Annals of the American Thoracic Society

Rationale: Understanding how systemic forces and environmental exposures impact patient outcomes is critical to advancing health equity and improving population health for patients with pulmonary disease. This relationship has not yet been assessed at the population level nationally.

Objectives: To determine whether neighborhood socioeconomic deprivation is independently associated with 30-day mortality and readmission for hospitalized patients with pulmonary conditions, after controlling for demographics, access to healthcare resources, and characteristics of admitting healthcare facilities.

Methods: This was a retrospective, population-level cohort study of 100% of United States nationwide Medicare inpatient and outpatient claims from 2016–2019. Patients were admitted for one of four pulmonary conditions (pulmonary infections, chronic lower respiratory disease, pulmonary embolism, and pleural and interstitial lung diseases), defined by diagnosis-related group. The primary exposure was neighborhood socioeconomic deprivation, measured by the area deprivation index. The main outcomes were 30-day mortality and 30-day unplanned readmission, defined by Centers for Medicare and Medicaid Services methodologies. Generalized estimating equations were used to estimate logistic regression models for the primary outcomes, addressing clustering by hospital. A sequential adjustment strategy was first adjusted for age, legal sex, Medicare–Medicaid dual eligibility, and comorbidity burden, then adjusted for metrics of access to healthcare resources, and finally adjusted for characteristics of the admitting healthcare facility.

Results: After full adjustment, patients from low socioeconomic status neighborhoods had greater 30-day mortality after admission for pulmonary embolism (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.13–1.40), respiratory infections (OR, 1.20; 95% CI, 1.16–1.25), chronic lower respiratory disease (OR, 1.31; 95% CI, 1.22–1.41), and interstitial lung disease (OR, 1.15; 95% CI, 1.04–1.27) when compared to patients from the highest SES neighborhoods. Low neighborhood socioeconomic status was also associated with 30-day readmission for all groups except the interstitial lung disease group.

Conclusions: Neighborhood socioeconomic deprivation may be a key factor driving poor health outcomes for patients with pulmonary diseases.

Correspondence and requests for reprints should be addressed to Bradley G. Hammill, Dr.P.H., Duke University School of Medicine, Department of Population Health Sciences, 215 Morris Street, Durham, NC 27701. E-mail: .

Supported by the Duke University Health System. The funder had no role in the conduct of the research or in the decision to submit the manuscript for publication.

Author Contributions: J.B.L.: Conceptualization, investigation, writing – original draft; M.N.H. and H.M.: conceptualization, formal analysis, investigation, writing – review and editing; A.G.C. and B.B.: conceptualization, investigation, writing – review and editing; J.B.: conceptualization, writing – review and editing; D.C.A. and C.E.C.: writing – review and editing; B.G.H.: conceptualization, investigation, formal analysis, supervision, writing – review and editing.

Data sharing: The data can be obtained from the United States Centers for Medicare and Medicaid Services.

This article has a related editorial.

Author disclosures are available with the text of this article at

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Annals of the American Thoracic Society

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