 Solution

There is an apparent reversal, but not a mathematical contradiction. The crude odds ratio averages over the actual background distribution in each group, whereas the adjusted logistic regression compares groups at the same fitted background values. Strong confounding could make those distributions very different: for example, elective patients might disproportionately come from low-risk backgrounds or clinics, while the reference patients come from higher-risk backgrounds. The Simpson paradox can then reverse the marginal comparison even when every conditional comparison favours the same direction.

The noncollapsibility of the odds ratio can also make marginal and conditional odds ratios differ in magnitude. It does not, by itself, explain a sign reversal if both groups have the same covariate distribution and the common conditional effect has one sign: if $p(1,x)>p(0,x)$ for every $x$, averaging over the same distribution of $x$ still gives a larger exposed risk. A genuine reversal therefore requires differing background distributions, heterogeneous effects or another change in what is being compared. The observed reversal is a reason to investigate these issues, not proof of a programming error.