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Clin Colon Rectal Surg
DOI: 10.1055/s-0045-1807758
Review Article

The Impact of Social Determinants of Health on Severe Colorectal Complications

Wendelyn M. Oslock
1   Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
2   Department of Quality, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
,
Leanne D. Jeong
3   School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
,
Mei Lin N. Dye
4   East Tennessee State University, College of Medicine, Johnson City, Tennessee
,
Meet Patel
5   Gujarat Medical Education and Research Society, Medical College, Gandhinagar, Gujarat, India
,
Daniel I. Chu
1   Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
› Author Affiliations Funding D.I.C. was supported in part by K12 HS023009 (2017–2019), K23 MD013903 (2019–2022), R01 MD013858 (2020–2025), and R01 CA271303 (2023–2028). W.M.O. was supported by the AAS/AASF Clinical Outcomes/Health Services Trainee Research Award and the Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations VA Quality Scholars Advanced Fellowship Program. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government (Program Award Number 3Q022019C).
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Abstract

Complications following colorectal surgery remain a persistent issue despite advances in surgical technique, development of enhanced recovery, and improvements in perioperative care. Social determinants of health (SDOHs) at the individual, interpersonal, institutional, community, and policy levels have been associated with the risk of patients experiencing a complication. At the individual level, race and ethnicity are associated with complications, with the Black race having the most robust data demonstrating increased risk for complication. Additional individual-level factors associated with complications include food insecurity, health literacy, or the presence of an SDOH diagnostic Z-ICD code. Institutionally, hospital size, case volume, and teaching status were characteristics associated with the risk of complications, while safety net status was not. Hospital and home rurality, as well as food deserts, are community-level characteristics associated with an increased likelihood of complication. For policy-level SDOH, insurance type was associated with complications. Specifically, patients with Medicare, Medicaid, uninsured, or a combination of the three were more likely to experience a complication than a patient with private insurance. Additionally, composite measures for SDOH, such as the social vulnerability index, are associated with postoperative complications. There are SDOH at each level that influence the risk of complications following colorectal surgery, highlighting the need to incorporate these factors into quality improvement efforts.

Keywords

socioecological determinants of health - social determinants of health - postoperative complications - colorectal surgery


Publication History

Article published online:
24 April 2025

© 2025. Thieme. All rights reserved.

