1
|
Vyas N, Zaheer A, Wijeysundera HC. Untangling the Complex Multidimensionality of the Social Determinants of Cardiovascular Health: A Systematic Review. Can J Cardiol 2024; 40:1000-1006. [PMID: 38513932 DOI: 10.1016/j.cjca.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/21/2024] [Accepted: 03/09/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The cardiovascular literature is limited by the lack of consensus on what are the best metrics for reporting social determinants of health (SDH) or social deprivation, and if they should be reported as a single metric or separately by their domains. METHODS A systematic review of the literature on cardiovascular surgeries and procedures was conducted, identifying articles from January 1, 2010, to December 31, 2023, that studied the relationship between health outcomes after cardiovascular procedures or surgeries and SDH/social deprivation. The cardiovascular procedures/surgeries of interest were coronary and valve surgeries and procedures including coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), valve replacement or repair, and transcatheter aortic valve intervention. RESULTS After screening 638 articles, we identified 47 papers that met our inclusion and exclusion criteria. The most common procedure evaluated was CABG and PCI; 46 of the studies focused on these 2 procedures. Almost all of the articles reported a different metric for SDH/social deprivation (41 different metrics); despite this, all of the metrics showed a consistent relationship with worse outcomes associated with greater degrees of SDH/deprivation. Only 9 reported on the individual domains of SDH/social deprivation; 3 studies showed a discordant relationship. CONCLUSIONS Although our systematic review identified numerous articles evaluating the relationship between SDH/social deprivation in cardiovascular disease, there was substantial heterogeneity in which metric was used and how it was reported. This reinforces the need for standards as to the best metrics for SDH/social deprivation as well as best practices for reporting.
Collapse
Affiliation(s)
- Navya Vyas
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aida Zaheer
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
2
|
Chakravarti S, Kuo CC, Oak A, Ranganathan S, Jimenez AE, Kazemi F, Saint-Germain MA, Gallia G, Rincon-Torroella J, Jackson C, Bettegowda C, Mukherjee D. The Socioeconomic Distressed Communities Index Predicts 90-Day Mortality Among Intracranial Tumor Patients. World Neurosurg 2024; 186:e552-e565. [PMID: 38599377 DOI: 10.1016/j.wneu.2024.03.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/31/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Socioeconomic status (SES) is a major determinant of quality of life and outcomes. However, SES remains difficult to measure comprehensively. Distress communities index (DCI), a composite of 7 socioeconomic factors, has been increasingly recognized for its correlation with poor outcomes. As a result, the objective of the present study is to determine the predictive value of the DCI on outcomes following intracranial tumor surgery. METHODS A single institution, retrospective review was conducted to identify adult intracranial tumor patients undergoing resection (2016-2021). Patient ZIP codes were matched to DCI and stratified by DCI quartiles (low:0-24.9, low-intermediate:25-49.9, intermediate-high:50-74.9, high:75-100). Univariate followed by multivariate regressions assessed the effects of DCI on postoperative outcomes. Receiver operating curves were generated for significant outcomes. RESULTS A total of 2389 patients were included: 1015 patients (42.5%) resided in low distress communities, 689 (28.8%) in low-intermediate distress communities, 445 (18.6%) in intermediate-high distress communities, and 240 (10.0%) in high distress communities. On multivariate analysis, risk of fracture (adjusted odds ratio = 1.60, 95% confidence interval 1.26-2.05, P < 0.001) and 90-day mortality (adjusted odds ratio = 1.58, 95% confidence interval 1.21-2.06, P < 0.001) increased with increasing DCI quartile. Good predictive accuracy was observed for both models, with receiver operating curves of 0.746 (95% CI 0.720-0.766) for fracture and 0.743 (95% CI 0.714-0.772) for 90-day mortality. CONCLUSIONS Intracranial tumor patients from distressed communities are at increased risk for adverse events and death in the postoperative period. DCI may be a useful, holistic measure of SES that can help risk stratifying patients and should be considered when building healthcare pathways.
Collapse
Affiliation(s)
- Sachiv Chakravarti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cathleen C Kuo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Atharv Oak
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sruthi Ranganathan
- School of Clinical Medicine, University of Cambridge, Cambridge, England
| | - Adrian E Jimenez
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Foad Kazemi
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA
| | - Max A Saint-Germain
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gary Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York, USA.
| |
Collapse
|
3
|
Shih E, Squiers JJ, Banwait JK, Harrington KB, Ryan WH, DiMaio JM, Schaffer JM. Race, neighborhood disadvantage, and survival of Medicare beneficiaries after aortic valve replacement and concomitant coronary artery bypass grafting. J Thorac Cardiovasc Surg 2024; 167:2076-2090.e19. [PMID: 36894351 DOI: 10.1016/j.jtcvs.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 01/17/2023] [Accepted: 02/04/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Race, neighborhood disadvantage, and the interaction between these 2 social determinants of health remain poorly understood with regards to survival after aortic valve replacement with concomitant coronary artery bypass grafting (AVR+CABG). METHODS Weighted Kaplan-Meier survival analyses and Cox proportional hazards modeling were used to evaluate the association between race, neighborhood disadvantage, and long-term survival in 205,408 Medicare beneficiaries undergoing AVR+CABG from 1999 to 2015. Neighborhood disadvantage was measured using the Area Deprivation Index, a broadly validated ranking of socioeconomic contextual disadvantage. RESULTS Self-identified race was 93.9% White and 3.2% Black. Residents of the most disadvantaged quintile of neighborhoods included 12.6% of all White beneficiaries and 40.0% of all Black beneficiaries. Black beneficiaries and residents of the most disadvantaged quintile of neighborhoods had more comorbidities compared with White beneficiaries and residents of the least disadvantaged quintile of neighborhoods, respectively. Increasing neighborhood disadvantage linearly increased the hazard for mortality for Medicare beneficiaries of White but not Black race. Residents of the most and least disadvantaged neighborhood quintiles had weighted median overall survival of 93.0 and 82.1 months, respectively, a significant difference (P < .001 by Cox test for equality of survival curves). Black and White beneficiaries had weighted median overall survival of 93.4 and 90.6 months, respectively, a nonsignificant difference (P = .29 by Cox test for equality of survival curves). A statistically significant interaction between race and neighborhood disadvantage was noted (likelihood ratio test P = .0215) and had implications on whether Black race was associated with survival. CONCLUSIONS Increasing neighborhood disadvantage was linearly associated with worse survival after combined AVR+CABG in White but not Black Medicare beneficiaries; race, however, was not independently associated with postoperative survival.
Collapse
Affiliation(s)
- Emily Shih
- Department of General Surgery, Baylor University Medical Center, Dallas, Tex; Baylor Scott and White Research Institute, Dallas, Tex.
| | - John J Squiers
- Department of General Surgery, Baylor University Medical Center, Dallas, Tex; Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | | | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | - William H Ryan
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | - J Michael DiMaio
- Baylor Scott and White Research Institute, Dallas, Tex; Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| | - Justin M Schaffer
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex
| |
Collapse
|
4
|
Akinyemi OA, Jones MD LS, Ochoa A, Nelson L, Weldeslase TA, Yousuf SJ. Socioeconomic Disparities and Emergency Department Visits for Diabetic Retinopathy in California. JOURNAL OF VITREORETINAL DISEASES 2024; 8:293-298. [PMID: 38770079 PMCID: PMC11102713 DOI: 10.1177/24741264241234132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Purpose: To investigate the association between neighborhood-level socioeconomic factors, quantified by the Distressed Communities Index, and emergency department visits for diabetic retinopathy (DR). Methods: All patients who presented to the emergency department for DR in California were analyzed using the State Emergency Department Database (2018-2020). Patients were stratified by Distressed Communities Index score and DR severity. Logistic regression was applied to explore the independent correlation between Distressed Communities Index scores and proliferative DR (PDR). Results: Of 2 725 195 emergency department visits for diabetic patients, Distressed Communities Index data were available for 2 459 577 (90.3%); 39 693 were for DR, including 13 617 (34.3%) for PDR. Hispanics (44.2%) were the largest racial/ethnic group to present for PDR, followed by non-Hispanic Whites (19.6%) and non-Hispanic Blacks (19.3%). A significant association was observed between the Distressed Communities Index and emergency department visits for PDR, with distressed neighborhoods having the highest incidence (adjusted odds ratio [aOR], 1.63; 95% CI, 1.20-2.23; P = .001). Other predictors included Hispanic ethnicity (aOR, 2.21; 95% CI, 1.97-2.48; P < .001) and Black race (aOR, 1.46; 95% CI, 1.28-1.67; P < .001) compared with White race and having Medicaid (aOR, 1.37; 95% CI, 1.13-1.65; P = .001) compared with private insurance. Conclusions: The Distressed Communities Index identified patients residing in the most distressed neighborhoods as being at the highest risk for presenting to the emergency department for PDR based on 7 socioeconomic factors. Policymakers may consider the Distressed Communities Index as a tool for targeting DR prevention strategies and improving healthcare accessibility.
Collapse
Affiliation(s)
- Oluwasegun A. Akinyemi
- The Clive O. Callender, M.D., Howard-Harvard Health Sciences Outcomes Research Center, Department of Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Leslie S. Jones MD
- Department of Ophthalmology, Howard University College of Medicine, Washington, DC, USA
| | - Alejandro Ochoa
- Department of Ophthalmology, Howard University College of Medicine, Washington, DC, USA
| | - Luke Nelson
- Howard University College of Medicine, Washington, DC, USA
| | - Terhas A. Weldeslase
- The Clive O. Callender, M.D., Howard-Harvard Health Sciences Outcomes Research Center, Department of Surgery, Howard University College of Medicine, Washington, DC, USA
| | - Salman J. Yousuf
- Department of Ophthalmology, Howard University College of Medicine, Washington, DC, USA
| |
Collapse
|
5
|
Schults A, Tham RL, Nelson CP, Finkelstein JB. Factors contributing to telemedicine efficacy in pediatric urology. J Pediatr Urol 2024:S1477-5131(24)00200-6. [PMID: 38679525 DOI: 10.1016/j.jpurol.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 04/06/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION Despite swift implementation of telemedicine with the coronavirus disease 2019 pandemic, there is a paucity of research on its use for management of pediatric urology patients. Specifically, there is limited knowledge and inconsistent data on the effectiveness of telemedicine for various pediatric urologic conditions. Our aim was to evaluate the efficacy of pediatric urological care provided via video visits (VVs) at a large tertiary care children's hospital. MATERIAL AND METHODS We performed a prospective assessment of pediatric urology patients younger than 21 years who had a VV between 5/18/2022 and 5/17/2023. New patients with a testicular diagnosis were not eligible for VVs. After entering the diagnosis and submitting billing using a modifier for telemedicine, clinicians were mandated to select whether the VV allowed for: complete case management (CCM), suboptimal case management (SCM), or incomplete case management (ICM) requiring an in-person visit. Case management categorizations were analyzed according to patient pathology, visit type (i.e., new or established), and patient-centered variables including age, sex, race, insurance type, need for an interpreter, and distress score [a proxy for socioeconomic status]. RESULTS During the one-year period, there were 3267 telemedicine patients with a median age of 9 years (IQR 3-13) and 57.0% were male. Most VVs (89.3%) were established encounters. Almost 12% of telemedicine patients had external organ pathology (EOP, e.g., phimosis), 43.0% had internal organ pathology (IOP, e.g., hydronephrosis), and 45.1% had functional urological pathology (FUP, e.g., dysfunctional voiding). Clinicians deemed 96.9%, 2.7%, and 0.5% of VVs as having CCM, SCM or ICM, respectively. Telemedicine patients with IOP or FUP were more likely to have CCM, than those with EOP (98.5% and 97.8% vs 87.1%, p < 0.0001). On multivariable analysis, patient age, pathology, and visit type were predictive of VV efficacy. DISCUSSION Now that telemedicine use has slowed, it is necessary to evaluate and establish its optimal role in pediatric urology. Factors associated with VV efficacy included older patient age, internal organ or functional urological pathology, and established encounters. The long-term success of telemedicine requires suitable patient selection. CONCLUSIONS Telemedicine is quite effective for the management of a wide variety of pediatric urology patients. Continued evaluation of telemedicine, including multi-institutional investigation and corroboration, is necessary for the development of evidence-based best practice guidelines regarding appropriate, safe, and effective integration of telemedicine that drives pediatric urological care forward to meet the demands of the future.
Collapse
Affiliation(s)
- Austin Schults
- Department of Urology Massachusetts General Hospital, Boston, MA, USA.
| | - Regina L Tham
- Department of Urology, Boston Children's Hospital, Boston, MA, USA.
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Boston, MA, USA.
| | | |
Collapse
|
6
|
Gordon AM, Ng MK, Elali F, Piuzzi NS, Mont MA. A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Health Care Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient. J Arthroplasty 2024:S0883-5403(24)00341-3. [PMID: 38615971 DOI: 10.1016/j.arth.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Socioeconomic status has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in the following: (1) medical complications; (2) emergency department (ED) utilizations; (3) readmissions; and (4) costs of care. METHODS A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index. This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P values less than .003 were significant. RESULTS High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = .0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = .001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < .0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = .0008). The 90-day expenditures ($15,066 versus $12,459; P < .0001) were higher in patients who have a high ADI. CONCLUSIONS Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform health care policy and improve postdischarge care. The socioeconomic status metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Adam M Gordon
- Questrom School of Business, Boston University, Boston, Massachusetts; Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Faisal Elali
- SUNY Downstate Health Sciences University, College of Medicine, Brooklyn, New York
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Mont
- Rubin Institute of Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| |
Collapse
|
7
|
Salafian K, Mazimba C, Volodin L, Varadarajan I, Pilehvari A, You W, Knio ZO, Ballen K. The impact of social vulnerability index on survival following autologous stem cell transplant for multiple myeloma. Bone Marrow Transplant 2024; 59:459-465. [PMID: 38238453 PMCID: PMC10994832 DOI: 10.1038/s41409-024-02200-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 04/06/2024]
Abstract
Autologous hematopoietic stem cell transplantation (ASCT) is the standard of care for eligible patients with multiple myeloma (MM) to prolong progression-free survival (PFS). While several factors affect survival following ASCT, the impact of social determinants of health such as the CDC Social Vulnerability Index (SVI) is not well documented. This single-center retrospective analysis evaluated the impact of SVI on PFS following ASCT in MM patients. 225 patients with MM who underwent ASCT participated, with 51% transplanted in the last 5 years. At 5 years post-transplant, 55 (50%) achieved PFS and 66 (60%) remained alive. Higher SVI values were significantly associated with lower odds of PFS (OR = 0.521, p < 0.01, 95% CI [0.41, 0.66]) and OS (OR = 0.592, p < 0.01, 95% CI [0.46, 0.76]) post-transplant. Greater vulnerability scores in the socioeconomic status (OR = 0.890; 95% CI: [0.82, 0.96]), household characteristics (OR = 0.912; 95% CI: [0.87, 0.95]), and racial and ethnic minority status (OR = 0.854; 95% CI: [0.81, 0.90]) themes significantly worsened the odds of PFS. These results suggest high SVI areas may need more resources to achieve optimal PFS and OS. Future studies will focus on addressing factors within the socioeconomic status, household characteristics, and racial and ethnic minority subthemes, as these have a more pronounced effect on PFS.
