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A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships between Race/Ethnicity, Insurance Type and Neighborhood Deprivation.
Jacobs MA, Schmidt S, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships between Race/Ethnicity, Insurance Type and Neighborhood Deprivation. Annals of surgery. 2023 Jul 14.
Develop an ordinal Desirability of Outcome Ranking (DOOR) for surgical outcomes to examine complex associations of Social Determinants of Health (SDoH).
SUMMARY BACKGROUND DATA:
Studies focused on single or binary composite outcome may not detect health disparities.
Three healthcare 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 multi-level SDoH of race/ethnicity, insurance type (Private 13,957; Medicare 15,198; Medicaid 2,835; Uninsured 2,963) and Area Deprivation Index (ADI) on DOOR and the binary Textbook Outcomes (TO).
Patients living in highly deprived neighborhoods (ADI > 85) had higher odds of PASC (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 but 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.
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.