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  • References

  • 1 Alves A, Civet A, Laurent A. et al.; Groupe COINCIDE. Social deprivation aggravates post-operative morbidity in carcinologic colorectal surgery: Results of the COINCIDE multicenter study. J Visc Surg 2021; 158 (03) 211-219
    PubMedSearch in Google Scholar
  • 2 Pandit V, Khalil M, Joseph B. et al. Disparities in management of patients with benign colorectal disease: impact of urbanization and specialized care. Am Surg 2016; 82 (11) 1046-1051
    PubMedSearch in Google Scholar
  • 3 Haag A, Nabi J, Herzog P. et al. Is the current referral trend a threat to the Military Health System? Perioperative outcomes and costs after colorectal surgery in the Military Health System versus civilian facilities. Surgery 2021; 170 (01) 67-74
    PubMedSearch in Google Scholar
  • 4 Pollak YLE, Lee JY, Khalid SI, Aquina CT, Hayden DM, Becerra AZ. Social determinants of health Z-codes and postoperative outcomes after colorectal surgery: A national population-based study. Am J Surg 2022; 224 (05) 1301-1307
    CrossrefPubMedSearch in Google Scholar
  • 5 van Rooijen SJ, Huisman D, Stuijvenberg M. et al. Intraoperative modifiable risk factors of colorectal anastomotic leakage: Why surgeons and anesthesiologists should act together. Int J Surg 2016; 36 (Pt A): 183-200
    PubMedSearch in Google Scholar
  • 6 Gunnells Jr DJ, Morris MS, DeRussy A. et al. Racial disparities in readmissions for patients with inflammatory bowel disease (IBD) after colorectal surgery. J Gastrointest Surg 2016; 20 (05) 985-993
    PubMedSearch in Google Scholar
  • 7 Pak H, Maghsoudi LH, Soltanian A, Gholami F. Surgical complications in colorectal cancer patients. Ann Med Surg (Lond) 2020; 55: 13-18
    CrossrefPubMedSearch in Google Scholar
  • 8 Lorentsen MK, Sanoff HK. Social determinants of health and the link to colorectal cancer outcomes. Curr Treat Options Oncol 2024; 25 (04) 453-464
    PubMedSearch in Google Scholar
  • 9 World Health Organization. Social determinants of health. Accessed September 11, 2024 at: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
    PubMed
  • 10 CDC/ASTDR - Centers for Disease Control and Prevention and Agency for Toxic Substances and Disease Registry. Models and Frameworks for the Practice of Community Engagement. Accessed September 11, 2024 at: https://www.atsdr.cdc.gov/communityengagement/pce_models.html#figure1
    PubMed
  • 11 Nead KT, Hinkston CL, Wehner MR. Cautions when using race and ethnicity in administrative claims data sets. JAMA Health Forum 2022; 3 (07) e221812
    PubMedSearch in Google Scholar
  • 12 Cairns AL, Schlottmann F, Strassle PD, Di Corpo M, Patti MG. Racial and socioeconomic disparities in the surgical management and outcomes of patients with colorectal carcinoma. World J Surg 2019; 43 (05) 1342-1350
    CrossrefPubMedSearch in Google Scholar
  • 13 Akinyemiju T, Meng Q, Vin-Raviv N. Race/ethnicity and socio-economic differences in colorectal cancer surgery outcomes: analysis of the nationwide inpatient sample. BMC Cancer 2016; 16 (01) 715
    CrossrefPubMedSearch in Google Scholar
  • 14 Greenberg AL, Brand NR, Zambeli-Ljepović A. et al. Exploring the complexity and spectrum of racial/ethnic disparities in colon cancer management. Int J Equity Health 2023; 22 (01) 68
    PubMedSearch in Google Scholar
  • 15 Sharp SP, Ata A, Chismark AD. et al. Racial disparities after stoma construction in colorectal surgery. Colorectal Dis 2020; 22 (06) 713-722
    PubMedSearch in Google Scholar
  • 16 Smith BP, Jones BA, Cofer KD. et al. Racial disparities in postoperative outcomes persist for patients with inflammatory bowel disease under a colorectal enhanced recovery program. Am J Surg 2023; 226 (02) 227-232
    CrossrefPubMedSearch in Google Scholar
  • 17 Theiss LM, Wood T, McLeod MC. et al. The association of health literacy and postoperative complications after colorectal surgery: A cohort study. Am J Surg 2022; 223 (06) 1047-1052
