The association of Social Determinants of Health and Necrotizing Fasciitis

Author(s):
Jennifer Hubbard; Chibueze Nwaiwu; Daithi Heffernan; Andrew Stephen

Background:

Necrotizing Fasciitis (NecFasc) is a rapidly spreading soft tissue infection, requiring emergent and timely surgical intervention. Racial and social discrepancies exist with both delivery of health care and outcomes across many aspects of health care. However, to date there is no data addressing how socioethnic factors affect outcomes of patients with NecFasc.

Methods:

This is a retrospective review of the National In-Patient Sample (NIS) of HCUP patients aged 18 years and older who were admitted with a diagnosis of NecFasc over a 3 year period. Data analyzed included demographics, (race and insurance status), teaching status of hospital, and hospital course and outcomes. The primary outcome was the effects of race and social determinants of health on surgical intervention, transfer status, and outcomes.

Results:

 A total of 2,410 patients were admitted with a diagnosis of NecFasc over the 3-year period. Of these patients, 856 patients (35.5%) were non-White race. White patients were slightly older (53.3 versus 50.5 years;p<0.001) but with no difference in sex. Non-White patients more likely had diabetes (59% versus 49.4%;p<0.001), hypertension (57.6% versus 52%;p=0.01), but had lower rates of COPD (6.9% vs 13.9%;p <0..001). Both non-White and White patients had a high rate of operative management (91.6% vs 90.8%;p=0.07) with no difference in time to operation. Non-White patients underwent more operations on average (5.1 versus 4.5;p<0.0012) compared to White patients. Reviewing transfer status, there was no difference in age, sex, or private insurance status between patients transferred into the hospital versus those who presented directly to an academic hospital. Transferred patients were more often non-White (30.7% vs 13.5%;p=0.02) versus non transferred patients. With respect to outcomes, length of stay was longer for non-White (13.5 versus 11.9;p=0.04) versus White patients. Average cost of stay was more for non-white ($183,556 versus $139,073;p=0.0016) versus White patients. Adjusting for age and comorbidities Non-White patients had higher mortality in rural hospitals (OR=1.58 (95%CI=1.1-2.5), a finding that was not present in urban teaching hospitals (OR=0.6 (95%CI=0.4-1.1).

Conclusions:

Despite similar operative interventions, non-white patients had higher mortality. Healthcare systems should target modifiable risk factors that would prevent chronic comorbidities that may be drivers of mortality among critically ill patients with necrotizing fasciitis infection.