This decision analytical model evaluates projected changes in cancer screening and outcomes following changes to federal Medicaid funding and eligibility restrictions enacted with the 2025 Budget Reconciliation Bill.

Importance:Rural hospital-level surgical quality has been extensively evaluated. However, rural people in the US face growing inequities in care, and quality of surgical care experienced by rural patients nationally remains poorly defined. Objective:To evaluate surgical quality among rural vs nonrural Medicare beneficiaries undergoing common general surgery procedures. Design, Setting, and Participants:This retrospective cohort study used 100% Medicare inpatient claims linked with the American Hospital Association Annual Survey between 2016 and 2023. The cohort included beneficiaries aged 65 to 99 years who underwent admission for appendectomy, cholecystectomy, colectomy, or incisional hernia repair. This analysis was undertaken between August and October 2025. Exposure:Rural vs nonrural residence, defined using Rural-Urban Commuting Area codes based on patient home zip code (1-3: nonrural; 4-10: rural). Main Outcomes and Measures:Risk-adjusted 30-day mortality, in-hospital mortality, complications, 30-day readmission, discharge disposition, and hospital length of stay. Multivariable logistic regression models adjusted for patient factors, hospital factors, and year of surgery. Results:Among 2 317 497 beneficiaries (55.5% female; mean [SD] age, 75.2 [7.2] years), 462 358 (19.9%) were rural. Rural patients were more often male (46.4% vs 44.1%) and traveled longer for surgery (median, 45.0 [IQR, 22.0-77.0] minutes vs 20.0 [IQR, 13.0-31.0] minutes). Rural patients had higher adjusted 30-day mortality (6.78% [95% CI, 6.65%-6.90%] vs 5.84% [95% CI, 5.76%-5.93%]; odds ratio [OR], 1.21 [95% CI, 1.18-1.24]; P < .001), in-hospital mortality (3.65% [95% CI, 3.56%-3.74%] vs 3.20% [95% CI, 3.14%-3.25%]; OR, 1.17 [95% CI, 1.14-1.21]; P < .001), and 30-day readmission (14.31% [95% CI, 14.14%-14.48%] vs 13.57% [95% CI, 13.45%-13.69%]; OR, 1.07 [95% CI, 1.05-1.08]; P < .001). Complication rates were higher (29.31% [95% CI, 29.04%-29.57%] vs 28.58% [95% CI, 28.40%-28.76%]; OR, 1.05 [95% CI, 1.03-1.07]; P < .001). Rural patients were less likely to be discharged home (75.56% [95% CI, 75.24%-75.88%] vs 77.61% [95% CI, 77.36%-77.86%]; OR, 0.85 [95% CI, 0.83-0.88]; P < .001) and more likely to be transferred to another facility (1.40% [95% CI, 1.33%-1.47%] vs 0.70% [95% CI, 0.67%-0.73%]; OR, 2.04 [95% CI, 1.92-2.17]; P < .001). Conclusions and Relevance:In this cohort study of Medicare beneficiaries undergoing common general surgery procedures, rural residence was independently associated with worse clinical outcomes across most measures. These findings identify significant opportunities for quality improvement focused on common rural surgical needs.

OBJECTIVE:To compare the influence of private equity acquisition on surgical quality among rural hospitals. SUMMARY AND BACKGROUND DATA:Despite the growth of private equity's presence in healthcare markets and growing concerns of its adverse associations with quality of care, less is known about its influence on rural hospitals. METHODS:We evaluated common general surgery procedures (appendectomy, cholecystectomy, colectomy, and incisional hernia repair) among Medicare beneficiaries between 2011 and 2020. We defined rurality using Rural-Urban Commuting Area codes and identified rural hospitals acquired by private equity using the Private Equity Stakeholder Project Private Equity Hospital Tracker. We matched each private equity-acquired hospital with up to 10 similar rural hospitals not acquired by private equity. The primary outcome was 30-day postoperative mortality, and secondary outcomes included complications, serious complications, failure to rescue, and 30-day readmissions. We applied an event-time difference-in-differences framework with hospital and year fixed effects, controlling for beneficiary characteristics and comorbidities. RESULTS:Among 96,048 patients across 390 rural hospitals, private equity acquisition was associated with statistically significant increases in 30-day mortality (1.1 percentage point increase, P=0.04), complications (2.5 percentage point increase, P=0.03), and serious complications (1.5 percentage point increase, P=0.02) despite similar hospital characteristics and modest differences in patient demographics. CONCLUSIONS:Private equity acquisition of rural hospitals was associated with some declines in surgical quality, which underscores the need to continue closely monitoring private equity's impact on rural healthcare delivery.

