One cutoff is not enough: Assessing different area deprivation index cutoffs for insurance types on surgical Desirability of Outcome Ranking (DOOR)

Abstract

Background

Social Determinants of Health impact health outcomes. Area Deprivation Index (ADI) is used to risk-adjust for neighborhood affluence/deprivation but guidance on choosing deprivation cutoffs is lacking. We hypothesize that different ADI cutoffs are required for different insurance types.

Methods

National Surgical Quality Improvement Program data 2013–2019 merged with electronic health records from three academic healthcare systems. Desirability of Outcome Ranking (DOOR) assessed the association of ADI cutoffs for different insurance types, adjusted for operative stress, frailty, and case status (elective, urgent, emergent). Secondary analyses assessed the association of ADI with case status.

Results

Patients with Private insurance living in areas with ADI>85 had higher/worse DOOR outcomes, which lost significance after adjusting for case status. Medicare cases with ADI>75 exhibited higher/worse DOOR outcomes even after adjusting for case status. ADI was not associated with outcomes in the Medicaid and Uninsured groups. High ADI was associated with increased odds of urgent and emergent cases for the Private and Medicare but not Medicaid or Uninsured groups.

Conclusions

ADI is a useful metric to identify at-risk patients and can be used for risk adjustment. Health systems must understand their population demographics and use their data to determine ADI cutoffs. Patients in deprived neighborhoods have higher odds of urgent and emergent surgeries, despite having Private insurance or Medicare, suggesting that delays/barriers to primary and preventive care may be a major driver of worse outcomes. While insurance coverage is important, healthcare policies supporting reductions in urgent/emergent cases could have the largest impact on improving outcomes.