Comparing Deprivation vs Vulnerability Index Performance Using Medicare Beneficiary Surgical Outcomes.

IF 15.7 1区 医学 Q1 SURGERY JAMA surgery Pub Date : 2024-10-02 DOI:10.1001/jamasurg.2024.4195
Kimberly A Rollings, Grace A Noppert, Jennifer J Griggs, Andrew M Ibrahim, Philippa J Clarke
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Abstract

Importance: Health care researchers, professionals, payers, and policymakers are increasingly relying on publicly available composite indices of area-level socioeconomic deprivation to address health equity. Implications of index selection, however, are not well understood.

Objective: To compare the performance of 2 frequently used deprivation indices using policy-relevant outcomes among Medicare beneficiaries undergoing 3 common surgical procedures.

Design, setting, and participants: This cross-sectional study examined outcomes among Medicare beneficiaries (65 to 99 years old) undergoing 1 of 3 common surgical procedures (hip replacement, knee replacement, or coronary artery bypass grafting) between 2016 and 2019. Index discriminative performance was compared for beneficiaries residing in tracts with high- and low-deprivation levels (deciles) according to each index. Analyses were conducted between December 2022 and August 2023.

Main outcomes and measures: Tract-level deprivation was operationalized using 2020 releases of the area deprivation index (ADI) and the social vulnerability index (SVI). Binary outcomes were unplanned surgery, 30-day readmissions, and 30-day mortality. Multivariable logistic regression models, stratified by each index, accounted for beneficiary and hospital characteristics.

Results: A total of 2 433 603 Medicare beneficiaries (mean [SD] age, 73.8 [6.1] years; 1 412 968 female beneficiaries [58.1%]; 24 165 Asian [1.0%], 158 582 Black [6.5%], and 2 182 052 White [89.7%]) were included in analyses. According to both indices, beneficiaries residing in high-deprivation tracts had significantly greater adjusted odds of all outcomes for all procedures when compared with beneficiaries living in low-deprivation tracts. However, compared to ADI, SVI resulted in higher adjusted odds ratios (adjusted odds ratios, 1.17-1.31 for SVI vs 1.09-1.23 for ADI), significantly larger outcome rate differences (outcome rate difference, 0.07%-5.17% for SVI vs outcome rate difference, 0.05%-2.44% for ADI; 95% CIs excluded 0), and greater effect sizes (Cohen d, 0.076-0.546 for SVI vs 0.044-0.304 for ADI) for beneficiaries residing in high- vs low-deprivation tracts.

Conclusions and relevance: In this cross-sectional study of Medicare beneficiaries, SVI had significantly better discriminative performance-stratifying surgical outcomes over a wider range-than ADI for identifying and distinguishing between high- and low-deprivation tracts, as indexed by outcomes for common surgical procedures. Index selection requires careful consideration of index differences, index performance, and contextual factors surrounding use, especially when informing resource allocation and health care payment adjustment models to address health equity.

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利用医疗保险受益人的手术结果,比较贫困指数与弱势指数的表现。
重要性:医疗保健研究人员、专业人士、付款人和政策制定者越来越依赖于公开的地区级社会经济贫困综合指数来解决健康公平问题。然而,人们对指数选择的影响还不甚了解:目的:在接受 3 种常见外科手术的医疗保险受益人中,使用与政策相关的结果,比较 2 种常用贫困指数的表现:这项横断面研究调查了 2016 年至 2019 年期间接受 3 种常见外科手术(髋关节置换术、膝关节置换术或冠状动脉旁路移植术)中一种手术的医疗保险受益人(65 岁至 99 岁)的治疗效果。根据每个指数,比较了居住在高贫困水平和低贫困水平(十分位数)地区的受益人的指数判别性能。分析在 2022 年 12 月至 2023 年 8 月期间进行:采用 2020 年发布的地区贫困指数 (ADI) 和社会脆弱性指数 (SVI) 来计算地区贫困程度。二元结果为非计划手术、30 天再入院和 30 天死亡率。多变量逻辑回归模型根据每个指数进行分层,并考虑受益人和医院的特征:共有 2 433 603 名医疗保险受益人(平均 [SD] 年龄 73.8 [6.1] 岁;1 412 968 名女性受益人 [58.1%];24 165 名亚裔 [1.0%]、158 582 名黑人 [6.5%] 和 2 182 052 名白人 [89.7%])被纳入分析。根据这两项指数,与居住在低贫困地区的受益人相比,居住在高贫困地区的受益人在所有程序中出现所有结果的调整后几率明显更高。然而,与 ADI 相比,SVI 的调整后几率更高(SVI 的调整后几率为 1.17-1.31 vs ADI 的调整后几率为 1.09-1.23),结果率差异更大(SVI 的结果率差异为 0.07%-5.17%;95% CIs 不包括 0),居住在高贫困区与低贫困区的受益人的效应大小更大(Cohen d,SVI 为 0.076-0.546 vs ADI 为 0.044-0.304):在这项针对医疗保险受益人的横断面研究中,在识别和区分高贫困区和低贫困区方面,SVI 的判别性能--在更大范围内对手术结果进行分级--明显优于 ADI(以常见手术的结果为指标)。指数的选择需要仔细考虑指数的差异、指数的性能以及使用的环境因素,尤其是在为资源分配和医疗支付调整模型提供信息以解决健康公平问题时。
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来源期刊
JAMA surgery
JAMA surgery SURGERY-
CiteScore
20.80
自引率
3.60%
发文量
400
期刊介绍: JAMA Surgery, an international peer-reviewed journal established in 1920, is the official publication of the Association of VA Surgeons, the Pacific Coast Surgical Association, and the Surgical Outcomes Club.It is a proud member of the JAMA Network, a consortium of peer-reviewed general medical and specialty publications.
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