Private equity (PE) firms have increasingly invested in US hospitals, raising concerns about their effects on the quality of surgical care. We evaluated the impact of PE acquisition of acute care hospitals on outcomes from four common general surgical operations among Medicare beneficiaries, using a difference-in-differences approach. Our study included 67 hospitals acquired by PE and 634 control hospitals not acquired by or previously owned by PE. We found that PE acquisition was associated with a 2.7-percentage-point increase in thirty-day postoperative mortality compared with control hospitals, driven primarily by an increase in failure to rescue (3.9 percentage points), with no observed change in the rate of complications. Subset analysis revealed that the increase in mortality was particularly pronounced for unplanned (emergent) surgeries, whereas no significant changes were observed for planned (elective) surgeries. Our findings suggest that PE acquisition may adversely affect the management of emergent surgical cases, raising critical considerations for policy makers and health care stakeholders regarding the influence of PE ownership on patient safety.

There are rising concerns about the effects of rural hospital closure on access to and quality of care for impacted patients, but little remains known about surgical care. The objective of this study was to evaluate the association of hospital closure with outcomes and access to surgery for common surgical conditions. Using Medicare claims data from 2010-2020, we evaluated the impact of rural hospital closures on surgical quality and access for common operations (colectomy, cholecystectomy, appendectomy, and hernia repair). Using a dynamic difference-in-differences approach, we analyzed 36 884 and 41 185 beneficiaries who lost their nearest and second-nearest rural hospital, respectively. Our findings revealed no significant impacts on surgical quality as measured by 30-day mortality, complications, serious complications, reoperations, and readmissions. While rates of unplanned surgery did not change, median travel distance increased from 13.1 to 16.4 miles for beneficiaries who lost their nearest hospital but was unchanged for those losing their second-nearest hospital. These findings suggest that, while rural hospital closure does not adversely impact surgical quality, it does pose challenges in ensuring access to timely surgical care. Policymakers should consider tailored interventions to mitigate the persistent and growing travel disparities to obtain care in rural America.

OBJECTIVE:To characterize the extent of private equity (PE) investment affecting surgical care. BACKGROUND:Over the last decade, investor-backed, for-profit PE groups have invested in health care at an unprecedented rate, but the breadth of these investments affecting surgical practice remains largely unknown. METHODS:Four nationally representative databases were used to identify all merger/acquisitions involving surgical practices between 2015 and 2019, determine PE investment in those transactions, and link the acquisitions with a physician data set. RESULTS:A total of 1542 unique transactions were identified, of which 539 were financed by PE. Fifty-eight transactions were then classified into their respective categories within surgical care: digestive disease, orthopedics, urology, vascular surgery, and plastic/cosmetic surgery. These transactions accounted for 199 practice sites and 1405 physicians, averaging 24.2 physicians per transaction. Acquisition activity peaked in 2017, with a total of 63 practices involved. Digestive disease, urology, and orthopedic surgery accounted for the most activity. General surgeons were involved in a small share of the digestive disease practice acquisitions. Three "surgery-adjacent" categories were also identified: anesthesiology, ambulatory surgery centers, and surgical staffing firms. Among these, anesthesia was the largest category in terms of practices (194) and physicians (2660) involved in transactions across the study period. Medical Service Organizations were a key mechanism through which PE firms invested in surgical care. CONCLUSIONS:PE has engaged in substantial investment within surgical specialties, creating increased practice consolidation. These investments affect all levels of medical care and have notable implications for patients, practitioners, and policymakers.

