BACKGROUND : The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in "textbook outcome (TO)" relative to social vulnerability among Medicare beneficiaries who underwent surgery for cancer.

METHODS : Individuals who underwent surgery for lung, esophageal, colon, or rectal cancer between 2013- 2017 were identified using 2016-2017 Medicare database, which was merged with CDC's social vulnerability index(SVI). TO was defined as a surgical episode with the absence of complications, extended length-of-stay, readmission and mortality. The association of SVI and TO was assessed using mixed effects logistic regression.

RESULTS : Among 203,800 patients(colon, n=113,929; lung, n=70642; rectal, n=14,849; esophageal, n=4,380), median age was 75 years(IQR: 70-80) and the overwhelming majority were White(n=184,989, 90.8%). The overall incidence of TO was 56.1%(n=114,393). The incidence of complications(low-SVI: 21.5% vs. high-SVI: 24.0%) and 90-day mortality(low-SVI: 7.0% vs. high-SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both p<0.05). In turn, there were lower odds of achieving TO among high versus low SVI patients(OR 0.83, 95%CI 0.78- 0.87). While high-SVI White patients had 10% lower odds(95%CI: 0.87-0.93) of achieving a TO, high-SVI non-White patients were at 22% lower odds(95%CI: 0.71-0.85) of post- operative TO. Compared with low-SVI White patients, high SVI minority patients had 47% increased odds of an extended length-of-stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality(all p<0.05).

CONCLUSION : Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncological procedures. The effect of high SVI was most pronounced among minority patients.