Collapse
Affiliation(s)
- Kiarash Salafian
- Department of Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Christine Mazimba
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA
| | - Leonid Volodin
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA
| | - Indumathy Varadarajan
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA
| | - Asal Pilehvari
- Department of Public Health Sciences, University of Virginia, and University of Virginia Comprehensive Cancer Center, Charlottesville, VA, USA
| | - Wen You
- Department of Public Health Sciences, University of Virginia, and University of Virginia Comprehensive Cancer Center, Charlottesville, VA, USA
| | - Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Karen Ballen
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA.
| |
Collapse
|
8
|
Liu T, Devlin PJ, Whippo B, Vassallo P, Hoel A, Pham DT, Johnston DR, Chris Malaisrie S, Mehta CK. Neighborhood Socioeconomic Status and Readmission in Acute Type A Aortic Dissection Repair. J Surg Res 2024; 296:772-780. [PMID: 38382156 DOI: 10.1016/j.jss.2023.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 12/08/2023] [Accepted: 12/29/2023] [Indexed: 02/23/2024]
Abstract
INTRODUCTION We examined the association of socioeconomic status as defined by median household income quartile (MHIQ) with mortality and readmission patterns following open repair of acute type A aortic dissection (ATAAD) in a nationally representative registry. METHODS Adults who underwent open repair of ATAAD were selected using the US Nationwide Readmissions Database and stratified by MHIQ. Patients were selected based on diagnostic and procedural codes. The primary endpoint was 30-d readmission. RESULTS Between 2016 and 2019, 10,288 individuals (65% male) underwent open repair for ATAAD. Individuals in the lowest income quartile were younger (median: 60 versus 64, P < 0.05) but had greater Elixhauser comorbidity burden (5.9 versus 5.7, P < 0.05). Across all groups, in-hospital mortality was approximately 15% (P = 0.35). On multivariable analysis adjusting for baseline comorbidity burden, low socioeconomic status was associated with increased readmission at 90 d, but not at 30 d. Concomitant renal disease (odds ratio [OR], 1.68; P < 0.001), pulmonary disease (OR, 1.26; P < 0.001), liver failure (OR 1.2, P = 0.04), and heart failure (OR, 1.17; P < 0.001) were all associated with readmission at 90 d. The primary indication for readmission was most commonly cardiac (33%), infectious (16.5%), and respiratory (9%). CONCLUSIONS In patients who undergo surgery for ATAAD, lower MHIQ was associated with higher odds of readmission following open repair. While early readmission for individuals living in the lowest income communities is likely attributable to greater baseline comorbidity burden, we observed that 90-d readmission rates are associated with lower MHIQ regardless of comorbidity burden. Further investigation is required to determine which patient-level and system-level interventions are needed to reduce readmissions in the immediate postoperative period for resource poor areas.
Collapse
Affiliation(s)
- Tom Liu
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paul J Devlin
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Beth Whippo
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patricia Vassallo
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew Hoel
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Duc Thinh Pham
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Douglas R Johnston
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sukit Chris Malaisrie
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher K Mehta
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| |
Collapse
|
9
|
Dyas AR, Carmichael H, Bronsert MR, Stuart CM, Garofalo DM, Henderson WG, Colborn KL, Schulick RD, Meguid RA, Velopulos CG. Social vulnerability is associated with higher risk-adjusted rates of postoperative complications in a broad surgical population. Am J Surg 2024; 229:26-33. [PMID: 37775458 DOI: 10.1016/j.amjsurg.2023.09.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/08/2023] [Accepted: 09/22/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE The purpose of this study was to determine if an association between Social Vulnerability Index (SVI) and risk-adjusted complications exists in a broad spectrum of surgical patients. SUMMARY BACKGROUND DATA Growing evidence supports the impact of social circumstances on surgical outcomes. SVI is a neighborhood-based measure accounting for sociodemographic factors putting communities at risk. METHODS This was a multi-hospital, retrospective cohort study including a sample of patients within one healthcare system (2012-2017). Patient addresses were geocoded to determine census tract of residence and estimate SVI. Patients were grouped into low SVI (score<75) and high SVI (score≥75) cohorts. Perioperative variables and postoperative outcomes were tracked and compared using local ACS-NSQIP data. Multivariable logistic regression was performed to generate risk-adjusted odds ratios of postoperative complications in the high SVI cohort. RESULTS Overall, 31,224 patients from five hospitals were included. Patients with high SVI were more likely to be racial minorities, have 12/18 medical comorbidities, have high ASA class, be functionally dependent, be treated at academic hospitals, and undergo emergency operations (all p < 0.05). Patients with high SVI had significantly higher rates of 30-day mortality, overall morbidity, respiratory, cardiac and infectious complications, urinary tract infections, postoperative bleeding, non-home discharge, and unplanned readmissions (all p < 0.05). After risk-adjustment, only the associations between high SVI and mortality and unplanned readmission became non-significant. CONCLUSIONS High SVI was associated with multiple adverse outcomes even after risk adjustment for preoperative clinical factors. Targeted preventative interventions to mitigate risk of these specific complications should be considered in this high-risk population.
Collapse
Affiliation(s)
- Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Heather Carmichael
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christina M Stuart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Denise M Garofalo
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - William G Henderson
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kathryn L Colborn
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA; Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Catherine G Velopulos
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
10
|
Sakowitz S, Bakhtiyar SS, Mallick S, Curry J, Ascandar N, Benharash P. Impact of Community Socioeconomic Distress on Survival Following Heart Transplantation. Ann Surg 2024; 279:376-382. [PMID: 37641948 DOI: 10.1097/sla.0000000000006088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
OBJECTIVE The aim of this study was to assess the impact of community-level socioeconomic deprivation on survival outcomes following heart transplantation. BACKGROUND Despite growing awareness of socioeconomic disparities in the US health care system, significant inequities in outcomes remain. While recent literature has increasingly considered the effects of structural socioeconomic deprivation, the impact of community socioeconomic distress on outcomes following heart transplantation has not yet been elucidated. METHODS All adult heart transplant recipients from 2004 to 2022 were ascertained from the Organ Procurement and Transplantation Network. Community socioeconomic distress was assessed using the previously validated Distressed Communities Index, a metric that represents education level, housing vacancies, unemployment, poverty rate, median household income, and business growth by zip code. Communities in the highest quintile were considered the Distressed cohort (others: Non-Distressed ). Outcomes were considered across 2 eras (2004-2018 and 2019-2022) to account for the 2018 UNOS Policy Change. Three- and 5-year patient and graft survival were assessed using Kaplan-Meier and Cox proportional hazards models. RESULTS Of 36,777 heart transplants, 7450 (20%) were considered distressed . Following adjustment, distressed recipients demonstrated a greater hazard of 5-year mortality from 2004 to 2018 [hazard ratio (HR)=1.10, 95% confidence interval (CI): 1.03-1.18; P =0.005] and 3-year mortality from 2019 to 2022 (HR=1.29, 95% CI: 1.10-1.51; P =0.002), relative to nondistressed . Similarly, the distressed group was associated with increased hazard of graft failure at 5 years from 2004 to 2018 (HR=1.10, 95% CI: 1.03-1.18; P =0.003) and at 3 years from 2019 to 2022 (HR=1.31, 95% CI: 1.11-1.53; P =0.001). CONCLUSIONS Community-level socioeconomic deprivation is linked with inferior patient and graft survival following heart transplantation. Future interventions are needed to address pervasive socioeconomic inequities in transplantation outcomes.
Collapse
Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
- Department of Surgery, University of Colorado, Aurora, CO
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
| | - Nameer Ascandar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
- Department of Surgery, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, CA
| |
Collapse
|
11
|
Strobel RJ, Kaplan EF, Young AM, Rotar EP, Mehaffey JH, Hawkins RB, Joseph M, Quader MA, Yarboro LT, Teman NR. Socioeconomic distress is associated with failure to rescue in cardiac surgery. J Thorac Cardiovasc Surg 2024; 167:1100-1114.e1. [PMID: 36031426 PMCID: PMC9852359 DOI: 10.1016/j.jtcvs.2022.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/06/2022] [Accepted: 07/10/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The influence of socioeconomic determinants of health on failure to rescue (mortality after a postoperative complication) after cardiac surgery is unknown. We hypothesized that increasing Distressed Communities Index, a comprehensive socioeconomic ranking by ZIP code, would be associated with higher failure to rescue. METHODS Patients undergoing Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) who developed a failure to rescue complication were included. After excluding patients with missing ZIP code or Society of Thoracic Surgeons predicted risk of mortality, patients were stratified by Distressed Communities Index scores (0-no distress, 100-severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. The upper 2 quintiles of distress (Distressed Communities Index >60) were compared to all other patients. Hierarchical logistic regression analyzed the association between Distressed Communities Index and failure to rescue. RESULTS A total of 4004 patients developed 1 or more of the defined complications across 17 centers. Of these, 582 (14.5%) experienced failure to rescue. High socioeconomic distress (Distressed Communities Index >60) was identified among 1272 patients (31.8%). Before adjustment, failure to rescue occurred more frequently among those from socioeconomically distressed communities (Distressed Communities Index >60; 16.9% vs 13.4%, P = .004). After adjustment, residing in a socioeconomically distressed community was associated with 24% increased odds of failure to rescue (odds ratio, 1.24; confidence interval, 1.003-1.54; P = .044). CONCLUSIONS Increasing Distressed Communities Index, a measure of poor socioeconomic status, is associated with greater risk-adjusted likelihood of failure to rescue after cardiac surgery. These findings highlight that current quality metrics do not account for socioeconomic status, and as such underrepresent procedural risk for these vulnerable patients.
Collapse
Affiliation(s)
- Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Emily F Kaplan
- School of Medicine, University of Virginia, Charlottesville, Va
| | - Andrew M Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Evan P Rotar
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Robert B Hawkins
- Virginia Cardiac Services Quality Initiative, South Riding, Va; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Mark Joseph
- Virginia Cardiac Services Quality Initiative, South Riding, Va; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Virginia Tech Carilion School of Medicine, Roanoke, Va
| | - Mohammed A Quader
- Virginia Cardiac Services Quality Initiative, South Riding, Va; Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Va
| | - Leora T Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va.
| |
Collapse
|
12
|
Ram C, Yousef S, Ma WG, Vallabhajosyula I, Singh S, Agarwal R, Milewski RK, Assi R, Patel PA, Williams M, Geirsson A, Vallabhajosyula P. Living in disadvantaged neighborhoods linked to less intervention for severe aortic stenosis. Sci Rep 2024; 14:4952. [PMID: 38418864 PMCID: PMC10902341 DOI: 10.1038/s41598-024-52660-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024] Open
Abstract
To investigate the association between area deprivation index (ADI) and aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). Patients aged 40-95 years with severe AS confirmed by echocardiography were included. The 9-digit zip code of patient residence address was used to identify the ADI ranking, based on which patients were divided into 5 groups (with Group E being most deprived). The rates of AV intervention were compared among 5 groups using competing risks analysis, with death as a competing event. We included 1751 patients with severe AS from 2013 to 2018 followed for a median 2.8 (interquartile range, 1.5-4.8) years. The more distressed ADI groups tended to be younger (P = 0.002), female (P < 0.001), and of African American race (P < 0.001), have higher presentation of sepsis (P = 0.031), arrhythmia (P = 0.022), less likely to have previous diagnosis of AS (P < 0.001); and were less likely to undergo AVR (52.5% vs 46.9% vs 46.1% vs 48.9% vs 39.7%, P = 0.023). Using competing risk analysis, the highest ADI group (E) were the least and the lowest ADI group (A) the most likely to undergo AVR (Gray's test, P = 0.025). The association between ADI ranking and AVR rates was influenced by sex and race. Within group analysis, there was significant association between race and AVR (Gray's test, P < 0.001), and between sex and AVR (Gray's test, P < 0.001). Patients with severe AS living in more deprived neighborhoods were less likely to undergo aortic valve interventions, which was influenced by female gender, and African American race.
Collapse
Affiliation(s)
- Chirag Ram
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sameh Yousef
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Wei-Guo Ma
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Ishani Vallabhajosyula
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Saket Singh
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Ritu Agarwal
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, USA
| | - Rita K Milewski
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Roland Assi
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Prakash A Patel
- Division of Cardiac Anesthesiology, Yale School of Medicine, New Haven, CT, USA
| | - Matthew Williams
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA.
| |
Collapse
|
13
|
Giberson-Chen C, Liu C, Grisdela P, Liu D, Model Z, Steele A, Blazar P, Earp BE, Zhang D. Risk Factors for Rescue Opioid Prescription After Cubital Tunnel Surgery. Hand (N Y) 2024:15589447241232015. [PMID: 38357894 DOI: 10.1177/15589447241232015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND Concerns regarding the ongoing opioid epidemic have led to heightened scrutiny of postoperative opioid prescribing patterns for common orthopedic surgical procedures. This study investigated patient- and procedure-specific risk factors for additional postoperative opioid rescue prescriptions following ambulatory cubital tunnel surgery. METHODS A retrospective review was performed of patients who underwent cubital tunnel surgery at 2 academic medical centers between June 1, 2015 and March 1, 2020. Patient demographics, comorbidities, prior opioid history, and surgical variables were recorded. The primary outcome was postoperative rescue opioid prescription. Univariate and bivariate statistical analyses were performed. RESULTS Two hundred seventy-four patients were included, of whom 171 (62%) underwent in situ ulnar nerve decompression and 103 (38%) underwent ulnar nerve decompression with anterior transposition. The median postoperative opioid prescription amount was 90 morphine equivalent units (MEU) for the total cohort, 77.5 MEU for in situ ulnar nerve decompression, and 112.5 MEU for ulnar nerve decompression with transposition. Twenty-two patients (8%) required additional rescue opioid prescriptions postoperatively. Female sex, fibromyalgia, chronic opioid use, chronic pain diagnosis, and recent opioid were associated with the need for additional postoperative rescue opioid prescriptions. CONCLUSIONS While most patients do not require additional rescue opioid prescriptions after cubital tunnel surgery, chronic pain patients and patients with pain sensitivity syndromes are at risk for requiring additional rescue opioid prescriptions. For these high-risk patients, preoperative collaboration of a multidisciplinary team may be beneficial for developing a perioperative pain management plan that is both safe and effective.
