title: The necessity of sociodemographic status adjustment in hospital value rankings for perforated appendicitis in children.
abstract: Hospitals are increasingly focused on demonstration of high-value care for common surgical procedures. Although sociodemographic status (SDS) factors have been tied to various surgical outcomes, the impact of SDS factors on hospital value rankings has not been well explored. Our objective was to examine effects of SDS factors on high-value surgical care at the patient level, and to illustrate the importance of SDS adjustment when evaluating hospital-level performance.
  
  
  
  Perforated appendicitis hospitalizations were identified from the 2012 Kids' Inpatient Database. The primary outcome of interest was high-value care as defined by evaluation of duration of stay and cost. SDS factors included race, health insurance type, median household income, and patient location. The impact of SDS on high-value care was estimated using regression models after accounting for hospital-level variation. Risk-adjusted value rankings were compared before and after adjustment for SDS.
  
  
  
  From 9,986 hospitalizations, 998 high-value encounters were identified. African Americans were less likely to experience high-value care compared with white patients after adjusting for all SDS variables. Although private insurance and living in nonmetro counties were associated independently with high-value care, the effects were attenuated in the fully adjusted models. For the 136 hospitals ranked according to risk-adjusted value status, 59 hospitals' rankings improved after adjustment and 53 hospitals' rankings declined.
  
  
  
  After adjustment for patient and hospital factors, SDS has a small but significant impact on risk-adjusted hospital performance ranking for pediatric appendicitis. Adjustment for SDS should be considered in future comparative performance assessment.
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, GA.
authors.forename: Yao
authors.initials: Y
authors.lastname: Tian
authors.affiliation: Department of Surgery, Emory University School of Medicine, Emory University, Atlanta, GA.
authors.forename: John F
authors.initials: JF
authors.lastname: Sweeney
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
authors.forename: Mark L
authors.initials: ML
authors.lastname: Wulkan
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.
authors.forename: Kurt F
authors.initials: KF
authors.lastname: Heiss
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA. Electronic address: mehulvraval@emory.edu.
authors.forename: Mehul V
authors.initials: MV
authors.lastname: Raval
mesh_terms: D000293:Adolescent; D001062:Appendectomy; D001064:Appendicitis / Q000453:epidemiology* / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D016208:Databases, Factual; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D011787:Quality of Health Care; D012044:Regression Analysis; D012189:Retrospective Studies; D020379:Risk Adjustment; D012959:Socioeconomic Factors; D014481:United States / Q000453:epidemiology