Faculty, Staff and Student Publications
Publication Date
2-1-2024
Journal
Annals of Surgery
Abstract
Objective: Develop an ordinal Desirability of Outcome Ranking (DOOR) for surgical outcomes to examine complex associations of Social Determinants of Health.
Background: Studies focused on single or binary composite outcomes may not detect health disparities.
Methods: Three health care system cohort study using NSQIP (2013-2019) linked with EHR and risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status and operative stress assessing associations of multilevel Social Determinants of Health of race/ethnicity, insurance type (Private 13,957; Medicare 15,198; Medicaid 2835; Uninsured 2963) and Area Deprivation Index (ADI) on DOOR and the binary Textbook Outcomes (TO).
Results: Patients living in highly deprived neighborhoods (ADI>85) had higher odds of PASC [adjusted odds ratio (aOR)=1.13, CI=1.02-1.25, P < 0.001] and urgent/emergent cases (aOR=1.23, CI=1.16-1.31, P < 0.001). Increased odds of higher/less desirable DOOR scores were associated with patients identifying as Black versus White and on Medicare, Medicaid or Uninsured versus Private insurance. Patients with ADI>85 had lower odds of TO (aOR=0.91, CI=0.85-0.97, P =0.006) until adjusting for insurance. In contrast, patients with ADI>85 had increased odds of higher DOOR (aOR=1.07, CI=1.01-1.14, P < 0.021) after adjusting for insurance but similar odds after adjusting for PASC and urgent/emergent cases.
Conclusions: DOOR revealed complex interactions between race/ethnicity, insurance type and neighborhood deprivation. ADI>85 was associated with higher odds of worse DOOR outcomes while TO failed to capture the effect of ADI. Our results suggest that presentation acuity is a critical determinant of worse outcomes in patients in highly deprived neighborhoods and without insurance. Including risk adjustment for living in deprived neighborhoods and urgent/emergent surgeries could improve the accuracy of quality metrics.
Keywords
Aged, Humans, United States, Ethnicity, Medicare, Cohort Studies, Insurance Coverage, Medicaid, Retrospective Studies, health disparities, social determinants of health, surgical AQ1 outcomes
DOI
10.1097/SLA.0000000000005994
PMID
37450703
PMCID
PMC10787813
PubMedCentral® Posted Date
2-1-2025
PubMedCentral® Full Text Version
Author MSS
Published Open-Access
yes
Included in
Gender and Sexuality Commons, Medical Sciences Commons, Race and Ethnicity Commons, Surgery Commons