Patients from poorer neighbourhoods at greater risk of post-surgery death

Patients from disadvantaged neighbourhoods are at greater risk of dying within 30 days of elective surgery than those from wealthier neighbourhoods, according to a cohort study of more than one million patients in Ontario.

The sample included Ontario patients who underwent planned surgery between 2017 and 2023. However, there is no reason to believe that the situation would be any different for Quebec patients, according to Sandy Torres, a sociologist at the Observatoire québécois des inégalités.

She is not at all surprised to see that there is an association between poverty and an increased risk of mortality, in this case dying after surgery. “We find the same kind of association when we talk about other types of mortality or the risk of hospitalization or health problems in general,” she points out.

Torres notes that there may be certain specificities to the healthcare system in Ontario, but she points out that Canadian studies, and more broadly studies in Western countries, show “this same association between socioeconomic status and health status and the fact that people experience shorter lives when they are disadvantaged.”

“We know that these inequalities are more pronounced in Ontario. Despite this, I don’t think the situation is any better in Quebec. As we’ve seen recently, there are many people living in precarious situations. I have no reason to believe that it’s any different in Quebec,” she comments.

Situation in Quebec

In a statement to CityNews, Quebec’s health ministry (MSSS) said that the link between health outcomes and socioeconomic status was well-establish.

“For example, between 2019 and 2021, the most socioeconomically disadvantaged group recorded 222.3 more premature deaths (per 100,000) compared to the most advantaged group,” the ministry said.

“The MSSS therefore believes that health‑prevention efforts must target the entire population, but that the level of support and resources should be adjusted according to people’s needs—an approach known as proportionate universalism,” the ministry added, emphasizing that its National Health Prevention Strategy aimed to reduce premature mortality gaps linked to socioeconomic inequalities by 10 per cent.

Paul Brunet, chair of Council for the Protection of patients in Montreal, said, “The waiting is the worst enemy of patients who are waiting to get a medical intervention.”

“Afterwards, it’s the re-adaptation, the follow-up from the pivot nurses who sometimes want to do the best, but patients feel that sometimes they are left alone. So this is another key element for better re-adaptation and see patients recovering from any kind of interventions they had in the hospital,” Brunet added.

Brunet said public transit strikes can also make matters worse, especially for seniors.

“If (you) go on strike and you diminish the service,” Brunet explained. “You render the elders already vulnerable with less possibility to move on, go to their appointment, go to the hospital, come back, take a taxi, a lot of them don’t have the resources for it.”

Flaws in universal healthcare system

The study, published in the medical journal Jama, points out that despite advances in perioperative medicine, nearly two per cent of patients die within 30 days of surgery, a figure that has not changed over the past decade.

Previous research conducted in private, for-profit healthcare systems has suggested that social determinants of health, including the conditions in which people are born, grow up, work, live, and age, play a role in adverse postoperative outcomes. However, it was unclear whether these findings also applied to universal healthcare systems, such as in Canada.

The results of the study of Ontario patients show that those from more disadvantaged neighbourhoods have a 52 per cent higher risk of death than those from wealthier areas.

This rate is significant, Torres points out. “Unfortunately, it doesn’t surprise me at all,” she says. “It’s a major contribution of the study to put a number on it, to quantify this association. We need this kind of data.”

Moreover, the association between death and disadvantaged neighbourhoods persisted even when taking into account known comorbidities in patients, such as cancer, heart failure, diabetes, or hypertension. This link was also present despite taking into account demographic factors, patient health status, hospital variables, and the complexity of surgical procedures.

Although Canada has a universal healthcare system, where cost is theoretically not a barrier to accessing surgical care, social determinants of health affect access to certain healthcare services, including planned surgeries, Torres argues.

“What we see in various studies conducted in Quebec and Canada is that material and social disadvantage can lead to delays in seeking healthcare. For example, you may only seek medical attention when the problem has become really serious. And it can even lead to people giving up on seeking treatment,” explains the researcher.

She cites the example that certain jobs leave very little time or few opportunities to take time off to attend medical appointments.

“Maybe you’re working two jobs, maybe you have split shifts, or maybe you don’t even know from week to week what your schedule will look like. All of that job insecurity means you’re not starting from the same place as people who have more stable, better‑paid work,” Torres explained. “It’s just one example, but it illustrates what we mean when we talk about living conditions that make things harder.”

“There are access barriers that mean some people won’t seek out the care they need — they may even delay getting care, which can make their conditions worse. When people delay or avoid care, they also don’t get diagnosed,” Torres continued.

Priority solution

Less affluent people are often unable to meet their basic needs, such as food and shelter, which makes them much more vulnerable to nutritional deficiencies and disease, according to a document from the Observatoire québécois des inégalités. They may also reduce their spending on medication. In addition, living in poverty also causes stress, which contributes to mental health problems.

Improving postoperative outcomes likely requires addressing underlying disparities in the social determinants of health, the study suggests.

For Torres, if there were one solution to prioritize, it would be to enable people to cover their basic needs. “This requires better financial support, but it can also involve improvements to the neighbourhood. It’s a lot of things. It’s about allowing people to be self-sufficient so they can buy enough good-quality food, have decent housing, and be able to clothe themselves… These are basic fundamental needs. Participating in social life to a minimum extent and having some leisure activities are also part of basic needs, and of course, being able to take care of oneself and have access to healthcare like everyone else,” explains the researcher.

She acknowledges that this is not a magic wand and that the positive impacts would take time to be felt. The causes of health problems are multifactorial and have a cumulative effect, and social inequalities are one of them.

Torres also added that, in Quebec, the currently available data showing a difference of 6.3 years in life expectancy between the richest and poorest populations was almost a decade old and needed an update.

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