The Burden of Income Disparity and Behavioral Factors on Infectious Complications in Emergency General Surgery

Author(s):
Emanuele Lagazzi; Jefferson Proaño-Zamudio; Dias Argandykov; Wardah Rafaqat; May Abiad; Anne-Sophie Romijn ; Elaine van Ee; Angela Renne; George Velmahos; Haytham Kaafarani; John Hwabejire

Background:

Compared to elective surgery, emergency general surgery (EGS) is associated with several folds higher risk of complications, including postoperative infections. The impact of social and behavioral determinants of health on infections following EGS remains unclear.

Hypothesis:

We hypothesized that socioeconomic disparity, mental health, and behavioral determinants of health are associated with postoperative infectious complications after EGS.

Methods:

All patients undergoing EGS in the 2019 National Readmission Database were included. We defined EGS as all non-elective general surgery procedures. The primary outcome was any 30-day infectious complication. Secondary outcomes included infectious complication type (e.g. pneumonia, urinary tract infection, sepsis, surgical site infection) and mortality. Multivariable regression analyses were used to study the impact of patient characteristics, social characteristics (e.g. annual income, insurance type), and behavioral characteristics (e.g. substance use disorder, psychiatric illness, neurodevelopmental disorders) on postoperative infection. Substance use disorders were divided into opioid, cocaine, and other substance use disorder.  Psychiatric illness was categorized as depression, bipolar disorder, and schizophrenia.

Results:

Of 367,348 patients included in this study, 75,522 (20.53%) had infectious complications during the index hospitalization or within 30 days from discharge. Medicare (OR, 1.3; 95% CI, 1.26-1.34), Medicaid (OR,1.24; 95%CI,1.19-1.29), lowest income by quartile (OR, 1.17; 95% CI, 1.13-1.22), opioid use disorder (OR,1.18; 95% CI,1.10-1.29), other substance use disorder (OR, 1.14; 95% CI, 1.02-1.26),  schizophrenia (OR, 1.23; 95% CI, 1.13-1.34) and neurodevelopmental disorders (OR, 2.16; 95% CI, 1.90-2.45) were associated with higher rates of 30-day infectious complication. Similar findings were seen in the specific infectious complication types, such as pneumonia and UTI (Figure 1).

Conclusions:

In EGS patients, socioeconomic status, substance use disorder, psychiatric comorbidities, and neurodevelopmental disorders were associated with a higher risk of infectious complications at 30 days. These findings warrant targeted infection prevention programs and standardized interventions that postoperatively address social and behavioral determinants of health.