    CrossrefPubMedSearch in Google Scholar
  • 18 Smith BP, Katta MH, Hollis RH. et al. Understanding the impact of enhanced recovery programs on social vulnerability, race, and colorectal surgery outcomes. Dis Colon Rectum 2024; 67 (04) 566-576
    PubMedSearch in Google Scholar
  • 19 Frieder JS, Montorfano L, De Stefano F. et al. A national inpatient sample analysis of racial disparities after segmental colectomy for inflammatory colorectal diseases. Am Surg 2023; 89 (12) 5131-5139
    PubMedSearch in Google Scholar
  • 20 Azap L, Woldesenbet S, Akpunonu CC. et al. The association of food insecurity and surgical outcomes among patients undergoing surgery for colorectal cancer. Dis Colon Rectum 2024; 67 (04) 577-586
    PubMedSearch in Google Scholar
  • 21 Diaz A, Hyer JM, Barmash E, Azap R, Paredes AZ, Pawlik TM. County-level social vulnerability is associated with worse surgical outcomes especially among minority patients. Ann Surg 2021; 274 (06) 881-891
    PubMedSearch in Google Scholar
  • 22 Spaulding AC, Borkar S, Osagiede O. et al. Impact of travel distance on quality outcomes in colorectal cancer. Am J Manag Care 2020; 26 (11) e347-e354
    PubMedSearch in Google Scholar
  • 23 Chan SY, Suwanabol PA, Damle RN. et al. Characterizing short-term outcomes following surgery for rectal cancer: the role of race and insurance status. J Gastrointest Surg 2016; 20 (11) 1891-1898
    PubMedSearch in Google Scholar
  • 24 Ramkumar N, Colla CH, Wang Q, O'Malley AJ, Wong SL, Brooks GA. Association of rurality, race and ethnicity, and socioeconomic status with the surgical management of colon cancer and postoperative outcomes among medicare beneficiaries. JAMA Netw Open 2022; 5 (08) e2229247
    CrossrefPubMedSearch in Google Scholar
  • 25 Booth A, Colorado H, Magwood G, Forster E, Axon RN, Curran T. Far from home: the role of travel distance and care fragmentation in surgical outcomes for inflammatory bowel disease. Crohns Colitis 360 2023; 5 (02) otad015
    PubMedSearch in Google Scholar
  • 26 Leeds IL, Alimi Y, Hobson DR. et al. Racial and socioeconomic differences manifest in process measure adherence for enhanced recovery after surgery pathway. Dis Colon Rectum 2017; 60 (10) 1092-1101
    CrossrefPubMedSearch in Google Scholar
  • 27 Kelz RR, Gimotty PA, Polsky D, Norman S, Fraker D, DeMichele A. Morbidity and mortality of colorectal carcinoma surgery differs by insurance status. Cancer 2004; 101 (10) 2187-2194
    CrossrefPubMedSearch in Google Scholar
  • 28 Stamatiou D, Naumann DN, Foss H, Singhal R, Karandikar S. Effects of ethnicity and socioeconomic status on surgical outcomes from inflammatory bowel disease. Int J Colorectal Dis 2022; 37 (06) 1367-1374
    PubMedSearch in Google Scholar
  • 29 Eguia E, Cobb AN, Kirshenbaum EJ, Afshar M, Kuo PC. Racial and ethnic postoperative outcomes after surgery: the Hispanic paradox. J Surg Res 2018; 232: 88-93
    PubMedSearch in Google Scholar
  • 30 Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry/Geospatial Research A, and Services Program. CDC/ATSDR Social Vulnerability Index 2020 Database US.
    PubMed
  • 31 van den Berg I, Buettner S, van den Braak RRJC. et al. Low socioeconomic status is associated with worse outcomes after curative surgery for colorectal cancer: Results from a large, multicenter study. J Gastrointest Surg 2020; 24 (11) 2628-2636
    PubMedSearch in Google Scholar
  • 32 Neifert S, Ilonzo N, Gribben JL, Leitman IM. Economic disparities in patients undergoing sigmoidectomy. JSLS 2018; 22 (04) e2018.00066
    PubMedSearch in Google Scholar
  • 33 Tolkacz M, Reilly D, Studzinski DM. et al. Food insecurity in the elective enhanced recovery after surgery colorectal surgical population: Prevalence and implications for surgical outcomes. Am Surg 2024; 90 (03) 419-426
    PubMedSearch in Google Scholar
