Association of Historic Housing Policy, Modern Day Neighborhood Deprivation and Outcomes After Inpatient Hospitalization

Objective: To evaluate the association of historical racist housing policies and modern-day healthcare outcomes. Summary of Background Data: In 1933 the United States Government Home Owners Loan Corporation (HOLC) used racial composition of neighborhoods to determine creditworthiness and labeled them Best, Still Desirable, Definitely Declining, and Hazardous. Although efforts have been made to reverse these racist policies that structurally disadvantage those living in exposed neighborhoods, the lasting legacy on modern day healthcare outcomes is uncertain. Methods: We performed a cross-sectional retrospective review of 212,179 Medicare beneficiaries' living in 171,930 unique neighborhoods historically labeled by the HOLC who underwent 1 of 5 of common surgical procedures - coronary artery bypass, appendectomy, colectomy, cholecystectomy, and hernia repair - between 2012 and 2018. We compared 30-day mortality, complications, and readmissions across HOLC grade and Area Deprivation Index (ADI) of each neighborhood. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods ADI; a modern day measure of neighborhood disadvantage that includes education, employment, housing-quality, and poverty measures. Results: Overall, 212,179 Medicare beneficiaries (mean age, 71.2 years; 54.2% women) resided in 171,930 unique neighborhoods historically graded by the HOLC. Outcomes worsened in a stepwise fashion across HOLC neighborhoods. Overall, 30-day postoperative mortality was 5.4% in Best neighborhoods, 5.8% in Still Desirable, 6.1% in Definitely Declining, and 6.4% in Hazardous (Best vs Hazardous Odds Ration: 1.23, 95% CI: 1.13-1.24, P < 0.001). The same stepwise pattern was seen from Best to Hazardous neighborhoods for complications (30.5% vs 32.2%; OR: 1.12 [95% CI: 1.07-1.17]; P < 0.001) and Readmissions (16.3% vs 17.1%; OR: 1.06 [95% CI: 1.01-1.11]; P = 0.023). After controlling for modern day deprivation using ADI, the patterns persisted with Hazardous neighborhoods having higher mortality (OR: 1.17 [95% CI: 1.08-1.27]; P < 0.001) and complications (OR: 1.07 [95% CI: 1.02-1.12]; P = 0.003), but not for readmissions (OR: 1.02 [95% CI: 0.97-1.07]; P = 0.546). Conclusions: Patients residing in neighborhoods previously redlined or labeled Hazardous were more likely to experience worse outcomes after inpatient hospitalization compared to those living in Best neighborhoods, even after taking into account modern day measures of neighborhood disadvantage.

Automated summary

This study evaluated the association between historical racist housing policies and modern-day healthcare outcomes. Patients residing in neighborhoods previously redlined or labeled Hazardous were more likely to experience worse outcomes after inpatient hospitalization compared to those living in Best neighborhoods, even after taking into account modern day measures of neighborhood disadvantage.