Associations Between Social Risk Factors and Surgical Site Infections After Colectomy and Abdominal Hysterectomy

Andrew C Qi 1, Kate Peacock 1, Alina A Luke 1, Abigail Barker 2, Margaret A Olsen 1, Karen E Joynt Maddox 1

Affiliations

PMID: 31577353
PMCID: PMC6777422
DOI: 10.1001/jamanetworkopen.2019.12339

Free PMC article

Abstract

Importance: Surgical site infection (SSI) is an important patient safety outcome. Although social risk factors have been linked to many adverse health outcomes, it is unknown whether such factors are associated with higher rates of SSI.

Objectives: To determine whether social risk factors, including race/ethnicity, insurance status, and neighborhood income, are associated with higher rates of SSI after colectomy or abdominal hysterectomy, 2 surgical procedures for which SSI rates are publicly reported and included in pay-for-performance programs by Medicare and other groups.

Design, setting, and participants: This cross-sectional study analyzed adults undergoing colectomy or abdominal hysterectomy, as captured in State Inpatient Databases for Arizona, Florida, Iowa, Massachusetts, Maryland, New York, and Vermont. Operations were performed in 2013 through 2014 at general acute care hospitals in the United States. Data analysis was conducted from October 2018 through June 2019.

Exposures: Colectomy or hysterectomy.

Main outcomes and measures: Postoperative complex SSI rates.

Results: A total of 149 741 patients met the inclusion criteria, including 90 210 patients undergoing colectomies (mean [SD] age, 63.4 [15.6] years; 49 029 [54%] female; 74% white, 11% black, 9% Hispanic, and 5% other or unknown race/ethnicity) and 59 531 patients undergoing abdominal hysterectomies (mean [SD] age, 49.8 [11.8] years; 100% female; 52% white, 26% black, 14% Hispanic, and 8% other or unknown race/ethnicity). In the colectomy cohort, 34% had private insurance, 52% had Medicare, 9% had Medicaid, and 5% had other or unknown insurance or were uninsured; 24% were from the lowest quartile of median zip code income. In the hysterectomy cohort, 57% had private insurance, 16% had Medicare, 19% had Medicaid, and 3% had other or unknown insurance or were uninsured; 27% were from the lowest-income zip codes. Within 30 days of surgery, SSI rates were 2.55% for the colectomy cohort and 0.61% for the hysterectomy cohort. For colectomy, black race (adjusted odds ratio [AOR], 0.71; 95% CI, 0.61-0.82) was associated with lower odds of SSI, whereas Medicare (AOR, 1.25; 95% CI, 1.10-1.41), Medicaid (AOR, 1.23; 95% CI, 1.06-1.44), and low neighborhood income (AOR, 1.14; 95% CI, 1.01-1.29) were associated with higher odds of SSI. For hysterectomy, no social risk factors that were examined in this study had statistically significant associations with SSI after adjustment for clinical risk.

Conclusions and relevance: Inconsistent associations between social risk factors and SSIs were found. For colectomy, infection prevention programs targeting low-income groups may be important for reducing disparities in this postoperative outcome, and policy makers could consider taking social risk factors into account when evaluating hospital performance.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Olsen reported receiving grants from the National Institutes of Health (NIH) and Agency for Healthcare Research and Quality (AHRQ) during the conduct of the study, grants and personal fees from Pfizer, and grants from Merck and Sanofi-Pasteur outside the submitted work. Dr Joynt Maddox reported receiving grants from the National Heart, Lung, and Blood Institute, National Institute on Aging, and the Commonwealth Fund outside the submitted work and reported previously doing contract work for the US Department of Health and Human Services. No other conflicts were reported.