Objective: To determine whether hospital system affiliation was associated with changes in surgical episode spending or postoperative outcomes. Background: Over 70% of US hospitals are now part of a hospital system. The presumed benefits of hospital consolidation include concentrating volume and expertise, care integration, and investment in quality improvement. However, there is conflicting evidence as to whether expanding hospital systems are actually reducing health spending or improving quality. These observations call into question whether systems are leveraging their collective volume and experience to standardize care and maximize efficiencies. Methods: The American Hospital Association Annual Survey was used to identify whether a hospital was part of a system and in which year a hospital joined the respective system. Using 100% Medicare claims data, we identified fee-for-service Medicare patients undergoing elective inpatient coronary artery bypass graft colon resection, lung resection, hip replacement, or knee replacement from 2010 to 2018. We used a difference-in-differences framework to evaluate hospital spending and outcomes before and after joining a system. The primary outcome was Medicare 30-day episode spending, with specific attention to the total episode payment, index hospitalization, and post-acute care components. Secondary outcomes included serious complications, 30-day mortality, and 30-day readmission. Results: The cohort included 3,395,565 Medicare beneficiaries who underwent surgery between 2010 and 2018. Patients were treated at 3961 hospitals, of which 1097 (27.7%) were never in a system, 2262 (57.1%) were always in a system, and 602 (15.2%) joined a system during the study period. By 1 year after system affiliation, 30-day episode spending had decreased by $303 (95% CI: 63, 454, P=0.01), and after 5 years, 30-day episode spending decreased by $429 (95% CI: 5, 853, P=0.04). One year after system association, index hospitalization spending was not statistically different from before system affiliation ($-30, 95% CI: -160, 100, P=0.65). Conversely, 1 year after system association, postacute care spending decreased by $268 (95% CI: 107, 429, P<0.01) and remained lower for >= 5 years. There was no significant change in hospitals serious complications (-0.14, 95% CI: -0.40, 0.11, P=0.27), 30-day readmission (-0.14, 95% CI:-0.52, 0.25, P=0.48), or 30-day mortality (-0.08, 95% CI: -0.18, 0.03, P=0.17), 1 year after joining a system; similar patterns were observed at three and >= 5 years. Conclusions: system affiliation was associated with a small decrease in 30-day episode spending, driven by decreased spending in postacute care services. Notably, there was no difference in postoperative outcomes after system affiliation.

BACKGROUND:Given the well-established relationship between volume and outcomes related to pancreatic cancer surgery, there has been a growing interest in centralizing these procedures at high-volume centers. However, the distribution of high-volume centers and the socioeconomic characteristics of the population that they serve at a national level remain poorly understood. METHODS:Centers that performed pancreatic cancer surgery between 2017 and 2021 were identified using the Medicare Standard Analytical Files. Centers with an average annual volume of pancreatic cancer resections meeting the Leapfrog minimum volume thresholds over the study period were defined as high-volume centers. The centers were geolocated based on their address, as reported in the National Plan and Provider Enumeration System database. Service areas representing 90-minute drive-time areas around high-volume centers were defined. Populations within and outside these areas were compared based on their block-level sociodemographic characteristics obtained from the 2021 5-year American Community Survey data. RESULTS:A total of 832 centers were included in the analysis, of which 76 (9.1%) qualified as high-volume centers. High-volume centers performed a substantially higher number of pancreatectomies over the study period than low-volume centers (median: 70.5 [IQR, 60.2-101.0] vs 5.0 [IQR, 2.0-14.0], respectively) and were responsible for a median of 51.1% (IQR, 50.5%-51.6%) of all resections performed in any given year. A total of 127,519,167 individuals (38.3% of the population) resided outside the service areas of high-volume centers. Compared with individuals residing within the service areas of high-volume centers, those residing outside the service areas of high-volume centers were more often male (49.3% vs 49.8%, respectively), older (40.2 ± 9.7 vs 41.7 ± 10.8, respectively), White (64.0% vs 74.5%, respectively), veterans (6.0% vs 8.1%, respectively), uninsured (8.4% vs 9.3%, respectively), without higher education (54.8% vs 62.5%, respectively), without Internet access (8.9% vs 12.9%, respectively), and with a lower median household income ($85,846 ± 46,180 vs $64,876 ± 32,500, respectively). On multivariate logistic regression, factors associated with a higher likelihood of being included in the service area of a high-volume center were a higher median age (odds ratio [OR], 1.02 [95% CI, 1.01-1.03]), a higher proportion of non-White residents (OR, 1.20 [95% CI, 1.19-1.20]), a higher percentage of households in which English is not the first language spoken at home (OR, 1.23 [95% CI, 1.22-1.24]), and a higher median income (OR, 1.13 [95% CI, 1.13-1.13]). Conversely, factors that led to a lower likelihood of being included in a high-volume service area were a higher proportion of male residents (OR, 0.92 [95% CI, 0.91-0.93]), a higher proportion of Hispanic residents (OR, 0.86 [95% CI, 0.85-0.87]), a higher proportion of veteran residents (OR, 0.62 [95% CI, 0.61-0.63]), more households without Internet access (OR, 0.78 [95% CI, 0.77-0.79]), and a higher rate of noninsured residents (OR, 0.95 [95% CI, 0.94-0.96]). CONCLUSION:More than 1 in 3 individuals in the United States may face significant spatial barriers when seeking pancreatic cancer surgery at high-volume centers. These individuals mostly belong to rural, socially vulnerable communities.