  • 34 Qin PP, Jin JY, Min S, Wang WJ, Shen YW. Association between health literacy and enhanced recovery after surgery protocol adherence and postoperative outcomes among patients undergoing colorectal cancer surgery: A prospective cohort study. Anesth Analg 2022; 134 (02) 330-340
    CrossrefPubMedSearch in Google Scholar
  • 35 Chang ME, Baker SJ, Dos Santos Marques IC. et al. Health literacy in surgery. Health Lit Res Pract 2020; 4 (01) e46-e65
    PubMedSearch in Google Scholar
  • 36 Park G, Kim DH, Shao C. et al. Organizational assessment of health literacy within an academic medical center. Am J Surg 2023; 225 (01) 129-130
    CrossrefPubMedSearch in Google Scholar
  • 37 Dos Santos Marques IC, Herbey II, Theiss LM. et al. Understanding the surgical experience for Black and White patients with inflammatory bowel disease (IBD): The importance of health literacy. Am J Surg 2022; 223 (02) 303-311
    PubMedSearch in Google Scholar
  • 38 Irfan A, Lever JM, Fouad MN. et al. Does health literacy impact technological comfort in cancer patients?. Am J Surg 2022; 223 (04) 722-728
    PubMedSearch in Google Scholar
  • 39 Wang L, Wilson SE, Stewart DB, Hollenbeak CS. Marital status and colon cancer outcomes in US Surveillance, Epidemiology and End Results registries: does marriage affect cancer survival by gender and stage?. Cancer Epidemiol 2011; 35 (05) 417-422
    PubMedSearch in Google Scholar
  • 40 Yang CC, Cheng LC, Lin YW. et al. The impact of marital status on survival in patients with surgically treated colon cancer. Medicine (Baltimore) 2019; 98 (11) e14856
    PubMedSearch in Google Scholar
  • 41 Davis RE, Trickey AW, Abrahamse P, Kato I, Ward K, Morris AM. Association of cumulative social risk and social support with receipt of chemotherapy among patients with advanced colorectal cancer. JAMA Netw Open 2021; 4 (06) e2113533
    PubMedSearch in Google Scholar
  • 42 Borowski DW, Bradburn DM, Mills SJ. et al.; Northern Region Colorectal Cancer Audit Group (NORCCAG). Volume-outcome analysis of colorectal cancer-related outcomes. Br J Surg 2010; 97 (09) 1416-1430
    PubMedSearch in Google Scholar
  • 43 Yeo HL, Abelson JS, Mao J, O'Mahoney PR, Milsom JW, Sedrakyan A. Surgeon annual and cumulative volumes predict early postoperative outcomes after rectal cancer resection. Ann Surg 2017; 265 (01) 151-157
    PubMedSearch in Google Scholar
  • 44 Yasunaga H, Matsuyama Y, Ohe K. Japan Surgical Society. Effects of hospital and surgeon volumes on operating times, postoperative complications, and length of stay following laparoscopic colectomy. Surg Today 2009; 39 (11) 955-961
    PubMedSearch in Google Scholar
  • 45 Whitaker RG, Reiter KL, Weinberger M, Stearns SC. Colorectal cancer surgery outcomes for vulnerable patients in safety-net versus non-safety-net hospitals. J Health Care Poor Underserved 2013; 24 (02) 718-729
    PubMedSearch in Google Scholar
  • 46 van Gijn W, Gooiker GA, Wouters MW, Post PN, Tollenaar RA, van de Velde CJ. Volume and outcome in colorectal cancer surgery. Eur J Surg Oncol 2010; 36 (Suppl. 01) S55-S63
    CrossrefPubMedSearch in Google Scholar
  • 47 Yeh CM, Lai TY, Hu YW, Teng CJ, Huang N, Liu CJ. The impact of surgical volume on outcomes in newly diagnosed colorectal cancer patients receiving definitive surgeries. Sci Rep 2024; 14 (01) 8227
    PubMedSearch in Google Scholar
  • 48 National Institute for Health and Care Excellence (UK). Colorectal cancer (update): Surgical volumes and outcomes for rectal cancer. Evidence review F1. NICE guideline NG151. 2020
    PubMedSearch in Google Scholar
  • 49 Pandit V, Jehan F, Zeeshan M. et al. Failure to rescue in postoperative patients with colon cancer: time to rethink where you get surgery. J Surg Res 2019; 234: 1-6
    PubMedSearch in Google Scholar
  • 50 Ngoo AG, Tan AHM, Mushaya CD, Ho YH. Short and long course neoadjuvant therapy compared for management of locally advanced rectal cancer: 11 years' experience at a regional centre. ANZ J Surg 2020; 90 (05) 812-820
    PubMedSearch in Google Scholar
