However, adjusting for SDoH is unlikely to improve existing mortality-benchmarking models. Reduction efforts for postoperative mortality could focus on alleviating care fragmentation and designing care pathways that consider area deprivation. The adjusted survival advantage for rural and Black Veterans may be of interest to private sector hospitals as they attempt to alleviate enduring health-care disparities.

Keywords

Humans, Aged, Male, Social Determinants of Health, Female, United States, Aged, 80 and over, Veterans, United States Department of Veterans Affairs, Risk Factors, Quality Improvement, Postoperative Complications, Area deprivation, Care fragmentation, Risk prediction modeling, Rurality, Surgical outcomes

Published Open-Access

yes

Recommended Citation

Duncan, Carly A; Jacobs, Michael A; Gao, Yubo; et al., "Care Fragmentation, Social Determinants of Health, and Postoperative Mortality in Older Veterans" (2024). Faculty, Staff and Student Publications. 5902.
https://digitalcommons.library.tmc.edu/uthgsbs_docs/5902