Objective: This study aimed to determine the influence of structural racism, vis-à-vis neighborhood socioeconomic trajectory, on colorectal and breast cancer diagnosis and treatment. Summary Background Data: Inequities in cancer care are well documented in the United States but less is understood about how historical policies like residential redlining and evolving neighborhood characteristics influence current gaps in care. Methods: This retrospective cohort study included adult patients diagnosed with colorectal or breast cancer between 2010 and 2015 in 7 Indiana cities with available historic redlining data. Current neighborhood socioeconomic status was determined by the Area Deprivation Index (ADI). Based on historic redlining maps and current ADI, we created four “Neighborhood Trajectory” categories: Advantage Stable, Advantage Reduced, Disadvantage Stable, Disadvantage Reduced. Modified Poisson regression models estimated the relative risks (RR) of Neighborhood Trajectory on cancer stage at diagnosis and receipt of cancer-directed surgery (CDS). Results: A final cohort derivation identified 4,862 cancer patients with colorectal or breast cancer. Compared to Advantage Stable neighborhoods, Disadvantage Stable neighborhood was associated with late-stage diagnosis for both colorectal and breast cancer (RR=1.30 [95% CI=1.05 – 1.59]; RR=1.41 [1.09 – 1.83], respectively). Black patients had lower likelihood of receiving CDS in Disadvantage Reduced neighborhoods (RR=0.92 [0.86 – 0.99]) than White patients. Conclusions: Disadvantage Stable neighborhoods were associated with late-stage diagnosis for breast and colorectal cancer. Disadvantage Reduced (gentrified) neighborhoods were associated with racial-inequity in CDS. Improved neighborhood socioeconomic conditions may improve timely diagnosis but could contribute to racial inequities in surgical treatment.

Background: Patients with Acute Care Surgery needs (ie, emergency general surgery diagnosis or trauma admission) are at particularly high risk for nonmedical patient -related factors that can be important drivers of healthcare outcomes. These social determinants of health are typically ascertained at the geographic area level (ie, county or neighborhood) rather than at the individual patient level. Recently, the International Classification of Diseases Tenth Revision, Tenth Edition created codes to capture health hazards related to patient socioeconomic and psychosocial circumstances. We sought to characterize the impact of these social determinants of health -related codes on perioperative outcomes among patients with acute care surgery needs. Methods: Patients diagnosed between 2017 and 2020 with acute care surgery needs (ie, emergency general surgery diagnosis or a trauma admission) were identified in the California Department of Healthcare Access and information Patient Discharge database. Data on concomitant social determinants of health -related codes (International Classification of Diseases Tenth Revision, Tenth Edition Z55 -Z65), which designated health hazards related to socioeconomic and psychosocial (socioeconomic and psychosocial, respectively) circumstances, were obtained. After controlling for patient factors, including age, sex, race, payer type, and admitting hospital, the association of socioeconomic and psychosocial codes with perioperative outcomes and hospital disposition was analyzed. Results: Among 483,280 with an acute care surgery admission (emergency general surgery: n = 289,530, 59.9%; trauma: n = 193,705, 40.1%) mean age was 56.5 years (standard deviation: 21.5) and 271,911 (56.3%) individuals were male. Overall, 16,263 (3.4%) patients had a concomitant socioeconomic and psychosocial diagnosis code. The percentage of patients with a concurrent social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis increased throughout the study period from 2.6% in 2017 to 4.4% in 2020. Patients that were male (odds ratio 1.89; 95% confidence interval 1.82, 1.96), insured by Medicaid (odds ratio 5.43; 95% confidence interval 5.15, 5.72) or self -pay (odds ratio 3.04; 95% confidence interval 2.75, 3.36) all had higher odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. Black race did not have a significant association with an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis (odds ratio 0.99; 95% confidence interval 0.94, 1.04); however, Hispanic (odds ratio 0.44; 95% confidence interval 0.43, 0.46) and Asian (odds ratio 0.40; 95% confidence interval 0.36, 0.44) race/ethnicity was associated with a lower odds of having an social determinants of health International Classification of Diseases Tenth Revision, Tenth Edition diagnosis. After controlling for competing risk factors on multivariable analyses, the risk -adjusted probability of hospital postoperative death was 3.1% (95% confidence interval 2.8, 3.4) among patients with a social determinants of health diagnosis versus 5.9% (95% confidence interval 5.9, 6.0) (odds ratio 0.48; 95% confidence interval 0.44, 0.54) among patients without a social determinants of health diagnosis. Risk -adjusted complications were 26.7% (95% confidence interval 26.1, 37.3) among patients with a social determinants of health diagnosis compared with 31.9% (95% confidence interval 31.7, 32. 0) (odds ratio 0.74; 95% confidence interval 0.71, 0.77) among patients without a social determinants of health diagnosis. Conclusion: International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code use was low, with only 3.4% of patients having documentation of a socioeconomic and psychosocial circumstance. The presence of an International Classification of Diseases Tenth Revision, Tenth Edition social determinants of health code was not associated with greater odds of complications or death; however, it was associated with longer length of stay and higher odds of being discharged to a skilled nursing facility. (c) 2023 Elsevier Inc. All rights reserved.

