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Preventza O, Henry J, Khan L, Cornwell LD, Simpson KH, Chatterjee S, Amarasekara HS, Moon MR, Coselli JS. Unplanned readmissions, community socioeconomic factors, and their effects on long-term survival after complex thoracic aortic surgery. J Thorac Cardiovasc Surg 2025; 169:26-35.e2. [PMID: 38295953 DOI: 10.1016/j.jtcvs.2024.01.035] [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: 05/04/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE We evaluated community socioeconomic factors in patients who had unplanned readmission after undergoing proximal aortic surgery (ascending aorta, aortic root, or arch). METHODS Unplanned readmissions for any reason within 60 days of the index procedure were reviewed by race, acuity at presentation, and gender. We also evaluated 3 community socioeconomic factors: poverty, household income, and education. Kaplan-Meier survival curves were used to assess long-term survival differences by group (race, acuity, and gender). RESULTS Among 2339 patients who underwent proximal aortic surgery during the 20-year study period and were discharged alive, our team identified 146 (6.2%) unplanned readmissions. Compared with White patients, Black patients lived in areas characterized by more widespread poverty (20.8% vs 11.1%; P = .0003), lower income ($42,776 vs $65,193; P = .0007), and fewer residents with a high school diploma (73.7% vs 90.1%; P < .0001). Compared with patients whose index operation was elective, patients who had urgent or emergency index procedures lived in areas with lower income ($54,425 vs $64,846; P = .01) and fewer residents with a high school diploma (81.1% vs 89.2%; P = .005). Community socioeconomic factors did not differ by gender. Four- and 6-year survival estimates were 63.1% and 63.1% for Black patients versus 89.1% and 83.0% for White patients (P = .0009). No significant differences by acuity or gender were found. CONCLUSIONS Among readmitted patients, Black patients and patients who had emergency surgery had less favorable community socioeconomic factors and poorer long-term survival. Earlier and more frequent follow-up in these patients should be considered. Developing off-campus clinics and specific postdischarge measures targeting these patients is important.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, University of Virginia Health, Charlottesville, Va; 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.
| | - Jaymie Henry
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Lubna Khan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Katherine H Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, 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
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 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
| | - 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
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Crook S, Dragan K, Woo JL, Neidell M, Nash KA, Jiang P, Zhang Y, Sanchez CM, Cook S, Hannan EL, Newburger JW, Jacobs ML, Petit CJ, Goldstone A, Vincent R, Walsh-Spoonhower K, Mosca R, Kumar TKS, Devejian N, Biddix B, Alfieris GM, Swartz MF, Meyer D, Paul EA, Billings J, Anderson BR. Impact of Social Determinants of Health on Predictive Models for Outcomes After Congenital Heart Surgery. J Am Coll Cardiol 2024; 83:2440-2454. [PMID: 38866447 DOI: 10.1016/j.jacc.2024.03.430] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/13/2024] [Accepted: 03/28/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Despite documented associations between social determinants of health and outcomes post-congenital heart surgery, clinical risk models typically exclude these factors. OBJECTIVES The study sought to characterize associations between social determinants and operative and longitudinal mortality as well as assess impacts on risk model performance. METHODS Demographic and clinical data were obtained for all congenital heart surgeries (2006-2021) from locally held Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources Society of Thoracic Surgeons Congenital Heart Surgery Database data. Neighborhood-level American Community Survey and composite sociodemographic measures were linked by zip code. Model prediction, discrimination, and impact on quality assessment were assessed before and after inclusion of social determinants in models based on the 2020 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model. RESULTS Of 14,173 total index operations across New York State, 12,321 cases, representing 10,271 patients at 8 centers, had zip codes for linkage. A total of 327 (2.7%) patients died in the hospital or before 30 days, and 314 children died by December 31, 2021 (total n = 641; 6.2%). Multiple measures of social determinants of health explained as much or more variability in operative and longitudinal mortality than clinical comorbidities or prior cardiac surgery. Inclusion of social determinants minimally improved models' predictive performance (operative: 0.834-0.844; longitudinal 0.808-0.811), but significantly improved model discrimination; 10.0% more survivors and 4.8% more mortalities were appropriately risk classified with inclusion. Wide variation in reclassification was observed by site, resulting in changes in the center performance classification category for 2 of 8 centers. CONCLUSIONS Although indiscriminate inclusion of social determinants in clinical risk modeling can conceal inequities, thoughtful consideration can help centers understand their performance across populations and guide efforts to improve health equity.
