Unmeasured Risks: Social Determinants of Health Affect Rate of Surgical Complications Despite Clinical Risk Adjustment

Fischer, Chelsea P.; Liu, Yaoming; Cohen, Mark E.; Ko, Clifford Y.

doi:10.1016/j.jamcollsurg.2021.07.237

Cited by 2 publications

(3 citation statements)

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“…The American College of Surgeons has access to individual patient addresses and has published one abstract based on geocoded ADI. 39 However, ADI or other address-linked variables are not present in the Participant Use File, and are thus not subject to replication outside the American College of Surgeons NSQIP group. Our approach establishes a method for expanding the time horizon and outcomes of NSQIP.…”

Section: Discussionmentioning

confidence: 99%

“…However, the range of NSQIP outcomes is limited, assessed at only 30 days after surgery (not discharge) and omiting key social determinants of health. The American College of Surgeons has access to individual patient addresses and has published one abstract based on geocoded ADI 39 . However, ADI or other address-linked variables are not present in the Participant Use File, and are thus not subject to replication outside the American College of Surgeons NSQIP group.…”

Section: Discussionmentioning

confidence: 99%

“…The Risk Analysis Index (RAI) assesses frailty using NSQIP variables. RAI has been validated in multiple data sets [28][29][30] and renders a score ranging from 0 to 81 categorized as Robust ( ≤20), Normal (21)(22)(23)(24)(25)(26)(27)(28)(29), Frail (30)(31)(32)(33)(34)(35)(36)(37)(38)(39), and Very Frail ( ≥ 40). 28 RAI is used as a single variable estimate of patient-level variability that overcomes barriers to model fit encountered by less parsimonious models.…”

Section: Estimating Patient Frailty/premorbid Conditionsmentioning

confidence: 99%

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A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships between Race/Ethnicity, Insurance Type and Neighborhood Deprivation

Jacobs

Schmidt²,

Hall

et al. 2023

Annals of Surgery

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Objective: 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. Methods: 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). Results: 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. 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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Estimating Patient Frailty/premorbid Conditionsmentioning

confidence: 99%

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A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships between Race/Ethnicity, Insurance Type and Neighborhood Deprivation

Jacobs

Schmidt²,

Hall

et al. 2023

Annals of Surgery

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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

Schmidt²,

Hall³

et al. 2023

Journal of the American College of Surgeons

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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 to 2019) cohort study assessing DOOR outcomes across race/ethnicity groups risk-adjusted for frailty, operative stress, preoperative acute serious conditions, 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 ± 15.8, and 56.4% of the surgeries were performed on female patients. Minority race/ethnicity groups had increased odds of presenting with preoperative acute serious conditions (adjusted odds ratio [aORs] range 1.22 to 1.74), urgent (aOR range 1.04 to 2.21), and emergent (aOR range 1.15 to 2.18) surgeries vs the White group. Black (aOR range 1.23 to 1.34) and Native (aOR range 1.07 to 1.17) groups had increased odds of higher/worse DOOR outcomes; however, the Hispanic group had increased odds of higher/worse DOOR (aOR 1.11, CI 1.10 to 1.13), but decreased odds (aORs range 0.94 to 0.96) after adjusting for case status; the Asian group had better outcomes vs the White group. DOOR outcomes improved in minority groups when using elective vs elective/urgent cases as the reference group. CONCLUSIONS: NSQIP surgical DOOR is a new method to assess outcomes and reveals a complex interplay between race/ethnicity and presentation acuity. Combining elective and urgent cases in risk adjustment may penalize hospitals serving a higher proportion 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 preoperative acute serious conditions and urgent and emergent surgeries, possibly by improving access to care, especially for minority populations.

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Unmeasured Risks: Social Determinants of Health Affect Rate of Surgical Complications Despite Clinical Risk Adjustment

Cited by 2 publications

References 0 publications

A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships between Race/Ethnicity, Insurance Type and Neighborhood Deprivation

A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships between Race/Ethnicity, Insurance Type and Neighborhood Deprivation

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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