Collapse
Affiliation(s)
- Carew Giberson-Chen
- Harvard Combined Orthopaedic Residency Program, Harvard Affiliated Hospitals, Boston, MA, USA
| | - Christina Liu
- Harvard Combined Orthopaedic Residency Program, Harvard Affiliated Hospitals, Boston, MA, USA
| | - Phillip Grisdela
- Harvard Combined Orthopaedic Residency Program, Harvard Affiliated Hospitals, Boston, MA, USA
| | - David Liu
- Harvard Combined Orthopaedic Residency Program, Harvard Affiliated Hospitals, Boston, MA, USA
| | - Zina Model
- Harvard Combined Orthopaedic Residency Program, Harvard Affiliated Hospitals, Boston, MA, USA
| | - Amy Steele
- Harvard Combined Orthopaedic Residency Program, Harvard Affiliated Hospitals, Boston, MA, USA
| | - Philip Blazar
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Brigham and Women's Hospital, Boston, MA, USA
| | - Brandon E Earp
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Brigham and Women's Hospital, Boston, MA, USA
| | - Dafang Zhang
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
14
|
Chung MM, Yu A, Zhao Y, Wist E, Hohri Y, Kurlansky P, Leb J, O'Donnell TFX, Patel V, Takayama H. Utility of structured follow-up imaging after aortic surgery. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00112-0. [PMID: 38342429 DOI: 10.1016/j.jtcvs.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/16/2024] [Accepted: 02/01/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Although postoperative follow-up after aortic surgery is recommended by guidelines, its clinical utility is not well documented. We hypothesized that structured follow-up imaging by an aortic program would improve outcomes. We then documented radiologic findings on asymptomatic postoperative imaging. METHODS All patients who survived to discharge after open thoracic aortic surgery between January 2017 and July 2021 were included, excluding endocarditis. Patients who followed at our center and received scheduled imaging were compared with patients who did not. Survival was analyzed by the method of Kaplan-Meier, and reintervention was assessed using the Fine-Gray subhazard function. Routine imaging was reviewed for aortic growth, pseudoaneurysm, and perigraft density. RESULTS After aortic surgery, the cumulative incidence of follow-up was 38.6% at 3 years postoperatively. Patients with follow-up were more likely to have a dissection and fewer comorbidities but were similar in regards to socioeconomic factors and distance to hospital. After matching and accounting for immortal time bias, patients with follow-up had a greater reintervention rate (26.0% vs 9.0%) with similar survival (98.7% vs 95.2%, P = .110) at 4 years. The cumulative incidence of pseudoaneurysm, significant perigraft density, and growth ≥3 mm/year on routine imaging was 49.7% at 3 years. CONCLUSIONS Implementation of structured follow-up imaging by an aortic program resulted in low clinical compliance. Follow-up was associated with increased rates of aortic reintervention. Clinically relevant radiologic findings were common on asymptomatic imaging and increased throughout 5-year follow-up rather than plateauing in the early postoperative period.
Collapse
Affiliation(s)
- Megan M Chung
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Annie Yu
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Yanling Zhao
- Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY
| | - Elizabeth Wist
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Yu Hohri
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Paul Kurlansky
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY; Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY
| | - Jay Leb
- Department of Radiology, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Thomas F X O'Donnell
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Virendra Patel
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY.
| |
Collapse
|
15
|
Chen Q, Malas J, Emerson D, Megna D, Catarino P, Esmailian F, Chikwe J, Czer LS, Kobashigawa JA, Bowdish ME. Heart transplantation in patients from socioeconomically distressed communities. J Heart Lung Transplant 2024; 43:324-333. [PMID: 37591456 PMCID: PMC10843295 DOI: 10.1016/j.healun.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/20/2023] [Accepted: 08/06/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Studies examining heart transplantation disparities have focused on individual factors such as race or insurance status. We characterized the impact of a composite community socioeconomic disadvantage index on heart transplantation outcomes. METHODS From the Scientific Registry of Transplant Recipients (SRTR), we identified 49,340 primary, isolated adult heart transplant candidates and 32,494 recipients (2005-2020). Zip code-level socioeconomic disadvantage was characterized using the Distressed Community Index (DCI: 0-most prosperous, 100-most distressed) based on education, poverty, unemployment, housing vacancies, median income, and business growth. Patients from distressed communities (DCI ≥ 80) were compared to all others. RESULTS Patients from distressed communities were more often non-white, less educated, and had public insurance (all p < 0.01). Distressed patients were more likely to require ventricular assist devices at listing (29.4 vs 27.1%) and before transplant (44.8 vs 42.0%, both p < 0.001), and they underwent transplants at lower-volume centers (23 vs 26 cases/year, p < 0.01). Distressed patients had higher 1-year waitlist mortality or deterioration (12.3% [95% confidence interval (CI) 11.6-13.0] vs 10.9% [95% CI 10.5-11.3]) and inferior 5-year survival (75.3% [95% CI 74.0-76.5] vs 79.5% [95% CI 79.0-80.0]) (both p < 0.001). After adjustment, living in a distressed community was independently associated with an increased risk of waitlist mortality or deterioration hazard ratio (HR 1.10, 95% CI 1.02-1.18) and post-transplant mortality (HR 1.13, 95% CI 1.06-1.20). CONCLUSIONS Patients from socioeconomically distressed communities have worse waitlist and post-transplant mortality. These findings should not be used to limit access to heart transplantation, but rather highlight the need for further studies to elucidate mechanisms underlying the impact of community-level socioeconomic disparity.
Collapse
Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jad Malas
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dominick Megna
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Pedro Catarino
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Fardad Esmailian
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lawrence S Czer
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| |
Collapse
|
16
|
Brlecic PE, Hogan KJ, Treffalls JA, Sylvester CB, Coselli JS, Moon MR, Rosengart TK, Chatterjee S, Ghanta RK. Socioeconomic disparities in procedural choice and outcomes after aortic valve replacement. JTCVS OPEN 2023; 16:139-157. [PMID: 38204692 PMCID: PMC10775113 DOI: 10.1016/j.xjon.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/07/2023] [Accepted: 10/04/2023] [Indexed: 01/12/2024]
Abstract
Objective To identify potential socioeconomic disparities in the procedural choice of patients undergoing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) and in readmission outcomes after SAVR or TAVR. Methods The Nationwide Readmissions Database was queried to identify a total of 243,691 patients who underwent isolated SAVR and TAVR between January 2016 and December 2018. Patients were stratified according to a tiered socioeconomic status (SES) metric comprising patient factors including education, literacy, housing, employment, insurance status, and neighborhood median income. Multivariable analyses were used to assess the effect of SES on procedural choice and risk-adjusted readmission outcomes. Results SAVR (41.4%; 100,833 of 243,619) was performed less frequently than TAVR (58.6%; 142,786 of 243,619). Lower SES was more frequent among patients undergoing SAVR (20.2% [20,379 of 100,833] vs 19.4% [27,791 of 142,786]; P < .001). Along with such variables as small hospital size, drug abuse, arrhythmia, and obesity, lower SES was independently associated with SAVR relative to TAVR (adjusted odds ratio [aOR], 1.17; 95% confidence interval [CI], 1.11 to 1.24). After SAVR, but not after TAVR, lower SES was independently associated with increased readmission at 30 days (aOR, 1.19; 95% CI, 1.07-1.32), 90 days (aOR, 1.27; 95% CI, 1.15-1.41), and 1 year (adjusted hazard ratio, 1.19; 95% CI, 1.11 to 1.28; P < .05 for all). Conclusions Our study findings indicate that socioeconomic disparities exist in the procedural choice for patients undergoing AVR. Patients with lower SES had increased odds of undergoing SAVR, as well as increased odds of readmission after SAVR, but not after TAVR, supporting that health inequities exist in the surgical care of socioeconomically disadvantaged patients.
Collapse
Affiliation(s)
- Paige E. Brlecic
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Katie J. Hogan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Medical Scientist Training Program, Baylor College of Medicine, Houston, Tex
| | - John A. Treffalls
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Long School of Medicine, University of Texas Health San Antonio, San Antonio, Tex
| | - Christopher B. Sylvester
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Medical Scientist Training Program, Baylor College of Medicine, Houston, Tex
| | - Joseph S. Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Marc R. Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Todd K. Rosengart
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Ravi K. Ghanta
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| |
Collapse
|
17
|
Kellett W, Jalilvand A, Collins C, Ireland M, Baselice H, Abboud G, Wisler J. Area Deprivation Index Predicts Mortality for Critically Ill Surgical Patients With Sepsis. Surg Infect (Larchmt) 2023; 24:879-886. [PMID: 38079187 PMCID: PMC10714256 DOI: 10.1089/sur.2023.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
Background: The impact of socioeconomic status on outcomes after sepsis has been challenging to define, and no polysocial metric has been shown to predict mortality in sepsis. The primary objective of this study was to evaluate the association between the Area Deprivation Index (ADI) and mortality in patients admitted to the surgical intensive care unit (SICU) with sepsis. Patients and Methods: All patients admitted to the SICU with sepsis (Sequential Organ Failure Assessment [SOFA] score ≥2) were retrospectively reviewed. The ADI scores were obtained and classified as "high ADI" (≥85th percentile, n = 400, representative of high socioeconomic deprivation) and "control ADI" (ADI <85th percentile, n = 976). Baseline demographic and clinical characteristics were compared between groups. The primary outcome was 90-day mortality. Results: High ADI patients were younger (mean age 58.5 vs. 60.8; p = 0.01) and more likely to be non-white (23.7% vs. 10.0%; p < 0.0005) and to present with chronic obstructive pulmonary disease (26.5% vs. 19.0%; p = 0.002). High ADI patients had increased in-hospital (27.3% vs. 21.6%; p = 0.025) and 90-day mortality (35.0% vs. 28.9%; p = 0.03). High ADI patients also had increased rates of renal failure (20.3% vs. 15.3%; p = 0.02). Both cohorts had similar intensive care unit (ICU) lengths of stay and median hospital stay, Charlson comorbidity index, and rate of discharge to home. High ADI is an independent risk factor for 90-day mortality after admission for surgical sepsis (odds ratio [OR], 1.39 ± 0.24; p = 0.014). Conclusions: High ADI is an independent predictor of 90-day mortality in patients with surgical sepsis. Targeted community interventions are needed to reduce sepsis mortality for these at-risk patients.
Collapse
Affiliation(s)
- Whitney Kellett
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anahita Jalilvand
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Courtney Collins
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Megan Ireland
- Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Holly Baselice
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - George Abboud
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jon Wisler
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
18
|
Azap L, Woldesenbet S, Lima H, Munir MM, Diaz A, Endo Y, Yang J, Mokadam NA, Ganapathi A, Pawlik TM. The Association of Persistent Poverty and Outcomes Among Patients Undergoing Cardiac Surgery. J Surg Res 2023; 292:30-37. [PMID: 37572411 DOI: 10.1016/j.jss.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 08/14/2023]
Abstract
INTRODUCTION We sought to evaluate the association of county-level poverty duration and cardiac surgical outcomes. METHODS Patients who underwent coronary artery bypass graft, surgical aortic valve replacement, and mitral valve repair and replacement between 2016 and 2020 were identified using the Medicare Standard Analytical Files Database. County-level poverty data were acquired from the American Community Survey and US Department of Agriculture (1980-2015). High poverty was defined as ≥19.5% of residents in poverty. Patients were stratified into never-high poverty (NHP), intermittent low poverty, intermittent high poverty, and persistent poverty (PP). A mixed-effect hierarchical generalized linear model and Cox regression models that adjusted for patient-level covariates were used to evaluate outcomes. RESULTS Among 237,230 patients, 190,659 lived in NHP counties, while 10,273 resided in PP counties. Compared with NHP patients, PP patients were more likely to present at a younger median age (NHP: 75 y versus PP: 74 y), be non-Hispanic Black (5388, 2.9% versus PP: 1030, 10.1%), and live in the south (NHP: 66,012, 34.6% versus PP: 87,815, 76.1%) (all P < 0.001). PP patients also had more nonelective surgical operations (NHP: 58,490, 30.8% versus 3645, 35.6%, P < 0.001). Notably, PP patients had increased odds of 30-d mortality (odds ratio 1.13, 95% confidence interval [CI] 1.02-1.26), 90-d mortality (odds ratio 1.14, 95% CI 1.05-1.24), and risk of long-term mortality (hazard ratio 1.13, 95% CI 1.09-1.19) compared with patients in NHP counties (all P < 0.05). CONCLUSIONS County-level poverty was associated with a greater risk of short- and long-term mortality among cardiac surgical patients.