This cohort study evaluates the Health Professional Shortage Area Surgeon Incentive Program to determine how it may have changed the surgeon workforce in designated areas.

Hepatocellular carcinoma (HCC) poses a significant public health challenge within the US, exerting an increasingly substantial influence on cancer- related deaths. However, the HCC burden is not uniformly distributed, with significant disparities related to race, ethnicity, and socioeconomic status. This manuscript comprehensively reviews the multifaceted origins of HCC disparities, exploring their roots in the sociocultural environment, socioeconomics, the physical/built environment, and the healthcare/political systems. The sociocultural environment highlights the unique challenges faced by racial and ethnic minority populations, including language barriers, cultural beliefs, and limited healthcare access. The socioeconomics and the physical/ built environment section emphasize the impact of neighborhood poverty, geographic disparities, and healthcare infrastructure on HCC outcomes. The healthcare and political systems play a pivotal role in driving HCC disparities through practice guidelines, healthcare policies, insurance coverage, and access to care. Inconsistent practice guidelines across specialties and variations in insurance coverage contribute to disparities in HCC surveillance and treatment. In conclusion, addressing HCC disparities requires a multifaceted, patient-centered approach that includes cultural competence, infrastructure enhancements, policy changes, and improved access to care. Collaborative efforts among healthcare professionals, researchers, policymakers, and institutions are essential to reducing the burden of HCC on marginalized communities and ensuring equitable care for all individuals affected by this complex disease.

ImportanceDespite widespread use to guide patients to hospitals providing the best care, it remains unknown whether Centers for Medicare & Medicaid Services (CMS) hospital star ratings are a reliable measure of hospital surgical quality.ObjectiveTo examine the CMS hospital star ratings and hospital surgical quality measured by 30-day postoperative mortality, serious complications, and readmission rates for Medicare beneficiaries undergoing colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, and incisional hernia repair.Design, Setting, and ParticipantsThis cohort study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals with a CMS hospital star rating for calendar years 2014-2018. Data analysis was performed from January 15, 2022, to April 30, 2023. Participants included fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair with continuous Medicare coverage for 3 months before and 6 months after surgery.ExposureCenters for Medicare & Medicaid Services hospital star rating.Main Outcomes and MeasuresRisk- and reliability-adjusted hospital rates of 30-day postoperative mortality, serious complications, and 30-day readmissions were measured and compared across hospitals and star ratings.ResultsA total of 1 898 829 patients underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair at 3240 hospitals with a CMS hospital star rating. Mean (SD) age was 74.8 (7.0) years, 50.6% of the patients were male, and 86.5% identified as White. Risk- and reliability-adjusted 30-day mortality rate decreased in a stepwise fashion from 6.80% (95% CI, 6.79%-6.81%) in 1-star hospitals to 4.93% (95% CI, 4.93%-4.94%) in 5-star hospitals (adjusted odds ratio, 1.86; 95% CI, 1.73-2.00). There was wide variation in the rates of hospital mortality (variation, 1.89%; range, 2.4%-16.2%), serious complications (variation, 1.97%; range, 5.5%-45.1%), and readmission (variation, 1.27%; range, 9.1%-22.5%) across all hospitals. After stratifying hospitals by their star rating, similar patterns of variation were observed within star rating groups for 30-day mortality: 1 star (variation, 1.91%; range, 3.6%-12.0%), 2 star (variation, 1.86%; range, 2.8%-16.2%), 3 star (variation, 1.84%; range, 2.9%-12.3%), 4 star (variation, 1.76%; range, 2.9%-11.5%), and 5 star (variation, 1.79%; range, 2.4%-9.1%). Similar patterns were observed for serious complications and readmissions.Conclusion and RelevanceAlthough CMS hospital star rating was associated with postoperative mortality, serious complications, and readmissions, there was wide variation in surgical outcomes within each star rating group. These findings highlight the limitations of the CMS hospital star rating system as a measure of surgical quality and should be a call for continued improvement of publicly reported hospital grade measures.

