Differentiating Urgent from Elective Cases Matters in Minority Populations: Developing an Ordinal "Desirability of Outcome Ranking" to Increase Granularity and Sensitivity of Surgical Outcomes Assessment.

Jacobs MA, Schmidt S, Hall DE, Stitzenberg KB, Kao LS, Wang CP, Manuel LS, Shireman PK. Differentiating Urgent from Elective Cases Matters in Minority Populations: Developing an Ordinal "Desirability of Outcome Ranking" to Increase Granularity and Sensitivity of Surgical Outcomes Assessment. Journal of the American College of Surgeons. 2023 Jun 8.

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Abstract:

BACKGROUND: Surgical analyses often focus on single or binary outcomes; we developed an ordinal Desirability of Outcome Ranking (DOOR) for surgery to increase granularity and sensitivity of surgical outcome assessments. Many studies also combine elective and urgent procedures for risk adjustment. We used DOOR to examine complex associations of race/ethnicity and presentation acuity. STUDY DESIGN: NSQIP (2013-2019) cohort study assessing DOOR outcomes across race/ethnicity groups risk-adjusted for frailty, operative stress, preoperative acute serious conditions (PASC), and elective, urgent, and emergent cases. RESULTS: The cohort included 1,597,199 elective, 340,350 urgent and 185,073 emergent cases with patient mean age of 60.0 (SD = 15.8) and 56.4% of the surgeries were performed on female patients. Minority race/ethnicity groups had increased odds of presenting with PASC (aORs range 1.22-1.74), urgent (aORs range 1.04-2.21), and emergent (aORs range 1.15-2.18) surgeries vs White. Black (aORs range 1.23-1.34) and Native (aORs range 1.07-1.17) groups had increased odds of higher/worse DOOR outcomes, however, Hispanic group had increased odds of higher/worse DOOR (aOR = 1.11, CI = 1.10-1.13), but decreased odds (aORs range 0.94-0.96) after adjusting for case status; the Asian group had better outcomes vs White. DOOR outcomes improved in minority groups when using elective vs elective/urgent cases as the reference group. CONCLUSION: NSQIP surgical DOOR is a new method to assess outcomes and reveals complex interplay between race/ethnicity and presentation acuity. Combining elective and urgent cases in risk adjustment may penalize hospitals serving higher proportions of minority populations. DOOR can be used to improve detection of health disparities and serves as a roadmap for the development of other ordinal surgical outcomes measures. Improving surgical outcomes should focus on decreasing PASC and urgent and emergent surgeries, possibly by improving access to care, especially for minority populations.