Collapse
Affiliation(s)
- Lovette Azap
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio; Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Selamawit Woldesenbet
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Henrique Lima
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Muhammad Musaab Munir
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Adrian Diaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Yutaka Endo
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Jason Yang
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio
| | - Nahush A Mokadam
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Asvin Ganapathi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Center, Columbus, Ohio.
| |
Collapse
|
19
|
Thompson MP, Hou H, Stewart JW, Pagani FD, Hawkins RB, Keteyian SJ, Sukul D, Likosky DS. Relationship Between Community-Level Distress and Cardiac Rehabilitation Participation, Facility Access, and Clinical Outcomes After Inpatient Coronary Revascularization. Circ Cardiovasc Qual Outcomes 2023; 16:e010148. [PMID: 37855157 PMCID: PMC10953712 DOI: 10.1161/circoutcomes.123.010148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Although disparities in cardiac rehabilitation (CR) participation are well documented, the role of community-level distress is poorly understood. This study evaluated the relationship between community-level distress and CR participation, access to CR facilities, and clinical outcomes. METHODS A retrospective cohort study was conducted on a 100% sample of Medicare beneficiaries undergoing inpatient coronary revascularization between July 2016 and December 2018. Community-level distress was defined using the Distressed Community Index quintile at the beneficiary zip code level, with the first and fifth quintiles representing prosperous and distressed communities, respectively. Outpatient claims were used to identify any CR use within 1 year of discharge. Beneficiary and CR facility zip codes were used to describe access to CR facilities. Adjusted logistic regression models evaluated the association between Distressed Community Index quintiles, CR use, and clinical outcomes, including one-year mortality, all-cause hospitalization, and acute myocardial infarction hospitalization. RESULTS A total of 414 730 beneficiaries were identified, with 96 929 (23.4%) located in the first and 67 900 (16.4%) in the fifth quintiles, respectively. Any CR use was lower for beneficiaries in distressed compared with prosperous communities (26.0% versus 46.1%, P<0.001), which was significant after multivariable adjustment (odds ratio, 0.41 [95% CI, 0.40-0.42]). A total of 98 458 (23.7%) beneficiaries had a CR facility within their zip code, which increased from 16.3% in prosperous communities to 26.6% in distressed communities. Any CR use was associated with absolute reductions in mortality (-6.8% [95% CI, -7.0% to -6.7%]), all-cause hospitalization (-5.9% [95% CI, -6.3% to -5.6%]), and acute myocardial infarction hospitalization (-1.3% [95% CI, -1.5% to -1.1%]), which were similar across each Distressed Community Index quintiles. CONCLUSIONS Although community-level distress was associated with lower CR participation, the clinical benefits were universally received. Addressing barriers to CR in distressed communities should be considered a significant priority to improve survival after coronary revascularization and reduce disparities.
Collapse
Affiliation(s)
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI
| | - James W Stewart
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | | | | | - Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| |
Collapse
|
20
|
Read MD, Shah R, Janjua H, Docimo S, Grimsley EA, Weche M, Kuo PC. Causal analysis of socioeconomic influence on cost of care: The emergency general surgery model. Am J Surg 2023; 226:492-496. [PMID: 37117137 DOI: 10.1016/j.amjsurg.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND This study characterizes the relationship between SES and cost of emergency general surgery (EGS). METHODS Utilizing Florida AHCA (2016-2020), patients undergoing the 7 most common EGS were identified. Distressed Community Index (DCI) was linked, which quantifies SES through unemployment, poverty, and other factors. Zipcodes are assigned DCI 0 (no distress) to 100 (severe distress). Linear regression with stepwise elimination was conducted. Top and bottom DCI quintiles were propensity matched for demographics, comorbidities, and procedure. RESULTS 144,924 admissions were included. Linear regression eliminated 5 of 28 variables, including DCI. Top cost contributors were discharge-43%; comorbidities-14%; age-9%. Distressed patients received less home health and inpatient rehab. Distressed patients utilized 4-/5-star hospitals less and had higher odds of mortality. CONCLUSION Discharge, mortality, and hospital characteristics differ significantly between DCI communities. Total cost was similar, and is strongly influenced by discharge status, while DCI had no effect.
Collapse
Affiliation(s)
- Meagan D Read
- Department of Surgery, Morsani College of Medicine, Tampa, FL, USA; Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Rohan Shah
- Department of Surgery, Morsani College of Medicine, Tampa, FL, USA
| | - Haroon Janjua
- Department of Surgery, Morsani College of Medicine, Tampa, FL, USA
| | - Salvatore Docimo
- Department of Surgery, Morsani College of Medicine, Tampa, FL, USA
| | - Emily A Grimsley
- Department of Surgery, Morsani College of Medicine, Tampa, FL, USA
| | - McWayne Weche
- Department of Surgery, Morsani College of Medicine, Tampa, FL, USA
| | - Paul C Kuo
- Department of Surgery, Morsani College of Medicine, Tampa, FL, USA.
| |
Collapse
|
21
|
Issa TZ, Lee Y, Toci GR, Lambrechts MJ, Kalra A, Pipa D, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. The role of socioeconomic factors as barriers to patient reported outcome measure completion following lumbar spine fusion. Spine J 2023; 23:1531-1539. [PMID: 37209966 DOI: 10.1016/j.spinee.2023.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND CONTEXT Although incorporating patient reported outcomes (PROMs) into practice allows healthcare systems to evaluate the value of care provided, research and policy reflecting PROMs can only be valid if they represent all patients. Few studies have evaluated socioeconomic barriers to PROM completion, and none have done so in a spine patient population. PURPOSE To identify patient barriers to PROM completion one year following lumbar spine fusion. STUDY DESIGN/SETTING Retrospective single-institution cohort study. PATIENT SAMPLE A total of 2,984 patients undergoing lumbar fusion between 2014 and 2020 OUTCOME MEASURES: Completion of Mental Component Score (MCS-12) and Physical Component Score (PCS-12) of Short Form-12 questionnaire 1 year postoperatively. METHODS A retrospective review was conducted of all patients undergoing 1-3-level lumbar fusion at a single urban tertiary center. PROMs were queried from our prospectively managed electronic outcomes database. Patients were considered to have complete PROMs if 1-year outcomes were available. Community-level characteristics were collected from patients' zip codes using the Economic Innovation Group Distressed Communities Index. Bivariate analyses were performed to assess factors associated with PROM incompletion along with multivariate logistic regression to control for confounders. RESULTS A total of 1,968 (66.0%) had incomplete 1-year PROMs. Patients with incomplete PROMs were more likely to be Black (14.5% vs 9.3%, p<.001), Hispanic (2.9% vs 1.6%, p=.027), reside in a distressed community (14.7% vs 8.5%, p<.001), and be active smokers (22.4% vs 15.5%, p<.001). On multivariate regression, Black race (OR: 1.46, p=.014, Hispanic ethnicity (OR: 2.19, p=.027), distressed community status (OR: 1.47, p=.024), workers' compensation status (OR: 2.82, p=.001), and active smoking (OR:1.31, p=.034) all were independently associated with PROM incompletion. Surgical characteristics, including primary surgeon, revision status, approach, and levels fused were not associated with PROM incompletion. CONCLUSIONS Social determinants of health impact completion of PROMs. Patients completing PROMs are overwhelmingly White, non-Hispanic, and reside in wealthier communities. Efforts should be taken to provide better education regarding PROMs and ensure closer follow-up of certain subgroups of patients to avoid furthering disparities in PROM research.
Collapse
Affiliation(s)
- Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA; Feinberg School of Medicine, Northwestern University, 420 E Superior St, Chicago, IL 60611, USA.
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Gregory R Toci
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Andrew Kalra
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - David Pipa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| |
Collapse
|
22
|
Amabile A, Geirsson A. Commentary: Persistent racial disparity in myocardial revascularization: A call to action. J Thorac Cardiovasc Surg 2023; 166:1097-1098. [PMID: 35249757 DOI: 10.1016/j.jtcvs.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Andrea Amabile
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn.
| |
Collapse
|
23
|
Finkelstein JB, Rosoff JS, Tham RL, Perlman CA, Nelson CP. Characterizing digital access in pediatric urology. J Pediatr Urol 2023; 19:523.e1-523.e6. [PMID: 37121815 DOI: 10.1016/j.jpurol.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/24/2023] [Accepted: 04/10/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Virtual medicine has the potential to improve access for underserved populations by facilitating timely remote evaluation. However, challenges in the real-world implementation of this technology may paradoxically exacerbate health disparities. We sought to characterize families' digital access and how social determinants of health may impact virtual medicine access within pediatric urology. We hypothesized that disadvantaged socioeconomic status would be a barrier to virtual medicine access. STUDY DESIGN A digital access screening tool was prospectively developed and launched in July 2021. Schedulers are prompted to complete this optional screening questionnaire at the time of patient intake, for video or in-person encounters. The parent is screened for access to a device and reliable internet or cellular data that could be used to participate in a video visit. These represented the primary study outcomes. A modality preference for an in-person visit, video visit, or no preference was also recorded. Patient demographics were retrospectively evaluated, and socioeconomic status was estimated using the Distressed Communities Index generated for each patient's zip code. For each zip code, the Distressed Communities Index produces a normalized, comparative distress score ranging from 0 ("prosperous") to 100 ("distressed"). RESULTS 3885 patients were included, with median age of 5 years (IQR 1-11). Almost 74% were male, 71.3% were White, 20.9% had public insurance, and 2.9% required an interpreter. The median distress score was 14.2 (IQR 7.2-27.5). Screening revealed that 136 families (3.5%) lacked digital access. On multivariable logistic regression analysis, insurance type (p = 0.0020) and distress score (p = 0.0125) were significant predictors of digital access (Summary Table). Those patients who lacked access to a device (p < 0.0001) or reliable internet/cellular data (p < 0.0001) were more likely to prefer an in-person visit. DISCUSSION Family screening revealed that there is a small but significant proportion of families who lack digital access, and this cohort disproportionately represents underserved communities with higher distress scores, likely reflecting lower socioeconomic status. Those families without digital access were more likely to prefer an in-person visit. Improved identification of these socially complex "at-risk" patients can assist in the development of more inclusive health care strategies. CONCLUSIONS Despite the chance for virtual medicine to expand access for underserved populations, lack of digital tools may hinder its potential impact on health disparities in pediatric urology. Ongoing digital access screening and further studies are needed to design interventions tailored to the specific needs of our patients, allowing for more equitable pediatric urological care.
Collapse
Affiliation(s)
- Julia B Finkelstein
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - James S Rosoff
- Division of Urology, Brigham and Women's Hospital, 45 Francis Street, Boston, MA 02115, USA.
| | - Regina L Tham
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Caroline A Perlman
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| |
Collapse
|
24
|
Johns AJ, Luce MS, Kaneski MJ, Lowery RA, Jachniewicz B, Salas A, McCreary R, Russell RM, Lyo V, Ali MR, Ahmed SM. The long weight: association between distressed communities index and long-term weight outcomes following bariatric surgery. Surg Endosc 2023; 37:7218-7225. [PMID: 37369948 PMCID: PMC10462541 DOI: 10.1007/s00464-023-10158-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/20/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Socioeconomic status (SES) is multifactorial, and its effect on post-bariatric weight recurrence is unclear. Distressed Community Index (DCI) is a composite SES score measuring community economic well-being. This study aims to evaluate the effect of DCI on long-term post-bariatric weight outcomes. METHODS Retrospective analysis of patients undergoing primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between 2015 and 2020 was performed. All weights in the electronic medical record (EMR), including non-bariatric visits, were captured. Patients were stratified into low tier (LT) and high tier (HT) DCI groups. RESULTS Of 583 patients, 431 (73.9%) were HT and 152 (26.1%) were LT. Average bariatric follow up was 1.78 ± 1.6 years and average postoperative weight in the EMR was 3.96 ± 2.26 years. Rates of bariatric follow up within the last year were similar (13.8% LT vs 16.2% HT, p = 0.47). LT had higher percent total body weight loss (%TWL; 26% LT vs 23% HT, p < 0.01) and percent excess weight loss (%EWL; 62% vs 57%, p = 0.04) at 1 year on univariate analysis. On multivariate linear regression adjusting for baseline characteristics and surgery type, there were no differences in %EWL between groups at 1 year (p = 0.22), ≥ 3 years (p = 0.53) or ≥ 5 years (p = 0.34) postop. While on univariate analysis LT only trended towards greater percentage of patients with > 15% increase from their 1-year weight (33.3% LT vs 21.0% HT, p = 0.06), on multivariate analysis this difference was significant (OR 2.0, LT 95%CI 1.41-2.84). There were no differences in the percentage of patients with > 15% decrease in %EWL from 1 to 3 + years postop between groups (OR 0.98, LT 95% CI 0.72-1.35). CONCLUSIONS While low tier patients had similar weight loss at 1 year, they were twice as likely to have weight recurrence at ≥ 3 years. Further studies are needed to identify factors contributing to greater weight recurrence among this population.
Collapse
Affiliation(s)
- Alexandra J Johns
- Department of Surgery, University of California, Davis, 2335 Stockton Blvd, 6thFloor, Sacramento, CA, 95817, USA
| | - M Siobhan Luce
- Department of Surgery, University of California, Davis, 2335 Stockton Blvd, 6thFloor, Sacramento, CA, 95817, USA
| | - Mason J Kaneski
- Division of Foregut, Metabolic, and General Surgery, University of California, Davis, Sacramento, USA
| | - Ryan A Lowery
- University of California, Davis Health, Sacramento, USA
| | | | - Angela Salas
- University of California, Davis Health, Sacramento, USA
| | | | | | - Victoria Lyo
- Department of Surgery, University of California, Davis, 2335 Stockton Blvd, 6thFloor, Sacramento, CA, 95817, USA
- Division of Foregut, Metabolic, and General Surgery, University of California, Davis, Sacramento, USA
- Center for Metabolic and Alimentary Science, University of California, Davis, Sacramento, USA
| | - Mohammed R Ali
- Department of Surgery, University of California, Davis, 2335 Stockton Blvd, 6thFloor, Sacramento, CA, 95817, USA
- Division of Foregut, Metabolic, and General Surgery, University of California, Davis, Sacramento, USA
- Center for Metabolic and Alimentary Science, University of California, Davis, Sacramento, USA
| | - Shushmita M Ahmed
- Department of Surgery, University of California, Davis, 2335 Stockton Blvd, 6thFloor, Sacramento, CA, 95817, USA.
- Division of Foregut, Metabolic, and General Surgery, University of California, Davis, Sacramento, USA.