Health care providers and policymakers have long been concerned with increasing access to high-quality health care for all patients.Seminal work by Birkmeyer et al 1 demonstrated a strong volume-outcome relationship for high-risk operations.Subsequently, the volumeoutcome relationship has informed delivery of high-quality surgical oncology care over the past several decades.Because high-volume surgical centers have lower morbidity and mortality compared with low-volume centers, especially among patients undergoing complex, high-risk cancer-related surgical procedures, there has been extensive centralization of these cases across the country. 2 Despite quality improvements because of embracing the volume-outcome relationship, many providers have raised concerns that subsequent centralization has led to increased disparities and an additional burden to a subset of vulnerable patients. 2,3In the article that accompanies this editorial, Ramian et al 4 analyzed the statewide Pennsylvania Health Care Cost Containment Council inpatient data and reported that for many cancers analyzed, patients residing in rural areas were less likely to receive care at high-volume hospitals.

The role of historic residential redlining on health disparities is intertwined with policy changes made before and after the 1930s that influence current neighborhood characteristics and shape ongoing structural racism in the United States. We developed Neighborhood Trajectories which combine historic redlining data and the current neighborhood socioeconomic characteristics as a novel approach to studying structural racism. Home Owners Loan Corporation (HOLC) neighborhoods for the entire U.S. were used to map the HOLC grades to the 2020 U.S. Census block group polygons based on the percentage of HOLC areas in each block group. Each block group was also assigned an Area Deprivation Index (ADI) from the Neighborhood Atlas®. To evaluate changes in neighborhoods from historic HOLC grades to present degree of deprivation, we aggregated block groups into "Neighborhood Trajectories" using historic HOLC grades and current ADI. The Neighborhood Trajectories are "Advantage Stable"; "Advantage Reduced"; "Disadvantage Reduced"; and "Disadvantage Stable." Neighborhood Trajectories were established for 13.3% (32,152) of the block groups in the U.S., encompassing 38,005,799 people. Overall, the Disadvantage-Reduced trajectory had the largest population (16,307,217 people). However, the largest percentage of Non-Hispanic/Latino Black residents (34%) fell in the Advantage-Reduced trajectory, while the largest percentage of Non-Hispanic/Latino White residents (60%) fell in the Advantage-Stable trajectory. The development of the Neighborhood Trajectories affords a more nuanced mechanism to investigate dynamic processes from historic policy, socioeconomic development, and ongoing marginalization. This adaptable methodology may enable investigation of ongoing sociopolitical processes including gentrification of neighborhoods (Disadvantage-Reduced trajectory) and "White flight" (Advantage Reduced trajectory).

We sought to determine the impact of historical redlining on travel patterns and utilization of high-volume hospitals (HVHs) among patients undergoing complex cancer operations. The California Department of Health Care Access and Information database was utilized to identify patients who underwent esophagectomy (ES), pneumonectomy (PN), pancreatectomy (PA), or proctectomy (PR) for cancer between 2010 and 2020. Patient ZIP codes were assigned Home Owners’ Loan Corporation grades (A: ‘Best’; B: ‘Still Desirable’; C: ‘Definitely Declining’; and D: ‘Hazardous/Redlined’). A clustered multivariable regression was used to assess the likelihood of patients undergoing surgery at an HVH, bypassing the nearest HVH, and total real driving time and travel distance. Among 14,944 patients undergoing high-risk cancer surgery (ES: 4.7