Surgical Desirability of Outcomes Ranking: Implications of Racial and Economic Privilege on Days at Home after Major Operation

BACKGROUND: Racial and economic privilege can impact postoperative outcomes. We sought to assess the association of socioeconomic privilege with surgical outcomes using a composite measure called desirability of outcomes ranking (DOOR) and days at home within 90 days after the index procedure (DAH-90). STUDY DESIGN: Medicare claims data were used to identify patients who underwent a range of complex surgical procedures between 2016 and 2021. Socioeconomic privilege was measured using the Index of Concentration at the Extremes, and regression analyses were performed to evaluate its association with surgical outcomes and days at home. RESULTS: Among 445,872 patients, 62.4% (278,032) achieved the most desirable outcome (DOOR = 1). Living in areas with the highest privilege was associated with lower odds of achieving less desirable outcomes (odds ratio 0.94, 95% CI 0.92 to 0.96; p < 0.001) and increased days spent at home at the lower end of the distribution (0.10, 95% CI 0.02 to 0.19). A higher DOOR was associated with a reduction of 10 (95% CI -11.0 to -10.0), 2.8 (95% CI -2.8 to -2.7), and 1.2 (95% -1.2 to -1.1) days spent at home at the 25th, 50th, and 75th percentiles, respectively. The model based on DOOR demonstrated improved goodness of fit despite increased complexity compared with a model using textbook outcomes to predict days at home. CONCLUSIONS: A higher DOOR was associated with lower DAH-90, whereas privileged patients had the highest probability of achieving the most desirable outcome and had increased DAH-90. A composite outcome ranking such as DOOR may provide more insight and improve detection of complex relationships between social determinants of health and surgical outcomes.