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

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ImportanceInsurance coverage expansion has been proposed as a solution to improving health disparities, but insurance expansion alone may be insufficient to alleviate care access barriers.ObjectiveTo assess the association of Area Deprivation Index (ADI) with postsurgical textbook outcomes (TO) and presentation acuity for individuals with private insurance or Medicare.Design, Setting, and ParticipantsThis cohort study used data from the National Surgical Quality Improvement Program (2013-2019) merged with electronic health record data from 3 academic health care systems. Data were analyzed from June 2022 to August 2023.ExposureLiving in a neighborhood with an ADI greater than 85.Main Outcomes and MeasuresTO, defined as absence of unplanned reoperations, Clavien-Dindo grade 4 complications, mortality, emergency department visits/observation stays, and readmissions, and presentation acuity, defined as having preoperative acute serious conditions (PASC) and urgent or emergent cases.ResultsAmong a cohort of 29 924 patients, the mean (SD) age was 60.6 (15.6) years; 16 424 (54.9%) were female, and 13 500 (45.1) were male. A total of 14 306 patients had private insurance and 15 618 had Medicare. Patients in highly deprived neighborhoods (5536 patients [18.5%]), with an ADI greater than 85, had lower/worse odds of TO in both the private insurance group (adjusted odds ratio [aOR], 0.87; 95% CI, 0.76-0.99; P = .04) and Medicare group (aOR, 0.90; 95% CI, 0.82-1.00; P = .04) and higher odds of PASC and urgent or emergent cases. The association of ADIs greater than 85 with TO lost significance after adjusting for PASC and urgent/emergent cases. Differences in the probability of TO between the lowest-risk (ADI ≤85, no PASC, and elective surgery) and highest-risk (ADI &gt;85, PASC, and urgent/emergent surgery) scenarios stratified by frailty were highest for very frail patients (Risk Analysis Index ≥40) with differences of 40.2% and 43.1% for those with private insurance and Medicare, respectively.Conclusions and RelevanceThis study found that patients living in highly deprived neighborhoods had lower/worse odds of TO and higher presentation acuity despite having private insurance or Medicare. These findings suggest that insurance coverage expansion alone is insufficient to overcome health care disparities, possibly due to persistent barriers to preventive care and other complex causes of health inequities.

Section: Discussionmentioning

confidence: 99%

Presentation Acuity and Surgical Outcomes for Patients With Health Insurance Living in Highly Deprived Neighborhoods

Schmidt,

Jacobs,

Kim

et al. 2024

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“…By comparison, VASQIP cannot differentiate urgent from elective. Because urgent cases have been found to have worse outcomes compared with elective procedures in NSQIP, this could be a source of bias in our analysis . However, the more granular data in NSQIP would, if anything, bias toward the null, further supporting our main finding.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non–Veterans Affairs Care Settings

George,

Jacobs,

Reitz

et al. 2024

ImportanceRecent legislation facilitates veterans’ ability to receive non–Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non–VA care settings are lacking.ObjectiveTo compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals.Design, Setting, and ParticipantsThis coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older.ExposuresSurgical care in VA or private-sector hospitals.Main Outcomes and MeasuresPostoperative 30-day mortality and failure to rescue (FTR).ResultsAmong 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P &lt; .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P &lt; .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P &lt; .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P &lt; .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P &lt; .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P &lt; .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P &lt; .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures.Conclusions and RelevanceAlthough women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.

“…We aimed to develop such an outcome, a Desirability of Outcome Ranking (DOOR) with a single, ordinal score combining various surgical outcomes, for use in VA surgical data. DOOR was originally developed to evaluate antibiotic performance in clinical trials, and these methods were later adapted for surgical outcomes using National Surgical Quality Improvement Program (NSQIP) data and then adding electronic health record (EHR)–based outcomes . DOOR has more statistical power than analyzing outcomes separately or binary composites, like textbook outcomes.…”

Section: Introductionmentioning

confidence: 99%

“…At every iteration, surgical DOORs used a modified Delphi process, a valid, established method to substantiate consensus among experts (and previously used to determine research priorities for various surgical specialties and a surgical safety checklist). Surgical DOORs demonstrated improved detection of complex SDOH relationships within private-sector cohorts . We aimed to use a VA Surgical Quality Improvement Program (VASQIP)–specific DOOR to examine outcome disparities from a variety of SDOH simultaneously: (1) minoritized race; (2) living in highly resource-deprived areas; (3) living in rural areas; and (4) care fragmented between the VA and private-sector sources.…”

Section: Introductionmentioning

confidence: 99%

Social Determinants of Health and Surgical Desirability of Outcome Ranking in Older Veterans

Jacobs,

Gao,

Schmidt

et al. 2024

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ImportanceEvaluating how social determinants of health (SDOH) influence veteran outcomes is crucial, particularly for quality improvement.ObjectiveTo measure associations between SDOH, care fragmentation, and surgical outcomes using a Desirability of Outcome Ranking (DOOR).Design, Setting, And ParticipantsThis was a cohort study of US veterans using data from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP; 2013-2019) limited to patients aged 65 years or older with inpatient stays between 2 and 30 days, merged with multiple data sources, including Medicare. Race and ethnicity data were retrieved from VASQIP, Medicare and Medicaid beneficiary summary files, the Veterans Health Administration Corporate Data Warehouse, and the United States Veterans Eligibility Trends and Statistics file. Data were analyzed between September 2023 and February 2024.ExposureLiving in a highly deprived neighborhood (Area Deprivation Index &gt;85), race and ethnicity used as a social construct, rurality, and care fragmentation (percentage of non-VA care days).Main Outcomes and MeasuresDOOR is a composite, patient-centered ranking of 26 outcomes ranging from no complication (1, best) to 90-day mortality or near-death complications (6, worst). A series of proportional odds regressions was used to assess the impact of SDOH and care fragmentation adjusted for clinical risk factors, including presentation acuity (presenting with preoperative acute serious conditions and urgent or emergent surgical procedures).ResultsThe cohort had 93 644 patients (mean [SD] age, 72.3 [6.2] years; 91 443 [97.6%] male; 74 624 [79.7%] White). Veterans who identified as Black (adjusted odds ratio [aOR], 1.06; 95% CI, 1.02-1.10; P = .048) vs White and veterans with higher care fragmentation (per 20% increase in VA care days relative to all care days: aOR, 1.01; 95% CI, 1.01-1.02; P &lt; .001) were associated with worse (higher) DOOR scores until adjusting for presentation acuity. Living in rural geographic areas was associated with better DOOR scores than living in urban areas (aOR, 0.93; 95% CI, 0.91-0.96; P &lt; .001), and rurality was associated with lower presentation acuity (preoperative acute serious conditions: aOR, 0.88; 95% CI, 0.81-0.95; P = .001). Presentation acuity was higher in veterans identifying as Black, living in deprived neighborhoods, and with increased care fragmentation.Conclusions and RelevanceVeterans identifying as Black and veterans with greater proportions of non-VA care had worse surgical outcomes. VA programs should direct resources to reduce presentation acuity among Black veterans, incentivize veterans to receive care within the VA where possible, and better coordinate veterans’ treatment and records between care sources.