- Center for Metabolic and Alimentary Science, University of California, Davis, Sacramento, USA.
| |
Collapse
|
25
|
Schenck CS, Strand E, Smolderen KG, Romain G, Nagpal S, Cleman J, Blume PA, Mena-Hurtado C. Community distress and risk of adverse outcomes after peripheral vascular intervention. J Vasc Surg 2023; 78:166-174.e3. [PMID: 36944389 PMCID: PMC11146282 DOI: 10.1016/j.jvs.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/22/2023]
Abstract
INTRODUCTION Community distress is associated with adverse outcomes in patients with cardiovascular disease; however, its impact on clinical outcomes after peripheral vascular intervention (PVI) is uncertain. The Distressed Communities Index (DCI) is a composite measure of community distress measured at the zip code level. We evaluated the association between community distress, as measured by the DCI, and 24-month mortality and major amputation after PVI. METHODS We used the Vascular Quality Initiative database, linked with Medicare claims data, to identify patients who underwent initial femoropopliteal PVI between 2017 and 2018. DCI scores were assigned using patient-level zip code data. The primary outcomes were 24-month mortality and major amputation. We used time-dependent receiver operating characteristic curve analysis to determine an optimal DCI value to stratify patients into risk categories for 24-month mortality and major amputation. Mixed Cox regression models were constructed to estimate the association of DCI with 24-month mortality and major amputation. RESULTS The final cohort consisted of 16,864 patients, of whom 4734 (28.1%) were classified as having high community distress (DCI ≥70). At 24 months, mortality was elevated in patients with high community distress (30.7% vs 29.5%, P = .02), as was major amputation (17.2% vs 13.1%, P <.001). After adjusting for demographic and clinical characteristics, a 10-point higher DCI score was associated with increased risk of mortality (hazard ratio: 1.01; 95% confidence interval: 1.00-1.03) and major amputation (hazard ratio: 1.02; 95% confidence interval: 1.00-1.04). CONCLUSIONS High community distress is associated with increased risk of mortality and major amputation after PVI.
Collapse
Affiliation(s)
| | - Eric Strand
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Sameer Nagpal
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jacob Cleman
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Peter A Blume
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
| |
Collapse
|
26
|
Malas J, Chen Q, Emerson D, Gill G, Rowe G, Egorova N, Trento A, Chikwe J, Bowdish ME. Socioeconomic disparities in midterm outcomes after repair for degenerative mitral regurgitation. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00534-2. [PMID: 37385524 PMCID: PMC11181753 DOI: 10.1016/j.jtcvs.2023.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/17/2023] [Accepted: 05/29/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE The influence of socioeconomic disparities on survival after mitral repair is poorly defined. We examined the association between socioeconomic disadvantage and midterm outcomes of repair in Medicare beneficiaries with degenerative mitral regurgitation. METHODS US Centers for Medicare and Medicaid Services data were used to identify 10,322 patients undergoing isolated first-time repair for degenerative mitral regurgitation between 2012 and 2019. Zip code-level socioeconomic disadvantage was dichotomized with the Distressed Communities Index, which incorporates education level, poverty, unemployment, housing security, median income, and business growth; those with Distressed Communities Index score ≥80 were classified as distressed. The primary outcome was survival, censored at 3 years. Secondary outcomes included cumulative incidences of heart failure readmission, mitral reintervention, and stroke. RESULTS Of the 10,322 patients undergoing degenerative mitral repair, 9.7% (n = 1003) came from distressed communities. Patients from distressed communities underwent surgery at lower volume centers (11 vs 16 cases/year) and traveled further for surgical care (40 vs 17 miles) (both P values < .001). At 3 years, unadjusted survival (85.4%; 95% CI, 82.9%-87.5% vs 89.7%; 95% CI, 89.0%-90.4%) and cumulative incidence of heart failure readmission (11.5%; 95% CI, 9.6%-13.7% vs 7.4%; 95% CI, 6.9%-8.0%) were worse in patients from distressed communities (all P values < .001), whereas mitral reintervention rates were similar (2.7%; 95% CI, 1.8%-4.0% vs 2.8%; 95% CI, 2.5%-3.2%; P = .75). After adjustment, community distress was independently associated with 3-year mortality (hazard ratio, 1.21; 95% CI, 1.01-1.46) and heart failure readmissions (hazard ratio, 1.28; 95% CI, 1.04-1.58). CONCLUSIONS Community-level socioeconomic distress is associated with worse outcomes in degenerative mitral repair among Medicare beneficiaries.
Collapse
Affiliation(s)
- Jad Malas
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Qiudong Chen
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Dominic Emerson
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - George Gill
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Georgina Rowe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Natalia Egorova
- Department of Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alfredo Trento
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Michael E Bowdish
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif.
| |
Collapse
|
27
|
Rali AS, Larson EE, Tran LE, Rahaman ZM, Charles LJ, Stokes JW, Chin C, Hilton A, Gannon WD, Bacchetta MD, Shah AS. Area Deprivation Index and Distress Community Index Scores Are Not Associated With Short-Term and Long-Term Extracorporeal Life Support Outcomes. ASAIO J 2023; 69:583-587. [PMID: 36807257 DOI: 10.1097/mat.0000000000001888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Distressed Communities Index (DCI) and Area Deprivation Index (ADI) are two composite ranking scores that report community level socioeconomic status (SES) by ZIP codes. The objective of this study was to evaluate the impact of SES as estimated by DCI and ADI scores on short-term and long-term outcomes after extracorporeal life support (ECLS) at a quaternary medical center. All patients on ECLS between January 1, 2015 and August 31, 2020 (N = 428) at Vanderbilt University Medical Center in Nashville, Tennessee, had their ADI and DCI scores calculated. Primary outcome was mortality during index hospitalization, and secondary outcome was survival to end of study follow-up. There was no significant difference in primary outcome between the top 25% ADI vs . bottom 75% ADI (53.8% vs . 50.6%; p = 0.56) or between top 25% DCI vs . bottom 75% DCI (56.1 vs . 49.2; p = 0.21). Adjusted odds ratio for the primary outcome with ADI and DCI was 1.13 (95% CI, 0.63-2.0; p = 0.67) and 1.28 (95% CI, 0.70-2.34; p = 0.41), respectively. Additionally, there was no significant difference in long-term survival curves based on their ADI or DCI scores. In conclusion, SES as estimated by baseline DCI and ADI scores does not appear to impact short- or long-term survival post-ECLS at a large volume center. http://links.lww.com/ASAIO/A951.
Collapse
Affiliation(s)
- Aniket S Rali
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emilee E Larson
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lena E Tran
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Zakiur M Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lawrence J Charles
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John W Stokes
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Clifford Chin
- Vanderbilt University School of Medical, Nashville, Tennessee
| | - Alistair Hilton
- Vanderbilt University School of Medical, Nashville, Tennessee
| | - Whitney D Gannon
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew D Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
28
|
Julien HM, Wang Y, Curtis JP, Johnston-Cox H, Eberly LA, Wang GJ, Nathan AS, Fanaroff AC, Khatana SAM, Groeneveld PW, Secemsky EA, Eneanya ND, Vora AN, Kobayashi T, Barbery C, Chery G, Kohi M, Kirksey L, Armstrong EJ, Jaff MR, Giri J. Racial Differences in Presentation and Outcomes After Peripheral Arterial Interventions: Insights From the NCDR-PVI Registry. Circ Cardiovasc Interv 2023; 16:e011485. [PMID: 37339237 DOI: 10.1161/circinterventions.121.011485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 05/03/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND We assess the rates of device use and outcomes by race among patients undergoing lower extremity peripheral arterial intervention using the American College of Cardiology National Cardiovascular Data Registry-Peripheral Vascular Intervention (PVI) registry. METHODS Patients who underwent PVI between April 2014 and March 2019 were included. Socioeconomic status was evaluated using the Distressed Community Index score for patients' zip codes. Multivariable logistic regression was used to assess factors associated with utilization of drug-eluting technologies, intravascular imaging, and atherectomy. Among patients with Centers for Medicare and Medicaid Services data, we compared 1-year mortality, rates of amputation, and repeat revascularizations. RESULTS Of 63 150 study cases, 55 719 (88.2%) were performed in White patients and 7431 (11.8%) in Black patients. Black patients were younger (67.9 versus 70.0 years), had higher rates of hypertension (94.4% versus 89.5%), diabetes (63.0% versus 46.2%), less likely to be able to walk 200 m (29.1% versus 24.8%), and higher Distressed Community Index scores (65.1 versus 50.6). Black patients were provided drug-eluting technologies at a higher rate (adjusted odds ratio, 1.14 [95% CI, 1.06-1.23]) with no difference in atherectomy (adjusted odds ratio, 0.98 [95% CI, 0.91-1.05]) or intravascular imaging (adjusted odds ratio, 1.03 [95% CI, 0.88-1.22]) use. Black patients experienced a lower rate of acute kidney injury (adjusted odds ratio, 0.79 [95% CI, 0.72-0.88]). In Centers for Medicare and Medicaid Services-linked analyses of 7429 cases (11.8%), Black patients were significantly less likely to have surgical (adjusted hazard ratio, 0.40 [95% CI, 0.17-0.96]) or repeat PVI revascularization (adjusted hazard ratio, 0.42 [95% CI, 0.30-0.59]) at 1 year compared with White patients. There was no difference in mortality (adjusted hazard ratio [0.8-1.4]) or major amputation (adjusted hazard ratio, 2.5 [95% CI, 0.8-7.6]) between Black and White patients. CONCLUSIONS Black patients presenting for PVI were younger, had higher prevalence of comorbidities and lower socioeconomic status. After adjustment, Black patients were less likely to have surgical or repeat PVI revascularization after the index PVI procedure.
Collapse
Affiliation(s)
- Howard M Julien
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
- Penn Cardiovascular Center for Health Equity and Social Justice, Philadelphia (H.M.J., L.A.E.)
| | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (Y.W., J.P.C.)
- Center of Outcome Research and Evaluation Yale New Haven Health System, CT (Y.W., J.P.C.)
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (Y.W., J.P.C.)
- Center of Outcome Research and Evaluation Yale New Haven Health System, CT (Y.W., J.P.C.)
| | - Hillary Johnston-Cox
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Lauren A Eberly
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Penn Cardiovascular Center for Health Equity and Social Justice, Philadelphia (H.M.J., L.A.E.)
| | - Grace J Wang
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Ashwin S Nathan
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Alexander C Fanaroff
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
| | - Eric A Secemsky
- Department of Medicine, Harvard Medical School, Boston, MA (E.A.S.)
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.A.S.)
| | - Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
| | - Amit N Vora
- University of Pittsburgh Medical Center-Pinnacle, Wormleysburg, PA (A.N.V.)
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
| | - Carlos Barbery
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Godefroy Chery
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Maureen Kohi
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill (M.K.)
| | - Lee Kirksey
- Division of Vascular Surgery, Cleveland Clinic, OH (L.K.)
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO (E.J.A.)
- University of Colorado School of Medicine, Aurora (E.J.A.)
| | - Michael R Jaff
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston (M.R.J.)
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| |
Collapse
|
29
|
Kaplan EF, Strobel RJ, Young AM, Wisniewski AM, Ahmad RM, Mehaffey JH, Hawkins RB, Yarboro LT, Quader M, Teman NR. Cardiac Surgery Outcomes During the COVID-19 Pandemic Worsened Across All Socioeconomic Statuses. Ann Thorac Surg 2023; 115:1511-1518. [PMID: 36696937 PMCID: PMC9867828 DOI: 10.1016/j.athoracsur.2022.12.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/05/2022] [Accepted: 12/18/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Increasing socioeconomic distress has been associated with worse cardiac surgery outcomes. The extent to which the pandemic affected cardiac surgical access and outcomes remains unknown. We sought to examine the relationship between the COVID-19 pandemic and outcomes after cardiac surgery by socioeconomic status. METHODS All patients undergoing a Society of Thoracic Surgeons (STS) index operation in a regional collaborative, the Virginia Cardiac Services Quality Initiative (2011-2022), were analyzed. Patients were stratified by timing of surgery before vs during the COVID-19 pandemic (March 13, 2020). Hierarchic logistic regression assessed the relationship between the pandemic and operative mortality, major morbidity, and cost, adjusting for the Distressed Communities Index (DCI), STS predicted risk of mortality, intraoperative characteristics, and hospital random effect. RESULTS A total of 37,769 patients across 17 centers were included. Of these, 7269 patients (19.7%) underwent surgery during the pandemic. On average, patients during the pandemic were less socioeconomically distressed (DCI 37.4 vs DCI 41.9; P < .001) and had a lower STS predicted risk of mortality (2.16% vs 2.53%, P < .001). After risk adjustment, the pandemic was significantly associated with increased mortality (odds ratio 1.398; 95% CI, 1.179-1.657; P < .001), cost (+$4823, P < .001), and STS failure to rescue (odds ratio 1.37; 95% CI, 1.10-1.70; P = .005). The negative impact of the pandemic on mortality and cost was similar regardless of DCI. CONCLUSIONS Across all socioeconomic statuses, the pandemic is associated with higher cost and greater risk-adjusted mortality, perhaps related to a resource-constrained health care system. More patients during the pandemic were from less distressed communities, raising concern for access to care in distressed communities.
