Understanding the impact of socioeconomic deprivation on inpatient surgical care delivery costs in the Veterans Health Administration.

The impact of living in high neighborhood-level socioeconomic deprivation on inpatient surgery cost is not well known. This retrospective cohort study examines the relationship between the Area Deprivation Index (ADI) and noncardiac inpatient surgery costs in the Veterans Health Administration (VHA). Patients aged ≥65 years undergoing non-cardiac inpatient surgery during 2013-2019 were identified in Veterans Affairs Surgical Quality Improvement Program (VASQIP) data linked to additional VHA data sources. The cohort includes 136,631 predominantly male (97.7%) individuals with mean (SD) age of 72 (6.5) years. The 20,462 individuals with high ADI (>85) were more often Black race (27% vs 13.6%) with higher comorbidity burden (Gagne score 3.4 vs 3.1), higher frailty (29.1 vs 28.7), and more likely presenting with preoperative acute serious conditions (5.6% vs 4.5%) for more urgent (21.3% vs 18.7%) or emergent surgery (8.9% vs 8.1%, all p<0.001). After adjusting for facility and surgery year using regression, mean cost was $988 higher (95% CI: $657, $1319; p<0.001) for individuals with ADI>85. Using unconditional quantile regression, costs were even higher (>$1,600) for patients with ADI>85 at or above the 75th cost quantile. The higher costs among individuals living in high ADI areas were attenuated after controlling for comorbidity and frailty (mean cost difference of -$8; 95% CI: -$312, $296; p=0.96 after adjustment for those factors) and presentation acuity (-$57; 95% CI: -$356, $241; p=0.71). Among older patients undergoing inpatient surgery in the VHA, ADI>85 is associated with higher surgical cost, an effect which is eliminated by controlling for patient comorbidity, frailty, and presentation acuity. These results suggest potential for cost-savings by mitigating barriers to healthcare access, timely surgery access, and other downstream effects of high neighborhood-level socioeconomic deprivation before surgery becomes urgent.