Racial and Economic Segregation and Prolapse Surgery Outcomes for Black Women

Objectives: Residential segregation (RS) influences health outcomes even within a single racial or ethnic group. The impact of segregation on prolapse (POP) surgery outcomes is unknown. The objective of this study was to examine the relationship between RS and POP surgery complications and readmissions among older Black women.

Methods: We utilized the Medicare 5% Limited Data Set to identify Black women who underwent POP surgery from 2011-2018 and identified 90-day complications and 30 and 90-day readmissions. We used the US Census American Community Survey’s 5-year estimates to calculate the Index of Concentration at the Extremes (ICE) for the US county where each beneficiary’s primary residence was located. The ICE quantifies spatial concentrations of racial and economic privilege versus disadvantage within a given area. We calculated 3 ICE measures, ICErace, ICEincome, and ICErace+income, to measure geographic segregation by race and income, and both combined (Table 1). The ICE is scaled from -1 to +1. A value of +1 connotes that all county residents are in the most privileged group, and a value of -1 denotes that all residents are in the least privileged group. We categorized counties into quintiles for each ICE measure, with quintiles 1 and 5 representing the least privileged and most privileged counties, respectively. Descriptive and comparative analysis were used to compare the demographic and clinical patient characteristics living in quintile 1 compared to all other quintiles (Table 1 shows comparisons for quintiles 1 and 5). Poisson regression models were used to test the association between the three ICE measures and complication and readmissions.

Results: Among Black women included in this analysis, there were minimal demographic and clinical differences between women living in the least and most privileged counties for all ICE measures. (Table 1). The overall rate of 90-day complications was 29.7%. Black women residing in counties with the highest concentrations of Black residents had a 44% and 54% increased relative risk (quintiles 1 and 2) of 90-day complications compared to those in counties with the highest concentrations of White residents (Table 2). Conversely, Black women living in least segregated counties by race and income combined experienced 70% and 57% decreased risk of 30 and 90-day readmissions, respectively (Table 2). These results were minimally impacted by adjustment for age, Charlson comorbidity score, dual enrollment in Medicaid, procedure type, concomitant anti-incontinence procedure, and hysterectomy.

Conclusions: Geographical context influences perioperative outcomes for Black women undergoing POP surgery. Those residing in the most segregated majority Black counties had significantly elevated risks of 90-day complications. In contrast, those in counties with low levels of combined racial and income segregation had lower risks of readmissions. Further research into mechanisms of how residential segregation yields and protects against POP surgical disparities for Black women is warranted.