Collapse
Affiliation(s)
- Emily F Kaplan
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Andrew M Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Alex M Wisniewski
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Raza M Ahmad
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Leora T Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mohammad Quader
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
| |
Collapse
|
30
|
Siegel N, Lambrechts MJ, Karamian BA, Carter M, Magnuson JA, Toci GR, Krueger CA, Canseco JA, Woods BI, Kaye D, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities Following Lumbar Fusion. Clin Spine Surg 2023; 36:E123-E130. [PMID: 36127771 DOI: 10.1097/bsd.0000000000001386] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/17/2022] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine whether: (1) patients from communities of socioeconomic distress have higher readmission rates or postoperative healthcare resource utilization and (2) there are differences in patient-reported outcome measures (PROMs) based on socioeconomic distress. SUMMARY OF BACKGROUND DATA Socioeconomic disparities affect health outcomes, but little evidence exists demonstrating the impact of socioeconomic distress on postoperative resource utilization or PROMs. METHODS A retrospective review was performed on patients who underwent lumbar fusion at a single tertiary academic center from January 1, 2011 to June 30, 2021. Patients were classified according to the distressed communities index. Hospital readmission, postoperative prescriptions, patient telephone calls, follow-up office visits, and PROMs were recorded. Multivariate analysis with logistic, negative binomial regression or Poisson regression were used to investigate the effects of distressed communities index on postoperative resource utilization. Alpha was set at P <0.05. RESULTS A total of 4472 patients were included for analysis. Readmission risk was higher in distressed communities (odds ratio, 1.75; 95% confidence interval, 1.06-2.87; P =0.028). Patients from distressed communities (odds ratio, 3.94; 95% confidence interval, 1.60-9.72; P =0.003) were also more likely to be readmitted for medical, but not surgical causes ( P =0.514), and distressed patients had worse preoperative (visual analog-scale Back, P <0.001) and postoperative (Oswestry disability index, P =0.048; visual analog-scale Leg, P =0.013) PROMs, while maintaining similar magnitudes of clinical improvement. Patients from distressed communities were more likely to be discharged to a nursing facility and inpatient rehabilitation unit (25.5%, P =0.032). The race was not independently associated with readmissions ( P =0.228). CONCLUSION Socioeconomic distress is associated with increased postoperative health resource utilization. Patients from distressed communities have worse preoperative PROMs, but the overall magnitude of improvement is similar across all classes. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Nicholas Siegel
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Radtka JF, Zil-E-Ali A, Medina D, Aziz F. Patients from distressed communities are more likely to be symptomatic at endovascular aneurysm repair and have an increased risk of being lost to long-term follow-up. J Vasc Surg 2023; 77:1087-1098.e3. [PMID: 36343872 DOI: 10.1016/j.jvs.2022.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/17/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has become the preferred modality to repair abdominal aortic aneurysms (AAAs). However, the effect of the distressed communities index (DCI) on the outcomes of EVAR is still unknown. In the present study, we investigated the effect of DCI on the postoperative outcomes after EVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was used for the present study. Patients who had undergone EVAR from 2003 to 2021 were selected for analysis. The study cohort was divided into two groups according to their DCI score. Patients with DCI scores ranging from 61 to 100 were assigned to group I (DCI >60), and those with DCI scores ranging from 0 to 60 were assigned to group II (DCI ≤60). The primary outcomes included the 30-day and 1-year mortality and major adverse cardiovascular events at 30 days. Regression analyses were performed to study the postoperative outcomes. P values ≤ .05 were deemed statistically significant for all analyses in the present study. RESULTS A total of 60,972 patients (19.5% female; 80.5% male) had undergone EVAR from 2003 to 2021. Of these patients, 18,549 were in group I (30.4%) and 42,423 in group II (69.6%). The mean age of the study cohort was 73 ± 8.9 years. Group I tended to be younger (mean age, 72.6 vs 73.7 years), underweight (3.5% vs 2.5%), and African American (10.8% vs 3.5%) and were more likely to have Medicaid insurance (3.6% vs 1.9%; P < .05 for all). Group I had had more smokers (87.3% vs 85.3%), a higher rate of comorbidities, including hypertension (84.5% vs 82.9%), diabetes (21.7% vs 19.7%), coronary artery disease (30.3% vs 28.6%), chronic obstructive pulmonary disease (36.9% vs 31.8%), and moderate to severe congestive heart failure (2.6% vs 2%; P < .05 for all). The group I patients were more likely to undergo EVAR for symptomatic AAAs (11.1% vs 7.9%; P < .001; adjusted odds ratio [aOR], 1.25; 95% confidence interval [CI], 1.15-1.37; P < .001) with a higher risk of mortality at 30 days (aOR, 3.98; 95% CI, 2.23-5.44; P < .001) and 1 year (aOR, 1.74; 95% CI, 1.43-2.13; P < .001). A higher risk of being lost to follow-up (28.9% vs 26.3%; P < .001) was also observed in group I. CONCLUSIONS Patients from distressed communities who require EVAR tended to have multiple comorbidities. These patients were also more likely to be treated for symptomatic AAAs, with a higher risk of mortality. An increased incidence of lost to long-term follow-up was also observed for this population. Surgeons and healthcare systems should consider these outcomes and institute patient-centered approaches to ensure equitable healthcare.
Collapse
Affiliation(s)
- John F Radtka
- Division of Vascular Surgery, Pennsylvania State University College of Medicine, Hershey, PA
| | - Ahsan Zil-E-Ali
- Division of Vascular Surgery, Pennsylvania State University College of Medicine, Hershey, PA.
| | - Daniela Medina
- Office of Medical Education, Pennsylvania State University College of Medicine, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Pennsylvania State University College of Medicine, Hershey, PA
| |
Collapse
|
32
|
Iyengar A, Patrick WL, Helmers MR, Kelly JJ, Han J, Williams ML, Mackay EJ, Desai ND, Cevasco M. Neighborhood Socioeconomic Status Independently Predicts Outcomes After Mitral Valve Surgery. Ann Thorac Surg 2023; 115:940-947. [PMID: 36623633 DOI: 10.1016/j.athoracsur.2023.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 12/08/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
BACKGROUND Socioeconomic status has increasingly recognized influence on outcomes after cardiac surgery. However, singular metrics fail to fully capture the socioeconomic context within which patients live, which vary greatly between neighborhoods. We sought to explore the impact of neighborhood-level socioeconomic status on patients undergoing mitral valve surgery in the United States. METHODS Adults undergoing first-time, isolated mitral valve surgery were queried from The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2012 and 2018. Socioeconomic status was quantified using the Area Deprivation Index, a weighted composite including average housing prices, household incomes, education, and employment levels. The associations between regional deprivation, access to mitral surgery, valve repair rates, and outcomes were evaluated using logistic regression. RESULTS Among 137,100 patients included, patients with socioeconomic deprivation had fewer elective presentations, more comorbidity burden, and more urgent/emergent surgery. Patients from less disadvantaged areas received operations from higher volume surgeons and had higher repair rates (highest vs lowest quintile: 72% vs 51%, P < .001, more minimally-invasive approach (33% vs 20%, P < .001), lower composite complication rate (42% vs 50%, P < .001), and lower 30-day mortality (1.8% vs 3.9%, P < .001). After hierarchical multivariable adjustment, the Area Deprivation Index significantly predicted 30-day mortality and repair rate (P < .001). CONCLUSIONS In a risk-adjusted national analysis of mitral surgery, patients from more deprived areas were less likely to undergo mitral repair and more likely to have complications. Further work at targeting neighborhood-level disparity is important to improving mitral surgical outcomes in the United States.
Collapse
Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason Han
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew L Williams
- Division of Cardiovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Emily J Mackay
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
33
|
Strobel RJ, Mehaffey JH, Hawkins RB, Young AM, Scott EJ, Quader M, Dehmer GJ, Rich JB, Ailawadi G, Kron IL, Ragosta M, Yarboro LT, Teman NR. Socioeconomic Distress Associated With Increased Use of Percutaneous Coronary Intervention Over Coronary Artery Bypass Grafting. Ann Thorac Surg 2023; 115:914-921. [PMID: 35868555 DOI: 10.1016/j.athoracsur.2022.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/01/2022] [Accepted: 06/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The influence of socioeconomic determinants of health on choice of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) for coronary artery disease is unknown. We hypothesized that higher Distressed Communities Index (DCI) scores, a comprehensive socioeconomic ranking by zip code, would be associated with more frequent PCI. METHODS All patients undergoing isolated CABG or PCI in a regional American College of Cardiology CathPCI registry and The Society of Thoracic Surgeons database (2018-2021) were assigned DCI scores (0 = no distress, 100 = severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. Patients who presented with ST-segment elevation myocardial infarction or emergent procedures were excluded. The most distressed quintile (DCI ≥80) was compared with all other patients. Multivariable logistic regression analyzed the association between DCI and procedure type. RESULTS A total of 23 223 patients underwent either PCI (n = 16 079) or CABG (n = 7144) for coronary artery disease across 28 centers during the study period. Before adjustment, high socioeconomic distress occurred more frequently among CABG patients (DCI ≥80, 12.4% vs 8.42%; P < .001). After multivariable adjustment, high socioeconomic distress was associated with greater odds of receiving PCI, relative to CABG (odds ratio 1.26; 95% CI, 1.07-1.49; P = .007). High socioeconomic distress was significantly associated with postprocedural mortality (odds ratio 1.52; 95% CI, 1.02-2.26; P = .039). CONCLUSIONS High socioeconomic distress is associated with greater risk-adjusted odds of receiving PCI, relative to CABG, as well as higher postprocedural mortality. Targeted resource allocation in high DCI areas may help eliminate barriers to CABG.
Collapse
Affiliation(s)
- Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew M Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Erik J Scott
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mohammed Quader
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Gregory J Dehmer
- Department of Medicine Carilion Clinic/Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Irving L Kron
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Michael Ragosta
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Leora T Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
| |
Collapse
|
34
|
The Effect of Socioeconomic Disparity on Improvement in QuickDASH at 3 Months after Carpal Tunnel Release. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4878. [PMID: 36923712 PMCID: PMC10010810 DOI: 10.1097/gox.0000000000004878] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023]
Abstract
The primary objective of this study was to determine the association between socioeconomic disparity and improvement in QuickDASH score 3 months after carpal tunnel release (CTR). The secondary objectives of this study were to determine the association between socioeconomic disparity and baseline preoperative QuickDASH score and 3 months postoperative QuickDASH score after CTR. Methods A single-institutional, prospective, longitudinal study was performed of 85 patients who underwent isolated, unilateral CTR for idiopathic carpal tunnel syndrome. Sixty-three patients (74%) who completed patient-reported outcome measures at 3 months after surgery comprised our study cohort. Socioeconomic disparity was assessed using the zip code level Distressed Communities Index (DCI) and the neighborhood level Area Deprivation Index. The outcome variables were the improvement in the QuickDASH score, 3 months postoperative QuickDASH score, and the preoperative QuickDASH score. Associations between continuous variables were assessed using simple linear regression. Results The mean DCI of the study cohort was in the 23rd national percentile, and the mean Area Deprivation Index was in the 15th national percentile. The mean preoperative QuickDASH of the study cohort was 49.3. The mean 3 months postoperative QuickDASH of the study cohort was 29.8. The mean improvement in QuickDASH at 3 months after surgery was 19.5, which was statistically significant and clinically meaningful. Area Deprivation Index and DCI were not associated with improvement in QuickDASH score or 3 months postoperative QuickDASH score. Higher DCI was associated with poorer baseline preoperative QuickDASH score. Conclusion Patients of various socioeconomic backgrounds can expect similar short-term improvements in symptoms and function after CTR.
Collapse
|
35
|
Geskey JM, Kodish-Wachs J, Blonsky H, Hohman SF, Meurer S. National Documentation and Coding Practices of Noncompliance: The Importance of Social Determinants of Health and the Stigma of African-American Bias. Am J Med Qual 2023; 38:87-92. [PMID: 36855256 PMCID: PMC9973443 DOI: 10.1097/jmq.0000000000000112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Patient records serve many purposes, one of which includes monitoring the quality of care provided that they can be analyzed through coding and documentation. Z-codes can provide additional information beyond a specific clinical disorder that may still warrant treatment. Social Determinants of Health have specific Z-codes that may help clinicians address social factors that may contribute to patients' health care outcomes. However, there are Z-codes that specify patient noncompliance which has a pejorative connotation that may stigmatize patients and prevent clinicians from examining nonadherence from a social determinant of health perspective. A retrospective cross-sectional study was performed to examine the associations of patient and encounter characteristics with the coding of patient noncompliance. Included in the study were all patients >18 years of age who were admitted to hospitals participating in the Vizient Clinical Data Base (CDB) between January 1, 2019 and December 31, 2019. Almost 9 million US inpatients were included in the study. Of those, 6.3% had a noncompliance Z-code. Use of noncompliance Z-codes was associated with the following odds estimate ratio in decreasing order: the presence of a social determinant of health (odds ratio [OR], 4.817), African American race (OR, 2.010), Medicaid insurance (OR, 1.707), >3 chronic medical conditions (OR, 1.546), living in an economically distressed community (OR, 1.320), male gender (OR, 1.313), nonelective admission status (OR, 1.245), age <65 years (OR, 1.234). More than 1 in 15 patient hospitalizations had a noncompliance code. Factors associated with these codes are difficult, if not impossible, for patients to modify. Disproportionate representation of Africa-Americans among hospitalizations with noncompliance coding is concerning and urgently deserves further exploration to determine the degree to which it may be a product of clinician bias, especially if the term noncompliance prevents health care providers from looking into socioeconomic factors that may contribute to patient nonadherence.
Collapse
Affiliation(s)
| | | | | | | | - Steve Meurer
- Vizient, Inc., Chicago, IL
- Rush University, Chicago, IL
| |
Collapse
|
36
|
Williams C, Kellett W, Ireland M, Wahl W, Wisler J, Jalilvand A. Distressed Communities Index Is Not Associated with Mortality for Critically Ill Surgical Patients with Sepsis. Surg Infect (Larchmt) 2023; 24:169-176. [PMID: 36706443 PMCID: PMC9983141 DOI: 10.1089/sur.2022.329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background: The impact of socioeconomic metrics on outcomes after sepsis is unclear. The Distressed Communities Index (DCI) is a composite score quantifying socioeconomic well-being by zip code. The primary objective of this study was to evaluate the association between DCI and mortality in patients with sepsis admitted to the surgical intensive care unit (SICU). Patients and Methods: All patients with sepsis admitted to the SICU (Sequential Organ Failure Assessment [SOFA] score ≥2) were reviewed retrospectively. Composite DCI scores were obtained for each patient and classified into high-distress (DCI ≥75th percentile; n = 331) and control distress (DCI <50th percentile; n = 666) groups. Baseline demographic and clinical characteristics were compared between groups. The primary outcomes were in-hospital and 90-day mortality. Results: The high-distress cohort was younger and more likely to be African American (19.6% vs. 6.2%), transferred from an outside facility (52% vs. 42%), have chronic obstructive pulmonary disease (25.1% vs. 18.8%), and baseline liver disease (8.2% vs. 4.2%). Sepsis presentation was comparable between groups. Compared with the control cohort, high-distress patients had similar in-house (23% vs. 24%) and 90-day mortality (30% vs. 28%) but were associated with longer hospital stay (23 vs. 19 days). High DCI failed to predict in-hospital or 90-day mortality but was an independent risk factor for longer hospital length of stay (odds ratio [OR], 2.83 ± 1.42; p = 0.047). Conclusions: High DCI was not associated with mortality but did independently predict longer length of stay. This may reflect limitations of DCI score in evaluating mortality for patients with sepsis. Future studies should elucidate its association with length of stay, re-admissions, and follow-up.
