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 non-cardiac 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 (>$1600) 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. • Surgical cost is associated with neighborhood-level socioeconomic deprivation. • High deprivation, measured by the Area Deprivation Index (ADI), is defined as ADI>85. • Veterans Health Administration inpatient surgery cost was $988 higher in ADI>85. • Higher cost is partially explained by comorbidity, frailty, and presentation acuity. • Mitigating barriers to healthcare access can impact health and downstream surgical cost.