Document Type


Date of Degree

Fall 2018

Access Restrictions

Access restricted until 01/31/2021

Degree Name

PhD (Doctor of Philosophy)

Degree In

Health Management and Policy

First Advisor

Mueller, Keith

First Committee Member

Brock, André

Second Committee Member

Weiss, Bruce

Third Committee Member

Vaughn, Thomas

Fourth Committee Member

Wehby, George


Compared to wealthy individuals, individuals with low socioeconomic status (SES) often receive health services of lower intensity or quality and have difficulty accessing care. This is particularly true in the area of inpatient surgery. Individuals with low socioeconomic status are often less likely than individuals associated with high socioeconomic status to receive timely surgical care, and less likely than high SES to receive evidence-based treatments for surgical care. Despite these large gaps, there is a lack of consensus whether disparities in surgical outcomes are primarily due to differences in patient characteristics such as acuity or whether they are attributable to disparities in the quality of surgical care among those with access. The overall goal of this dissertation is to illuminate the relationship between socioeconomic status and surgical outcomes. The project aims are: 1) classify trends in post-surgical quality and analyze data on the relationship between socioeconomic status and surgical outcomes; 2) to evaluate whether changes in access to care can eliminate disparities in outcomes by analyzing the impact of the Massachusetts health reform on socioeconomic disparities in inpatient surgery; and 3) to show the potential effects of SES on surgical outcomes by using the Theory of Fundamental Causes. To meet the study objectives, this study proposes to use data from the Nationwide Inpatient Sample (NIS) and the State Inpatient Database (SID). This approach uses socioeconomic information in the NIS and SID that is a quartile classification of the estimated median household income of residents in the patient’s ZIP Code. The outcomes of interest are widely used quality measures: post-surgery mortality and complications at the national level, post-surgical mortality in Massachusetts for select inpatient surgeries, and difference-in-difference estimates. The approach used to identify trends in post-surgical quality uses two analytical software products to analyze the NIS using a regression-based approach. Study findings will identify progress and gaps in the quality of inpatient surgical care over recent years and further determine whether improving access to care through policy design can eliminate or reduce disparities in surgical care outcomes. In the face of health reform, this research will offer important insight into the study of surgical disparities and potential impact following health policy changes such as the expansion of Medicaid, implementation of health insurance exchanges, and the individual mandate requiring individuals to obtain health coverage.




xii, 94 pages


Includes bibliographical references.


Copyright © 2018 Mehwish Qasim

Available for download on Sunday, January 31, 2021