Despite the well-established importance of health-related social needs in shaping patient outcomes, gaps remain in the literature examining these relationships at the individual level among patients undergoing cardiac surgery. This retrospective study used data from the 2016–2018 Nationwide Readmission Database to evaluate postoperative complications and readmissions in patients undergoing cardiac surgery (coronary artery bypass grafting, aortic surgery, valve surgery, or a combination) using individual-level social vulnerability clinically acknowledged using ICD-10 Z-codes. Six domains of ICD-10 Z-codes (employment, family, housing, psychosocial needs, socioeconomic status, dependence) were considered social vulnerabilities. Data were analyzed using stratification by social vulnerability status and multivariable logistic regression. Among the 846,837 included patients, dependence-related needs were the most documented domain. Patients with social vulnerability at any point were younger, had a longer length of stay, and had a higher prevalence of comorbid conditions, readmissions, and complications. For patients with social vulnerability, the odds ratio of complications was 1.12 (1.03–1.22), and the odds ratio of 90-day readmissions was 1.15 (1.03–1.27). Clinically acknowledged social vulnerability at any point was associated with higher odds of complications or readmissions after cardiac surgery. Z-codes may be useful for identifying nonmedical factors that can affect patient outcomes, but further standardization and assessment are needed.
Centers for Disease Control and Prevention. Heart disease facts. Centers for Disease Control and Prevention. 2022. Available from: https://www.cdc.gov/heartdisease/facts.htm [Last accessed: February7, 2023].
2.
TsaoCW, AdayAW, AlmarzooqZI, et al.Heart disease and stroke statistics—2022 update: A report from the American heart association. Circulation2022;145(8):e153–e639; doi: 10.1161/CIR.0000000000001052
3.
StevensM, ShenoyAV, MunsonSH, et al.Healthcare utilization and costs of cardiopulmonary complications following cardiac surgery in the United States. PLoS One2019;14(12):e0226750; doi: 10.1371/journal.pone.0226750
4.
UdzikJ, SienkiewiczS, BiskupskiA, et al.Cardiac complications following cardiac surgery procedures. J Clin Med2020;9(10):3347; doi: 10.3390/jcm9103347
SchultzWM, KelliHM, LiskoJC, et al.Socioeconomic status and cardiovascular outcomes: Challenges and interventions. Circulation2018;137(20):2166–2178; doi: 10.1161/CIRCULATIONAHA.117.029652
8.
BoylanJM, RobertSA. Neighborhood SES is particularly important to the cardiovascular health of low SES individuals. Soc Sci Med2017;188:60–68; doi: 10.1016/j.socscimed.2017.07.005
9.
CharlesEJ, MehaffeyJH, HawkinsRB, et al.; Investigators for the Virginia Cardiac Services Quality Initiative. Socioeconomic ‘distressed communities index’ predicts risk-adjusted mortality after cardiac surgery. Ann Thorac Surg2019;107(6):1706–1712; doi: 10.1016/j.athoracsur.2018.12.022
10.
McCarthyFH, ZhangL, TamV, et al.Geographically Derived Socioeconomic Factors to Improve Risk Prediction in Patients Having Aortic Valve Replacement. Am J Cardiol2019;123(1):116–122; doi: 10.1016/j.amjcard.2018.09.019
11.
BennettKM, ScarboroughJE, PappasTN, et al.Patient socioeconomic status is an independent predictor of operative mortality. Ann Surg2010;252(3):552–558; doi: 10.1097/SLA.0b013e3181f2ac64
12.
AgabitiN, CesaroniG, PicciottoS, et al.; Italian Study Group on Inequalities in Health Care. The association of socioeconomic disadvantage with postoperative complications after major elective cardiovascular surgery. J Epidemiol Community Health2008;62(10):882–889; doi: 10.1136/jech.2007.067470
13.
CromhoutPF, ThygesenLC, MoonsP, et al.Social and emotional factors as predictors of poor outcomes following cardiac surgery. Interact Cardiovasc Thorac Surg2022;34(2):193–200; doi: 10.1093/icvts/ivab261
14.
BerkowitzSA, BaggettTP, EdwardsST. Addressing health-related social needs: Value-based care or values-based care? J Gen Intern Med2019;34(9):1916–1918; doi: 10.1007/s11606-019-05087-3
15.
FeldmanPJ, SteptoeA. How neighborhoods and physical functioning are related: The roles of neighborhood socioeconomic status, perceived neighborhood strain, and individual health risk factors. Ann Behav Med2004;27(2):91–99; doi: 10.1207/s15324796abm2702_3
16.
KolakM, BhattJ, ParkYH, et al.Quantification of neighborhood-level social determinants of health in the continental United States. JAMA Netw Open2020;3(1):e1919928; doi: 10.1001/jamanetworkopen.2019.19928
17.
SchiavoniKH, HelscelK, VogeliC, et al.Prevalence of social risk factors and social needs in a Medicaid accountable care organization (ACO). BMC Health Serv Res2022;22(1):1375; doi: 10.1186/s12913-022-08721-9
18.