Collapse
Affiliation(s)
- Chloe Williams
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Whitney Kellett
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Megan Ireland
- University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Wendy Wahl
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jon Wisler
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Anahita Jalilvand
- Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
37
|
Fisher Z, Hughes G, Staggs J, Moore T, Kinder N, Vassar M. Health Inequities in Coronary Artery Bypass Grafting Literature: A Scoping Review. Curr Probl Cardiol 2023; 48:101640. [PMID: 36792023 DOI: 10.1016/j.cpcardiol.2023.101640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 02/04/2023] [Indexed: 02/15/2023]
Abstract
Although life saving, health inequities exist regarding access and patient outcomes in Coronary artery bypass grafting (CABG), especially among marginalized groups. This scoping review's goal is to outline existing literature and highlight gaps for future research. Researchers followed guidance from the Joanna Briggs Institute and PRISMA extension for scoping reviews. We conducted a search to identify articles published between 2016 and 2022 regarding CABG and inequity groups, defined by the National Institutes of Health. Fifty-seven articles were included in our final sample. Race/Ethnicity was examined in 39 incidences, Sex or Gender 29 times, Income 17 instances, Geography 10 instances, and Education Level 3 instances. Occupation Status 2 instances, and LGBTQ+ 0 times. Important disparities exist regarding CABG access and outcomes, especially involving members of the LGBTQ+, Native American, and Black communities. Further research is needed to address health disparities and their root causes for focused action and improved health of minoritized groups.
Collapse
Affiliation(s)
- Zachariah Fisher
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK.
| | - Griffin Hughes
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK
| | - Jordan Staggs
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK
| | - Ty Moore
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK
| | | | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK
| |
Collapse
|
38
|
Spark TL, Reid CE, Adams RS, Schneider AL, Forster J, Denneson LM, Bollinger M, Brenner LA. Geography, rurality, and community distress: deaths due to suicide, alcohol-use, and drug-use among Colorado Veterans. Inj Epidemiol 2023; 10:8. [PMID: 36765427 PMCID: PMC9912586 DOI: 10.1186/s40621-023-00416-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 01/12/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND In the USA, deaths due to suicide, alcohol, or drug-related causes (e.g., alcohol-related liver disease, overdose) have doubled since 2002. Veterans appear disproportionately impacted by growing trends. Limited research has been conducted regarding the relationship between community-level factors (e.g., rurality, community distress resulting from economic conditions) and the presence of spatial clustering of suicide, alcohol-related, or drug-related deaths. We explored community-level relationships in Colorado Veterans and compared suicide, alcohol-, and drug-related death rates between the Colorado adult population and Veterans. METHODS 2009-2020 suicide, alcohol-related, and/or drug-related deaths were identified using qualifying multiple cause-of-death International Classification of Disease (ICD)-10 codes in CDC WONDER for the general adult population and Colorado death data for Veteran populations. Age and race adjusted rates were calculated to compare risk overall and by mortality type (i.e., suicide, alcohol-related, drug-related). In Veteran decedents, age-adjusted rates were stratified by rurality and community distress, measured by the Distressed Communities Index. Standardized mortality ratios were calculated to measure spatial autocorrelation and identify clusters using global and local Moran's I, respectively. RESULTS 6.4% of Colorado Veteran deaths (n = 6948) were identified as being related to suicide, alcohol, or drugs. Compared to rates in the general population of Colorado adults, Veterans had 1.8 times higher rates of such deaths overall (2.1 times higher for suicide, 1.8 times higher for alcohol-related, 1.3 times higher for drug-related). Among Veterans, community distress was associated with an increased risk of alcohol-related [age-adjusted rate per 100,000 (95% CI) = 129.6 (89.9-193.1)] and drug-related deaths [95.0 (48.6-172.0)]. This same significant association was not identified among those that died by suicide. Rurality was not associated with risk for any of the deaths of interest. There was significant spatial clustering for alcohol-related deaths in southeast Colorado. CONCLUSIONS Colorado Veterans have higher rates of deaths due to suicide, alcohol-related, and drug-related causes compared to members of the general adult population. Upstream prevention efforts, such as community-based interventions targeting alcohol-use and community economic distress, are warranted. More research is also needed to understand how community distress and other social determinants of health impact the community burden of suicide, alcohol-related, and drug-related mortality.
Collapse
Affiliation(s)
- Talia L. Spark
- grid.239186.70000 0004 0481 9574VISN 19 VA Rocky Mountain MIRECC for Veteran Suicide Prevention, Rocky Mountain Regional VA Medical Center, Veterans Health Administration, 1700 North Wheeling St., Aurora, CO 80045 USA ,grid.430503.10000 0001 0703 675XDepartment of Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, CO USA ,grid.430503.10000 0001 0703 675XInjury and Violence Prevention Center, Anschutz School of Medicine, University of Colorado, Aurora, CO USA
| | - Colleen E. Reid
- grid.266190.a0000000096214564Geography Department, University of Colorado Boulder, Boulder, CO USA
| | - Rachel Sayko Adams
- grid.239186.70000 0004 0481 9574VISN 19 VA Rocky Mountain MIRECC for Veteran Suicide Prevention, Rocky Mountain Regional VA Medical Center, Veterans Health Administration, 1700 North Wheeling St., Aurora, CO 80045 USA ,grid.253264.40000 0004 1936 9473Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA USA
| | - Alexandra L. Schneider
- grid.239186.70000 0004 0481 9574VISN 19 VA Rocky Mountain MIRECC for Veteran Suicide Prevention, Rocky Mountain Regional VA Medical Center, Veterans Health Administration, 1700 North Wheeling St., Aurora, CO 80045 USA
| | - Jeri Forster
- grid.239186.70000 0004 0481 9574VISN 19 VA Rocky Mountain MIRECC for Veteran Suicide Prevention, Rocky Mountain Regional VA Medical Center, Veterans Health Administration, 1700 North Wheeling St., Aurora, CO 80045 USA ,grid.430503.10000 0001 0703 675XDepartment of Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, CO USA
| | - Lauren M. Denneson
- grid.484322.bVA HSR&D Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR USA ,grid.5288.70000 0000 9758 5690Department of Psychiatry, Oregon Health & Science University, Portland, OR USA
| | - Mary Bollinger
- VA HSR&D Center for Mental Healthcare and Outcomes Research, North Little Rock, AR USA ,VA HSR&D Suicide Prevention Impact Network, Little Rock, AR USA ,grid.241054.60000 0004 4687 1637Center for Health Services Research, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Lisa A. Brenner
- grid.239186.70000 0004 0481 9574VISN 19 VA Rocky Mountain MIRECC for Veteran Suicide Prevention, Rocky Mountain Regional VA Medical Center, Veterans Health Administration, 1700 North Wheeling St., Aurora, CO 80045 USA ,grid.430503.10000 0001 0703 675XDepartment of Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, CO USA ,grid.430503.10000 0001 0703 675XInjury and Violence Prevention Center, Anschutz School of Medicine, University of Colorado, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDepartment of Psychiatry, Anschutz School of Medicine, University of Colorado, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDepartment of Neurology, Anschutz School of Medicine, University of Colorado, Aurora, CO USA
| |
Collapse
|
39
|
Amdani S, Tang A, Schold JD. Children from socioeconomically disadvantaged communities present in more advanced heart failure at the time of transplant listing. J Heart Lung Transplant 2023; 42:150-155. [PMID: 36270922 DOI: 10.1016/j.healun.2022.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 01/18/2023] Open
Abstract
Transplant registries in the US do not collect information about community level risk factors. We utilized a community level socio-economic risk indicator, the distressed communities' index to understand its association with clinical presentation among children listed for heart transplant (HT). We found that currently, majority (40%) of children listed from distressed communities are Black. On multivariable analysis, compared to children from prosperous communities, those from distressed communities listed for HT were significantly more likely to be Status 1A (adjusted odds ratio [aOR] 1.39) and on a ventricular assist device (aOR 1.44). Compared to White children from prosperous communities, both Black and White children from distressed communities were more likely to be listed Status 1A (aOR 2.1 and 1.36 respectively) and have renal dysfunction (aOR 1.71 and 1.52 respectively). In conclusion, heart failure severity at listing appears more likely associated with community-level risk factors and less so with child's race/ethnicity.
Collapse
Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Ohio.
| | - Anne Tang
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Jesse D Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
40
|
Magnuson JA, Griffin SA, Venkat N, Gold PA, Courtney PM, Krueger CA. Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty. Clin Orthop Relat Res 2023; 481:202-210. [PMID: 35446266 PMCID: PMC9831190 DOI: 10.1097/corr.0000000000002185] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/04/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk. QUESTIONS/PURPOSES (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization? METHODS Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included. RESULTS When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization. CONCLUSION We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions. LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Justin A. Magnuson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Sean A. Griffin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
- Florida Atlantic University College of Medicine, Boca Raton, FL, USA
| | - Nitya Venkat
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Peter A. Gold
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - P. Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Chad A. Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
41
|
National Analysis of Sternal Wound Complications and Readmissions After Coronary Bypass Surgery. Ann Thorac Surg 2022; 115:1136-1142. [PMID: 36581157 DOI: 10.1016/j.athoracsur.2022.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/09/2022] [Accepted: 12/19/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Wound complications are a cause for readmission after cardiac surgery. Health insurance status has been associated with poor postoperative outcomes. We investigate the association between health insurance status and post-CABG wound dehiscence or infection along with 30-day wound-related readmission using a national database. METHODS We queried the National Readmissions Database for the year 2018 for patients aged 18 years or more undergoing multivessel coronary artery bypass graft surgery (CABG). Patients were subcategorized by health insurance status (private, Medicaid, Medicare, uninsured). Our primary outcomes were wound dehiscence or infection during the index admission and 30-day readmission after discharge for wound-related complications. RESULTS In all, 131,976 patients met inclusion criteria: 32.7% private, 7.6% Medicaid, 59.3% Medicare, and 0.4% uninsured. Compared with patients having private insurance, Medicaid patients had greater odds of readmission for superficial wound dehiscence (odds ratio [OR] 2.11; 1.11-4.00; P = .022) and deep wound dehiscence (OR 2.11; 95% CI, 1.09-4.10; P = .026), as did Medicare patients (OR 2.34; 95% CI, 1.29-3.88; P = .004; and OR 3.23; 95% CI, 1.76-5.90; P = .001, respectively). Medicaid patients additionally had higher odds of readmission for superficial wound infection (OR 1.59; 95% CI, 1.11-4.00; P = .014). Compared with patients with private insurance, Medicaid patients had higher odds of deep wound dehiscence on index admission (OR 1.97; 95% CI, 1.02-3.83; P = .044), and Medicare patients had higher odds of superficial wound dehiscence (OR 2.55; 95% CI, 1.28-5.06; P = .001). CONCLUSIONS Patients with Medicaid and Medicare had greater odds of readmission for wound complications and higher rates of wound dehiscence in their index admission. Further research is warranted to characterize factors driving readmission due to postsurgical wound complications in low socioeconomic status populations.
Collapse
|
42
|
Patients From Socioeconomically Distressed Communities Experience Similar Clinical Improvements Following Anterior Cervical Discectomy and Fusion. Spine (Phila Pa 1976) 2022; 47:1701-1709. [PMID: 35960599 DOI: 10.1097/brs.0000000000004455] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/25/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVES The aim was to compare patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF) when categorizing patients based on socioeconomic status. Secondarily, we sought to compare PROMs based on race. SUMMARY OF BACKGROUND DATA Social determinants of health are believed to affect outcomes following spine surgery, but there is limited literature on how combined socioeconomic status metrics affect PROMs following ACDF. MATERIALS AND METHODS The authors identified patients who underwent primary elective one-level to four-level ACDF from 2014 to 2020. Patients were grouped based on their distressed community index (DCI) quintile (Distressed, At-Risk, Mid-tier, Comfortable, and Prosperous) and then race (White or Black). Multivariate regression for ∆PROMs was performed based on DCI group and race while controlling for baseline demographics and surgical characteristics. RESULTS Of 1204 patients included in the study, all DCI groups improved across all PROMs, except mental health component score (MCS-12) for the Mid-tier group ( P =0.091). Patients in the Distressed/At-Risk group had worse baseline MCS-12, visual analog scale (VAS) Neck, and neck disability index (NDI). There were no differences in magnitude of improvement between DCI groups. Black patients had significantly worse baseline VAS Neck ( P =0.002) and Arm ( P =0.012) as well as worse postoperative MCS-12 ( P =0.016), PCS-12 ( P =0.03), VAS Neck ( P <0.001), VAS Arm ( P =0.004), and NDI ( P <0.001). Multivariable regression analysis did not identify any of the DCI groupings to be significant independent predictors of ∆PROMs, but being White was an independent predictor of greater improvement in ∆PCS-12 (β=3.09, P =0.036) and ∆NDI (β=-7.32, P =0.003). CONCLUSIONS All patients experienced clinical improvements regardless of DCI or race despite patients in Distressed communities and Black patients having worse preoperative PROMs. Being from a distressed community was not an independent predictor of worse improvement in any PROMs, but Black patients had worse improvement in NDI compared with White patients. LEVEL OF EVIDENCE 3.
