# Understanding the effect of rurality and social risk factors on barriers to care and surgical outcomes.

> **NIH VA I01** · SOUTH TEXAS VETERANS HEALTH CARE SYSTEM · 2021 · —

## Abstract

Background: The Mission Act provides improved Veteran access to care both within the Veterans
Administration (VA) and community systems. An underlying assumption is that faster care with more choices
results in better care. However, care fragmentation is associated with increased length of stay, readmissions,
and mortality. Postoperative complications and readmissions are higher in minority and low socioeconomic
status (SES) patients. Low SES is also associated with frailty, one of the best predictors of 30-day
postoperative complications and hospital readmissions. Despite having a profound influence on health
outcomes, social risk factors are absent from risk adjustment for VA quality measures, further exacerbating
disparities in minority and low SES populations. This strategy may further constrain resources to care for
vulnerable populations, as many Veterans are economically disadvantaged and potentially adding avoidable
costs to care delivery. Another major issue is care fragmentation. Nevertheless, the impact of non-VA care and
care fragmentation is absent in performance metrics. Our goal is to identify social risk factors and levels of
care fragmentation that affect surgical outcomes to inform VA quality metric policy and institutional
resource allocation. We improve upon current practice by joining surgical outcomes data with 1) VA/Centers
for Medicare & Medicaid Services (CMS) claims data, 2) VA fee-basis files to identify encounters outside of the
VA health system and 3) using more granular proxy social risk factors and neighborhood disadvantage.
Significance/Impact: Our significance is modeling surgical outcomes using social risk factors, rurality, living in
a disadvantaged neighborhood and care fragmentation to identify factors contributing to health care disparities
and to inform VA policy. The impact is to develop quality metrics using social risk factors and care fragmentation.
HSR&D priority areas: Rural Health, Health Equity, Health Care Value and Health Care Informatics.
Innovation: Joining diverse data sources to develop predictive models using both traditional parametric methods
and exploratory machine learning techniques to provide clinicians and administrators with outcomes and
economic analyses necessary to change institutional practices to benefit our most vulnerable Veterans.
Specific Aims:
Aim 1: Identify factors affecting surgical outcomes by assessing the contributions of ethnicity, race, SES, place
 of residence and care fragmentation to surgical complications, readmissions and mortality
 Hypothesis: Using ethnic/racial minority status, SES, place of residence and care fragmentation will identify
important risk factors for postoperative complications, readmissions, and mortality
Aim 2: Assess the impact of social risk factors and care fragmentation on hospital performance metrics for
 readmissions and mortality
 Hypothesis: Including social risk factors and care fragmentation in risk adjustment models significantly
cha...

## Key facts

- **NIH application ID:** 10187736
- **Project number:** 1I01HX003095-01A2
- **Recipient organization:** SOUTH TEXAS VETERANS HEALTH CARE SYSTEM
- **Principal Investigator:** Daniel E Hall
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2021
- **Award amount:** —
- **Award type:** 1
- **Project period:** 2021-10-01 → 2025-03-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10187736

## Citation

> US National Institutes of Health, RePORTER application 10187736, Understanding the effect of rurality and social risk factors on barriers to care and surgical outcomes. (1I01HX003095-01A2). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10187736. Licensed CC0.

---

*[NIH grants dataset](/datasets/nih-grants) · CC0 1.0*