Neighborhood Factors: A Multivariate Analysis on the Social Determinants in Simple Appendicitis

The purpose of this study was to use factor analysis to explore potential underlying dimensions that explain associations between social determinants of health (SDoH), operationalized as Social Deprivation Index (SDI) and Area Deprivation Index (ADI) scores and other neighborhood characteristics, and postoperative outcomes in pediatric patients with simple appendicitis.

We retrospectively reviewed all children (age < 18 years) who underwent an appendectomy for simple appendicitis at our institution (January 2015-December 2021). Patients were identified and patient demographics, clinicopathologic factors, and postoperative outcomes were abstracted from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) institutional dataset. Supplemental patient-level data were obtained via the electronic medical record. Population-level variables, including SDI and ADI as well as other neighborhood characteristics were obtained after geocoding patient home addresses. Patient-level postoperative outcomes included length of stay, percutaneous drain insertion, peripherally inserted central catheter (PICC) placement, emergency department (ED) visit within 30 days of discharge, as well as any postoperative fever, antibiotics, imaging, and parenteral nutrition usage. A multivariable model predictive of outcomes was created using feature selection and exploratory factor analysis.

Factor analysis revealed two uncorrelated multivariable factors: factor 1 included SDI score and ADI score, and factor 2 included percentages of Black, Hispanic, high-needs, and linguistically isolated residents. Lower factor 1 scores were associated with increased length of stay and increased frequency of postoperative imaging, while low factor 2 scores were associated with increased postoperative antibiotic usage.

Two latent factors were identified encompassing broad socioeconomic advantage (factor 1: SDI and ADI) and specific neighborhood characteristics (factor 2: the proportion of minoritized, high-needs, and linguistically isolated residents). Dividing the population using these factors demonstrated that patients with more socioeconomic advantage (low factor 1 scores) had increased lengths of stay and more postoperative imaging. Similarly, patients from neighborhoods with lower proportions of minoritized, high-needs, and linguistically isolated residents had less postoperative antibiotic usage. These results suggest that postoperative outcomes in children with appendicitis extend beyond socioeconomic status in a broad sense and are also impacted by specific neighborhood characteristics. The ability to isolate individual drivers of outcomes that are associated with SDoH may help to develop more tailored interventions aimed at attenuating disparities for vulnerable populations.