A National Analysis of Community-Level Socioeconomic Status and Surgical Outcomes in Gynecologic Surgery

To evaluate whether higher Distressed Communities Index (DCI) scores, as a measure of community-level socioeconomic distress, are associated with worse risk-adjusted postoperative outcomes and healthcare resource utilization after gynecologic surgery.

This was a retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Gynecology Collaborative database. Generalized linear mixed-effect models and linear mixed-effect models were used to evaluate the association between DCI scores and surgical outcomes, with institution treated as a random effect and models adjusted for the ACS-NSQIP predicted morbidity percentage.

Six ACS-NSQIP Gynecology Collaborative sites in the United States, between January 1, 2018, and June 30, 2023.

Adult patients undergoing gynecologic operations during the study period. Patient records, including ZIP Code data, were merged with DCI scores ranging from 0 (low distress) to 100 (high distress), with DCI > 75 identifying distressed communities.

No therapeutic interventions were applied. Exposures of interest were community-level distress as measured by DCI. The primary outcome was a composite measure of postoperative morbidity. Secondary outcomes included markers of resource utilization (length of stay, discharge to nursing facility, and hospital readmission) and comparisons of outcomes between oncologic and benign procedures.

Patients with DCI > 75 had a higher mean body mass index, greater comorbidity burden, higher ACS-NSQIP predicted morbidity percentage, longer mean length of stay, and higher unadjusted composite postoperative complication rates compared with patients with DCI ≤ 75. In generalized and linear mixed-effect models adjusting for ACS-NSQIP predicted morbidity, DCI (modeled continuously or dichotomized at >75) was not independently associated with postoperative complications (OR 1.06, 95% CI 0.86-1.30, p = .62), discharge destination (OR 0.69, 95% CI 0.38-1.26, p = .23), unplanned readmission (OR 1.15, 95% CI 0.86-1.54, p = .34), or length of stay. By contrast, higher ACS-NSQIP predicted morbidity percentage remained strongly associated with composite complications and hospital length of stay.

In our multicenter cohort, DCI showed no independent association with postoperative outcomes in multivariable analysis. Future research should include samples with higher proportions of participants from highly distressed communities, as well as more precise socioeconomic status measures (income, education, neighborhood), since ZIP code-based indicators may lack granularity. Such efforts could enhance individual risk stratification and targeted interventions. Linking clinical and community data is promising, but success requires rigorous harmonization, quality control, and methodological refinement.