Collapse
|
43
|
Zhang D, Earp BE, Blazar P. Association of Economic Well-Being With Comorbid Conditions in Patients Undergoing Carpal Tunnel Release. J Hand Surg Am 2022; 47:1228.e1-1228.e7. [PMID: 34716055 DOI: 10.1016/j.jhsa.2021.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/12/2021] [Accepted: 09/15/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Medical comorbidities have been associated with the development of carpal tunnel syndrome (CTS), severity at the time of presentation, and outcomes of carpal tunnel release (CTR). Socioeconomic factors have also been associated with worse function in patients with CTS at presentation and after surgery. However, the effects of economic well-being on the prevalence of medical comorbidities in patients with CTS have not been well-described. The objective of this study was to determine whether economic well-being is associated with medical comorbidities in a cohort of patients undergoing CTR. METHODS Patients (n = 1,297) who underwent CTR at a single tertiary care referral center over a 5-year period from July 2008 to June 2013 were retrospectively identified. The exclusion criteria were acute trauma or infection, revision surgery, incomplete medical records, and neoplasm excision. Additionally, patients were excluded if they lacked documented confirmatory or normal electrodiagnostic study findings prior to CTR. Finally, this study comprised a cohort of 892 patients with electrodiagnostic study-confirmed CTS who underwent CTR. The economic well-being of patients was assessed using the Distressed Communities Index. The comorbidities of diabetes mellitus, chronic kidney disease, hypertension, hypothyroidism, cervical radiculopathy, tobacco use, and body mass index were assessed. Bivariate comparisons were used to determine the associations between the tiers of economic well-being and comorbidities. RESULTS Lower economic well-being was associated with body mass index, diabetes mellitus, chronic kidney disease, and tobacco use in these patients. Although hypertension, hypothyroidism, and cervical radiculopathy were not associated with economic well-being, their comparisons were underpowered. CONCLUSIONS Patients experiencing economic distress have a higher comorbidity burden, and as such, may be at an increased risk of complications or poorer outcomes. The association between economic well-being and comorbidities in this population suggests the need for a multidisciplinary care model that addresses both compressive neuropathy and the associated economic factors. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
Collapse
Affiliation(s)
- Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Brandon E Earp
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Philip Blazar
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| |
Collapse
|
44
|
Tran JS, Loveland MG, Alamer A, Piña IL, Sweitzer NK. Clinical and Socioeconomic Determinants of Angiotensin Receptor-Neprilysin Inhibitor Prescription at Hospital Discharge in Patients With Heart Failure With Reduced Ejection Fraction. Circ Heart Fail 2022; 15:e009395. [PMID: 36378759 PMCID: PMC9673159 DOI: 10.1161/circheartfailure.121.009395] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 07/11/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Angiotensin receptor-neprilysin inhibitor (ARNI) prescription in the United States remains suboptimal despite strong evidence for efficacy and value in heart failure with reduced ejection fraction. Factors responsible for under prescription are not completely understood. Economic limitations may play a disproportionate role in reduced access for some patients. METHODS This is an analysis of the Get With The Guidelines-Heart Failure registry, supplemented with data from the Distressed Community Index. Data were fit to a mixed-effects regression model to investigate clinical and socioeconomic factors associated with ARNI prescription at hospital discharge. Missing data were handled by multilevel multiple imputation. RESULTS Of the 136 144 patients included in analysis, 12.6% were prescribed an ARNI at discharge. The dominant determinants of ARNI prescription were ARNI use while inpatient (odds ratio [OR], 72 [95% CI, 58-89]; P<0.001) and taking an ARNI before hospitalization (OR 9 [95% CI, 7-13]; P<0.001). Having an ACE (angiotensin-converting enzyme) inhibitor/angiotensin receptor blocker (ARB)/ARNI contraindication was associated with lower likelihood of ARNI prescription at discharge (OR, 0.11 [95% CI, 0.10-0.12]; P<0.001). Socioeconomic factors associated with lower likelihood of ARNI prescription included having no insurance (OR, 0.60 [95% CI, 0.50-0.72]; P<0.001) and living in a ZIP Code identified as distressed (OR, 0.81 [95% CI, 0.70-0.93]; P=0.010). The rate of ARNI prescription is increasing with time (OR, 2 [95% CI, 1.8-2.3]; P<0.001 for patients discharged in 2020 as opposed to 2017), but the disparity in prescription rates between distressed and prosperous communities appears to be increasing. CONCLUSIONS Multiple medical and socioeconomic factors contribute to low rates of ARNI prescription at hospital discharge. Potential targets for improving ARNI prescription rates include initiating ARNIs during hospitalization and aggressively addressing patients' access barriers with the support of inpatient social services and pharmacists.
Collapse
Affiliation(s)
| | | | - Ahmad Alamer
- Department of Clinical Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Ileana L Piña
- Dept of Medicine, Detroit Medical Center, Detroit, MI
| | | |
Collapse
|
45
|
Samuels JM, Carmichael H, Beaty L, Colborn K, Rothchild K, Schoen JA. Demographic factors as determinant of selection of sleeve gastrectomy or gastric bypass for surgical weight loss. Surg Endosc 2022; 36:8154-8163. [PMID: 35477806 DOI: 10.1007/s00464-022-09247-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 04/07/2022] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Use of sleeve gastrectomy (SG) for weight loss has grown exponentially; however, clear indications for SG versus Roux-en-Y gastric bypass (RNYGB) are lacking. Certain populations may be more likely to undergo SG due to its simpler technique and without clear clinical indications. We aim to examine underlying predictors of patients undergoing SG vs RNY across a single state. METHODS We queried the Colorado All Payers Claim Database for patients undergoing laparoscopic SG or RNY. Patient-level variables included patient demographics, comorbidities, distance traveled for surgery, and distressed communities index (DCI), a zip code-based measure of socioeconomic status. Hospital-level variables included annual bariatric surgery volume, academic status, and whether hospitals were a bariatric Center of Excellence. We performed mixed-effects logistic regression adjusting for demographics, insurance coverage, and comorbidities to compare odds of undergoing SG vs RNY, with a random effect for hospital. RESULTS 5,017 patients were included with 3,042 (60.6%) undergoing SG and 1,975 (39.4%) undergoing RNY. On multivariable analysis, patients with a high DCI were not more likely to undergo a SG (OR 1.18, CI 0.89-1.55, p = 0.25). However, patients who underwent surgery at hospitals serving the greatest proportion of those from highly distressed communities were significantly more likely to undergo SG (OR 4.22, CI 1.38-12.96, p = 0.01). Patients managed at Bariatric Centers of Excellence were less likely to undergo SG (OR 0.22, CI 0.07-0.62, p = 0.005). Patients with higher BMI, diabetes, or GERD were all more likely to undergo RNY. CONCLUSION While patients with high DCI were more likely to undergo SG on univariate analysis, these associations disappeared after addition of a hospital-level random effect, suggesting that disparities may be due access to surgeons or systems with preference for one procedure. However, hospitals serving a higher proportion of high-DCI patients are more likely to utilize SG.
Collapse
Affiliation(s)
- Jason M Samuels
- Department of Surgery, University of Colorado Anschutz, Aurora, CO, USA.
| | | | - Laurel Beaty
- Center for Innovative Design and Analysis, Colorado School of Public Health, Aurora, CO, USA
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz, Aurora, CO, USA
| | - Kevin Rothchild
- Department of Surgery, University of Colorado Anschutz, Aurora, CO, USA
| | - Jonathan A Schoen
- Department of Surgery, University of Colorado Anschutz, Aurora, CO, USA
| |
Collapse
|
46
|
Bullock-Palmer RP, Bravo-Jaimes K, Mamas MA, Grines CL. Socioeconomic Factors and their Impact on Access and Use of Coronary and Structural Interventions. Eur Cardiol 2022; 17:e19. [PMID: 36643068 PMCID: PMC9820075 DOI: 10.15420/ecr.2022.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 01/18/2023] Open
Abstract
In the past few decades, the accelerated improvement in technology has allowed the development of new and effective coronary and structural heart disease interventions. There has been inequitable patient access to these advanced therapies and significant disparities have affected patients from low socioeconomic positions. In the US, these disparities mostly affect women, black and hispanic communities who are overrepresented in low socioeconomic. Other adverse social determinants of health influenced by structural racism have also contributed to these disparities. In this article, we review the literature on disparities in access and use of coronary and structural interventions; delineate the possible reasons underlying these disparities; and highlight potential solutions at the government, healthcare system, community and individual levels.
Collapse
Affiliation(s)
| | - Katia Bravo-Jaimes
- Division of Cardiology, Department of Internal Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, University of CaliforniaLos Angeles, CA, US
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele UniversityKeele, UK
| | - Cindy L Grines
- Division of Cardiology, Department of Internal Medicine, Northside Cardiovascular Institute, Northside HospitalAtlanta, GA, US
| |
Collapse
|
47
|
Frankel WC, Sylvester CB, Asokan S, Ryan CT, Zea-Vera R, Zhang Q, Wall MJ, Preventza O, Coselli JS, Rosengart TK, Chatterjee S, Ghanta RK. Outcomes, Cost, and Readmission After Surgical Aortic or Mitral Valve Replacement at Safety-Net and Non-Safety-Net Hospitals. Ann Thorac Surg 2022; 114:703-709. [PMID: 35202596 PMCID: PMC9413024 DOI: 10.1016/j.athoracsur.2022.01.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/10/2022] [Accepted: 01/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Safety-net hospitals provide essential services to vulnerable patients with complex medical and socioeconomic circumstances. We hypothesized that matched patients at safety-net hospitals and non-safety-net hospitals would have comparable outcomes, costs, and readmission rates after isolated surgical aortic valve replacement (AVR) or mitral valve replacement (MVR). METHODS The National Readmissions Database was queried to identify patients who underwent isolated AVR (n = 109 744) or MVR (n = 31 475) from 2016 to 2018. Safety-net burden was defined as the percentage of patients who were uninsured or insured with Medicaid, with hospitals in the top quartile designated as safety-net hospitals. After propensity score matching, outcomes for AVR and MVR at safety-net hospitals vs non-safety-net hospitals were compared. RESULTS Overall, 17 925 AVRs (16%) and 5516 MVRs (18%) were performed at safety-net hospitals, and these patients had higher comorbidity rates, had lower socioeconomic status, and more frequently required urgent surgery. Observed inhospital mortality was similar between safety-net hospitals and non-safety-net hospitals (AVR 2.2% vs 2.1%, P = .4; MVR 4.8% vs 4.3%, P = .1). After matching, rates of inhospital mortality, major morbidity, and readmission were similar; however, safety-net hospitals had longer length of stay after AVR (7 vs 6 days, P = .001) and higher total cost after AVR ($49 015 vs $42 473, P < .001) and MVR ($59 253 vs $52 392, P < .001). CONCLUSIONS Isolated surgical AVR and MVR are both performed at safety-net hospitals with outcomes comparable to those at non-safety-net hospitals, supporting efforts to expand access to these procedures for underserved populations. Investment in care coordination resources to reduce length of stay and curtail cost at safety-net hospitals is warranted.
Collapse
Affiliation(s)
- William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Christopher B Sylvester
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Medical Scientist Training Program, Baylor College of Medicine, Houston, Texas; Department of Bioengineering, Rice University, Houston, Texas
| | - Sainath Asokan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Christopher T Ryan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Rodrigo Zea-Vera
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Qianzi Zhang
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Mathew J Wall
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Todd K Rosengart
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Ravi K Ghanta
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas.
| |
Collapse
|
48
|
Development of a Machine Learning Model to Predict Outcomes and Cost after Cardiac Surgery. Ann Thorac Surg 2022; 115:1533-1542. [DOI: 10.1016/j.athoracsur.2022.06.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/25/2022] [Accepted: 06/18/2022] [Indexed: 11/23/2022]
|
49
|
Does Adding a Measure of Social Vulnerability to a Surgical Risk Calculator Improve Its Performance? J Am Coll Surg 2022; 234:1137-1146. [PMID: 35703812 DOI: 10.1097/xcs.0000000000000187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Emerging literature suggests that measures of social vulnerability should be incorporated into surgical risk calculators. The Social Vulnerability Index (SVI) is a measure designed by the CDC that encompasses 15 socioeconomic and demographic variables at the census tract level. We examined whether adding the SVI into a parsimonious surgical risk calculator would improve model performance. STUDY DESIGN The eight-variable Surgical Risk Preoperative Assessment System (SURPAS), developed using the entire American College of Surgeons (ACS) NSQIP database, was applied to local ACS-NSQIP data from 2012 to 2018 to predict 12 postoperative outcomes. Patient addresses were geocoded and used to estimate the SVI, which was then added to the model as a ninth predictor variable. Brier scores and c-indices were compared for the models with and without the SVI. RESULTS The analysis included 31,222 patients from five hospitals. Brier scores were identical for eight outcomes and improved by only one to two points in the fourth decimal place for four outcomes with addition of the SVI. Similarly, c-indices were not significantly different (p values ranged from 0.15 to 0.96). Of note, the SVI was associated with most of the eight SURPAS predictor variables, suggesting that SURPAS may already indirectly capture this important risk factor. CONCLUSION The eight-variable SURPAS prediction model was not significantly improved by adding the SVI, showing that this parsimonious tool functions well without including a measure of social vulnerability.
Collapse
|
50
|
Strobel RJ, Charles EJ, Mehaffey JH, Hawkins RB, Quader MA, Rich JB, Speir AM, Ailawadi G. Effect of Socioeconomic Distress on Risk-Adjusted Mortality After Valve Surgery for Infective Endocarditis. Semin Thorac Cardiovasc Surg 2022; 35:497-507. [PMID: 35588950 DOI: 10.1053/j.semtcvs.2022.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/11/2022]
Abstract
Infective endocarditis affects patients of all socioeconomic status. We hypothesized that the Distressed Communities Index (DCI), a comprehensive assessment of socioeconomic status, would be associated with risk-adjusted mortality for patients with endocarditis. All patients with endocarditis (2001-2017) in a regional Society of Thoracic Surgeons database were analyzed. DCI scores range from 0 (no socioeconomic distress) to 100 (severe distress) and account for unemployment, poverty rate, median income, housing vacancies, education level, and business growth by zip code. The most distressed patients (top quartile, DCI > 75) were compared to all other patients. Hierarchical logistic regression modeled the association between DCI and mortality. A total of 2,075 patients were included (median age 55 years, 65.2% urgent/emergent cases, 42.7% self-pay). Major morbidity was 32.8% and operative mortality was 9.5%. Tricuspid/pulmonic valve endocarditis was present in 12.5% of cases, with significantly worse mean DCI compared to patients with left-sided endocarditis (median 55.3, IQR 20.3-77.6 vs 46.8, IQR 17.3-74.2, P = 0.016). High socioeconomic distress (DCI > 75) was associated with higher rates of major morbidity, operative mortality, increased length of stay, and higher total cost. After risk-adjustment, DCI was independently predictive of higher operative mortality for patients with endocarditis (OR 1.24 per DCI quartile increase, 95% CI 1.06-1.45, P < 0.001). Increasing DCI, an indicator of poor socioeconomic status, independently predicts increased risk-adjusted mortality and resource utilization for patients with endocarditis. Accounting for socioeconomic status allows for more accurate risk prediction and resource allocation for patients with endocarditis.
Collapse
Affiliation(s)
- Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia; Virginia Cardiac Services Quality Initiative, Virginia Beach, Virginia
| | - Eric J Charles
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia; Virginia Cardiac Services Quality Initiative, Virginia Beach, Virginia
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia; Virginia Cardiac Services Quality Initiative, Virginia Beach, Virginia
| | - Robert B Hawkins
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Mohammed A Quader
- Virginia Cardiac Services Quality Initiative, Virginia Beach, Virginia; Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Jeffrey B Rich
- Virginia Cardiac Services Quality Initiative, Virginia Beach, Virginia; Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alan M Speir
- Virginia Cardiac Services Quality Initiative, Virginia Beach, Virginia; Department of Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Gorav Ailawadi
- Virginia Cardiac Services Quality Initiative, Virginia Beach, Virginia; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
| |
Collapse
|