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RESEARCH OBJECTIVE: In 1933 the United States Government Home Owners Loan Corporation 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 Black Americans, the lasting legacy on modern day healthcare outcomes is uncertain. The objective of this study was to evaluate the association of historical racist housing policies and modern day healthcare outcomes. STUDY DESIGN: Cross‐sectional retrospective review of Medicare beneficiaries' who underwent one of five of common surgical procedures across neighborhoods historically labeled by the Home Owners Loan Corporation. Outcomes were risk‐adjusted using a multivariable logistical regression model accounting forpatient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), and type of operation. POPULATION STUDIED: 525,690 Medicare beneficiaries' admissions between 2012 and 2016 who underwent one of five of common surgical procedures ‐ coronary artery bypass, appendectomy, colectomy, cholecystectomy and hernia repair – across neighborhoods historically labeled by the Home Owners Loan Corporation. PRINCIPAL FINDINGS: Overall, 473,732 Medicare beneficiaries (mean age, 74.6 years; 49.8% women) underwent 520,690 operations within neighborhoods that had been historically graded by the Home Owners Loan Corporation. Mortality increased in a stepwise fashion across neighborhoods. Overall, 30‐day postoperative mortality was 4.3% in “Best” neighborhoods, 4.7% in “Still Desirable”, 4.8% in “Definitely Declining” and 5.1% in “Hazardous” (Best vs. Hazardous Odds Ratio = 1.21 [1.16–1.26]; P

BACKGROUND Surgical resection is a cornerstone of curative-intent therapy for patients with solid organ malignancies. With increasing attention paid to the costs of surgical care, there is a new focus on variations in the costs of cancer surgery. This study evaluated the potential interactive effect of hospital quality and patient risk on expenditures for cancer resections. METHODS With 100% Medicare claim data for 2010-2013, patients aged 65 to 99 years who had undergone cancer resection were identified. Medicare payments were calculated for the surgical episode from the index admission through 30 days after discharge. Risk- and reliability-adjusted hospital rates of serious complications and mortality within 30 days of the index operation were assessed to categorize high- and low-quality hospitals. RESULTS There was no difference in patient characteristics between the highest and lowest quality hospitals. There were substantial increases in expenditures for procedures performed at the lowest quality hospitals for each procedure. Increased expenditures at the lowest quality hospitals were found for all patients, but they were highest for the highest risk patients. At low-quality hospitals, low-risk patients undergoing pancreatectomy had payments of $29,080, whereas high-risk patients had average payments of $62,687; this was a difference of $33,607 per patient episode. CONCLUSIONS Total episode expenditures for cancer resections were lower when care was delivered at low-complication, high-quality hospitals. Expenditure differences were particularly large for high-risk patients, and this suggests that the selective referral of high-risk patients to high-quality centers may be an effective strategy for optimizing value in cancer surgery. Cancer 2018;124:826-32. © 2017 American Cancer Society.