Association Between Neighborhood-Level Socioeconomic Vulnerability and Postoperative Complications in Benign Hysterectomy: A Retrospective Analysis Using the Vizient Vulnerability Index

INTRODUCTION: Socioeconomic disparities have long been recognized as significant determinants of surgical outcomes. The Vizient Vulnerability Index (VVI), a neighborhood-level measure of socioeconomic vulnerability, offers an opportunity to assess the relationship between socioeconomic factors and gynecologic care at a neighborhood level. OBJECTIVE: We aimed to investigate whether VVI is associated with postoperative complications in individuals undergoing benign hysterectomy. METHODS: This retrospective analysis included all patients who underwent benign hysterectomy between 2015 and 2024 within the Vizient clinical database, which is nationally representative across the United States. Only patients with available VVI scores were included. The VVI is based on ZIP code and assesses socioeconomic vulnerability across nine social domains, including public safety, transportation, social cohesion, environmental quality, housing, neighborhood safety nets, and access to food, healthcare access, education, and income. Patients were categorized by VVI quartiles (Q1 = least vulnerable to Q4 = most vulnerable), which served as our primary predictor variable. Using multivariable logistic regression, we examined the relationship between the VVI quartiles and postoperative complications, adjusting for demographic and clinical factors such as age, BMI, medical comorbidities, and surgical approach. Complications were defined using the Clavien-Dindo classification system (1–2 = minor, 3–5 = major). RESULTS: Among the 748,814 patients who met the inclusion criteria, 19.3% (144,582) experienced perioperative complications, including 9.7% (37,897) experiencing major complications and 13.6% (125,428) experiencing minor complications. Patients from higher VVI quartiles had significantly higher rates of major, minor, and all complications compared to less vulnerable patients (p<0.05). Patients of Black and Hispanic minorities had increased odds for complications within each VVI quartile, compared to White individuals. An adjusted logistic regression analysis confirmed that patients with higher VVI scores had a significantly greater likelihood of having major complications, independent of age, BMI, and comorbidities. Specifically, patients in VVI Q2 had an adjusted odds ratio (aOR) of 1.03 [95% CI 1.00–1.06], Q3 had aOR of 1.06 [95% CI 1.03–1.09], and Q4 had aOR 1.10 [95% CI 1.07–1.14] compared to Q1. Only patients in Q4 had significantly increased odds of minor and any complications (aOR 1.09 [95% CI 1.07–1.14]; 1.09 [95% CI 1.07–1.11], respectively) compared to Q1 (Figure 1). CONCLUSIONS: This study is the first to demonstrate that a higher neighborhood-level socioeconomic vulnerability index is associated with a greater risk of postoperative complications following benign hysterectomy. Unlike previous research focused on individual-level factors, these findings highlight the systemic and pervasive nature of disparities rooted in broader social determinants of health. Notably, we found that non-White race and Hispanic ethnicity were independently associated with increased risk of complications, regardless of VVI. This indicates that while the VVI incorporates multiple important social determinants of health, it may not fully account for the impact of systemic racism, for which race and ethnicity served as proxies in our study. Addressing these gaps is crucial for promoting equitable healthcare outcomes for all women, particularly those of minority populations. We encourage future prospective studies to utilize VVI as a tool to identify vulnerable patients who may benefit from early intervention (Tables 1 and 2).