  • 51 Galandiuk S, Mahid SS, Polk Jr HC, Turina M, Rao M, Lewis JN. Differences and similarities between rural and urban operations. Surgery 2006; 140 (04) 589-596
    PubMedSearch in Google Scholar
  • 52 Lansing SS, Diaz A, Hyer M, Tsilimigras D, Pawlik TM. Rural hospitals are not associated with worse postoperative outcomes for colon cancer surgery. J Rural Health 2022; 38 (03) 650-659
    PubMedSearch in Google Scholar
  • 53 Khalil M, Munir MM, Woldesenbet S. et al. Association of county-level food deserts and food swamps on postoperative outcomes among patients undergoing colorectal surgery. J Gastrointest Surg 2024; 28 (04) 494-500
    PubMedSearch in Google Scholar
  • 54 Lam MB, Phelan J, Orav EJ, Jha AK, Keating NL. Medicaid expansion and mortality among patients with breast, lung, and colorectal cancer. JAMA Netw Open 2020; 3 (11) e2024366
    CrossrefPubMedSearch in Google Scholar
  • 55 Tetley JC, Jacobs MA, Kim J. et al. Association of insurance type with colorectal surgery outcomes and costs at a safety-net hospital: A retrospective observational study. Ann Surg Open 2022; 3 (04) e215
    CrossrefPubMedSearch in Google Scholar
  • 56 Jacobs MA, Tetley JC, Kim J. et al. Association of cumulative colorectal surgery hospital costs, readmissions, and emergency department/observation stays with insurance type. J Gastrointest Surg 2023; 27 (05) 965-979
    PubMedSearch in Google Scholar
  • 57 Lee Y, Andrew L, Hill S. et al. Disparities in access to minimally invasive surgery for inflammatory bowel disease and outcomes by insurance status: analysis of the 2015 to 2019 National Inpatient Sample. Surg Endosc 2023; 37 (12) 9420-9426
    CrossrefPubMedSearch in Google Scholar
  • 58 Taylor K, Diaz A, Nuliyalu U, Ibrahim A, Nathan H. Association of dual medicare and medicaid eligibility with outcomes and spending for cancer surgery in high-quality hospitals. JAMA Surg 2022; 157 (04) e217586
    PubMedSearch in Google Scholar
  • 59 Kind AJH, Buckingham WR. Making neighborhood-disadvantage metrics accessible - the neighborhood atlas. N Engl J Med 2018; 378 (26) 2456-2458
    CrossrefPubMedSearch in Google Scholar
  • 60 EIG. Distressed Communities Index - Methodology. 2022
    PubMedSearch in Google Scholar
  • 61 Robert Graham Center. Social deprivation index (SDI). 2018
    Search in Google Scholar
  • 62 Agency for Toxic Substances and Disease Registry. Environmental Justice Index (EJI). 2022
    Search in Google Scholar
  • 63 Carmichael H, Dyas AR, Bronsert MR. et al. Social vulnerability is associated with increased morbidity following colorectal surgery. Am J Surg 2022; 224 (1 Pt A): 100-105
    PubMedSearch in Google Scholar
  • 64 Diaz A, Barmash E, Azap R, Paredes AZ, Hyer JM, Pawlik TM. Association of county-level social vulnerability with elective versus non-elective colorectal surgery. J Gastrointest Surg 2021; 25 (03) 786-794
    CrossrefPubMedSearch in Google Scholar
  • 65 Ghirimoldi FM, Schmidt S, Simon RC. et al. Association of socioeconomic area deprivation index with hospital readmissions after colon and rectal surgery. J Gastrointest Surg 2021; 25 (03) 795-808
    PubMedSearch in Google Scholar
  • 66 Reid TD, Shrestha R, Stone L, Gallaher J, Charles AG, Strassle PD. Socioeconomic disparities in ostomy reversal among older adults with diverticulitis are more substantial among non-Hispanic Black patients. Surgery 2021; 170 (04) 1039-1046
    PubMedSearch in Google Scholar
  • 67 Dik VK, Aarts MJ, Van Grevenstein WM. et al. Association between socioeconomic status, surgical treatment and mortality in patients with colorectal cancer. Br J Surg 2014; 101 (09) 1173-1182
    PubMedSearch in Google Scholar
  • 68 Godbole C, Bhangu A, Bowley DM, Subramanian T, Kamarajah SK, Karandikar S. Impact of socioeconomic deprivation on short-term outcomes and long-term overall survival after colorectal resection for cancer. Int J Colorectal Dis 2019; 34 (12) 2101-2109
    PubMedSearch in Google Scholar