Neighborhood-Level Vulnerability Index as Marker for Suboptimal Gynecological Care

INTRODUCTION: Individual-level socioeconomic factors such as White race and high socioeconomic status have been associated with access to better quality healthcare, particularly in surgical settings. In benign gynecologic surgery, undergoing a hysterectomy with ovarian conservation before age 35 or a hysterectomy with bilateral oophorectomy before age 45 are associated with increased risks of all-cause mortality compared to undergoing these procedures at older ages. Similarly, benign hysterectomy via laparotomy is associated with increased morbidity compared to hysterectomy via minimally invasive approaches. No studies have evaluated the role of neighborhood-based socioeconomic factors and their impact on gynecologic care. OBJECTIVE: We aimed to investigate the association between neighborhood-level socioeconomic vulnerability, as measured by the Vizient Vulnerability Index (VVI), and markers of suboptimal gynecological care for individuals undergoing benign hysterectomy. These markers included: 1) procedures associated with increased risk of all-cause mortality (hysterectomy without oophorectomy at <35 years and/or hysterectomy with bilateral oophorectomy at <45 years), and 2) hysterectomy via laparotomy. METHODS: This retrospective analysis included patients who underwent benign hysterectomy from 2015 to 2024, using data from the Vizient clinical database, a nationally representative database across the United States. Only patients with available VVI scores were included. VVI scores are based on ZIP codes and calculated according to nine social domains: public safety, transportation, social cohesion, environmental quality, housing ownership, 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. Multivariable logistic regression models were created to assess associations with markers of suboptimal gynecologic care, adjusting for age, BMI, race/ethnicity, comorbidities, and other confounders. Statistical significance was defined as p<.05. RESULTS: Among the 748,814 patients analyzed, those in higher VVI quartiles were significantly more likely to undergo procedures associated with increased risk of all-cause mortality including hysterectomy at <35 years and/or hysterectomy with bilateral oophorectomy at <45 years. Specifically, compared to Q1, patients in VVI Q2 had an adjusted odds ratio (aOR) of 1.46 [95% CI: 1.42–1.50], Q3 had an aOR of 1.87 [95% CI: 1.83–1.92], and Q4 had an aOR 2.48 [95% CI: 2.42–2.54]. Similarly, patients in higher VVI quartiles were significantly more likely to undergo hysterectomy via laparotomy (Q2: aOR 1.03 [95% CI: 1.01–1.05]; Q3: aOR 1.04 [95% CI: 1.02–1.06]; Q4: aOR 1.13 [95% CI: 1.11–1.15]) compared with Q1 (Figure 1). CONCLUSIONS: This study demonstrates that higher neighborhood-level socioeconomic vulnerability, as measured by the VVI, is associated with markers of poor quality of gynecological care in benign hysterectomy. Patients with a high vulnerability index have a higher likelihood of undergoing hysterectomy with or without oophorectomy at younger ages and an increased risk of hysterectomy via laparotomy, which are linked to increased all-cause mortality and morbidity. The use of the VVI tool may help healthcare providers identify at-risk patients and implement measures to ensure appropriate care, including expanding access to minimally invasive gynecologic surgeons and enhancing preventive care in these neighborhoods. Future prospective studies are needed to further evaluate VVI as a tool for identifying vulnerable patients (Tables 1 and 2).