MaksutJL, HodgeCJ, RazmiA, et al.Utilization of z codes for social determinants of health among medicare fee-for-service beneficiaries, 2019. Centers for Medicare and Medicaid Services (CMS); 2021. Available from: https://www.cms.gov/files/document/z-codes-data-highlight.pdf
19.
BenskenWP, AlbertiPM, StangeKC, et al.ICD-10 Z-code health-related social needs and increased healthcare utilization. Am J Prev Med2022;62(4):e232–e241; doi: 10.1016/j.amepre.2021.10.004
20.
BenskenWP, AlbertiPM, KoroukianSM. Health-related social needs and increased readmission rates: Findings from the nationwide readmissions database. J Gen Intern Med2021;36(5):1173–1180; doi: 10.1007/s11606-021-06646-3
21.
Agency for Healthcare Research and Quality. Nationwide readmissions database (NRD) overview. Healthcare Cost and Utilization Project (HCUP). 2022. Available from: https://www.hcup-us.ahrq.gov/nrdoverview.jsp [Last accessed: February7, 2023].
ElkaryoniA, ThakkerJ, BarakatAF, et al.P2668: Causes and predictors of 30 and 90 days readmission after cardiac arrest: Insights from the nationwide readmission database. Eur Heart J2019;40(Supplement_1); doi: 10.1093/eurheartj/ehz748.0986
24.
KhanMS, SreenivasanJ, LateefN, et al.Trends in 30- and 90-day readmission rates for heart failure. Circ Heart Fail2021;14(4):e008335; doi: 10.1161/CIRCHEARTFAILURE.121.008335
25.
AfilaloJ, MottilloS, EisenbergMJ, et al.Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity. Circ Cardiovasc Qual Outcomes2012;5(2):222–228; doi: 10.1161/CIRCOUTCOMES.111.963157
26.
SchiltzNK, ChaginK, SehgalAR. Clustering of social determinants of health among patients. J Prim Care Community Health2022;13:21501319221113543; doi: 10.1177/21501319221113543
27.
BerkowitzSA, SeligmanHK, ChoudhryNK. Treat or eat: Food insecurity, cost-related medication underuse, and unmet needs. Am J Med2014;127(4):303–310.e3; doi: 10.1016/j.amjmed.2014.01.002
28.
YandrapalliS, SanaaniA, HarikrishnanP, et al.Cardiogenic shock during heart failure hospitalizations: Age-, sex-, and race-stratified trends in incidence and outcomes. Am Heart J2019;213:18–29; doi: 10.1016/j.ahj.2019.03.015
29.
DeckerA, WeaverR. Health and social determinants associated with delay of health care among rural older adults. Innov Aging2021;5(Supplement_1):210–211; doi: 10.1093/geroni/igab046.813
30.
PatelPM, SinghS, TagoeI. Association of social risks with avoiding or delaying health care and with emergency department visits: Evidence from 2017 Ohio Medicaid assessment survey. Am J Manag Care2021;27(3):115–121.
31.
SalganicoffA. Women and Medicare: An unfinished agenda. Gener J Am Soc Aging2015;39:43–50.
32.
White-WilliamsC, RossiLP, BittnerVA, et al.; American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Epidemiology and Prevention. Addressing social determinants of health in the care of patients with heart failure: A scientific statement from the American heart association. Circulation2020;141(22):e841–e863; doi: 10.1161/CIR.0000000000000767
33.
VohraN, PaudyalV, PriceMJ. Homelessness and the use of emergency department as a source of healthcare: A systematic review. Int J Emerg Med2022;15(1):32; doi: 10.1186/s12245-022-00435-3
34.
FatemiF, ArdalanA, AguirreB, et al.Social vulnerability indicators in disasters: Findings from a systematic review. Int J Disaster Risk Reduct2017;22:219–227; doi: 10.1016/j.ijdrr.2016.09.006
35.
SterlingMR, RingelJB, PinheiroLC, et al.Social determinants of health and 30-day readmissions among adults hospitalized for heart failure in the REGARDS study. Circ Heart Fail2022;15(1):e008409; doi: 10.1161/CIRCHEARTFAILURE.121.008409
36.
InouyeCF, KaminskiMA. Z codes for social determinants of health: A better predictor of risk for value-based care. Popul Health Manag.2022;25(6):831–833; doi: 10.1089/pop.2022.0151
37.
TruongHP, LukeAA, HammondG, et al.Utilization of social determinants of health ICD-10 Z-codes among hospitalized patients in the United States, 2016–2017. Med Care2020;58(12):1037–1043; doi: 10.1097/MLR.0000000000001418
38.
WeeksWB, CaoSY, LesterCM, et al.Use of Z-codes to record social determinants of health among fee-for-service Medicare beneficiaries in 2017. J Gen Intern Med2020;35(3):952–955; doi: 10.1007/s11606-019-05199-w
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