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Affiliation(s)
- Sarah Crook
- Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Kacie Dragan
- New York University, Wagner Graduate School of Public Service, New York, New York, USA; Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts, USA
| | - Joyce L Woo
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew Neidell
- Department of Health Policy and Management; Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Katherine A Nash
- Division of Pediatric Critical Care and Hospital Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Pengfei Jiang
- Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yun Zhang
- Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Chantal M Sanchez
- Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Stephen Cook
- Department of Pediatrics, Internal Medicine, and Center for Community Health, University of Rochester Medical Center, Rochester, New York, USA; New York State Department of Health; Offices of Health Insurance Programs, Albany, New York, USA
| | - Edward L Hannan
- University at Albany School of Public Health, Rensselaer, New York, USA
| | - Jane W Newburger
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Marshall L Jacobs
- Division of Cardiac Surgery; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher J Petit
- Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Andrew Goldstone
- Department of Cardiothoracic Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center & Weill Cornell Medical Center, New York, New York, USA
| | - Robert Vincent
- Division of Pediatric Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | | | - Ralph Mosca
- Department of Cardiothoracic Surgery, New York University, New York, New York, USA
| | - T K Susheel Kumar
- Department of Cardiothoracic Surgery, New York University, New York, New York, USA
| | - Neil Devejian
- Division of Pediatric Cardiothoracic Surgery, Albany Medical College, Albany, New York, USA
| | - Ben Biddix
- Division of Pediatric Cardiology, Albany Medical College, Albany, New York, USA
| | - George M Alfieris
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA; Department of Surgery, State University of New York Upstate Medical Center, Syracuse, New York, USA
| | - Michael F Swartz
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - David Meyer
- Departments of Cardiothoracic Surgery and Pediatrics, Hofstra-Northwell School of Medicine, Uniondale, New York, USA
| | - Erin A Paul
- Division of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Billings
- New York University, Wagner Graduate School of Public Service, New York, New York, USA
| | - Brett R Anderson
- Center for Child Health Services Research, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Division of Pediatric Cardiology; Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA; Division of Pediatric Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Schneider K, de Loizaga S, Beck AF, Morales DLS, Seo J, Divanovic A. Socioeconomic Influences on Outcomes Following Congenital Heart Disease Surgery. Pediatr Cardiol 2024; 45:1072-1078. [PMID: 38472658 PMCID: PMC11056327 DOI: 10.1007/s00246-024-03451-7] [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: 11/09/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024]
Abstract
Associations between social determinants of health (SDOH) and adverse outcomes for children with congenital heart disease (CHD) are starting to be recognized; however, such links remain understudied. We examined the relationship between community-level material deprivation on mortality, readmission, and length of stay (LOS) for children undergoing surgery for CHD. We performed a retrospective cohort study of patients who underwent cardiac surgery at our institution from 2015 to 2018. A community-level deprivation index (DI), a marker of community material deprivation, was generated to contextualize the lived experience of children with CHD. Generalized mixed-effects models were used to assess links between the DI and outcomes of mortality, readmission, and LOS following cardiac surgery. The DI and components were scaled to provide mean differences for a one standard deviation (SD) increase in deprivation. We identified 1,187 unique patients with surgical admissions. The median LOS was 11 days, with an overall mortality rate of 4.6% and readmission rate of 7.6%. The DI ranged from 0.08 to 0.85 with a mean of 0.37 (SD 0.12). The DI was associated with increased LOS for patients with more complex heart disease (STAT 3, 4, and 5), which persisted after adjusting for factors that could prolong LOS (all p < 0.05). The DI approached but did not meet a significant association with mortality (p = 0.0528); it was not associated with readmission (p = 0.36). Community-level deprivation is associated with increased LOS for patients undergoing cardiac surgery. Future work to identify the specific health-related social needs contributing to LOS and identify targets for intervention is needed.
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Affiliation(s)
- Kristin Schneider
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Sarah de Loizaga
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew F Beck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Divisions of General & Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - JangDong Seo
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
| | - Allison Divanovic
- The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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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: 1] [Impact Index Per Article: 1.0] [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.
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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
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5
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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.
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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.
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Tjoeng YL, Werho DK, Algaze C, Nawathe P, Benjamin S, Schumacher KR, Chan T. Development of an Equity, Diversity, and Inclusion Committee for a collaborative quality improvement network: Pediatric Cardiac Critical Care Consortium (PC 4) Equity, Diversity and Inclusion (EDI) Committee: white paper 2023. Cardiol Young 2024; 34:563-569. [PMID: 37577942 DOI: 10.1017/s1047951123002950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Racial and ethnic disparities are well described in paediatric cardiac critical care outcomes. However, understanding the mechanisms behind these outcomes and implementing interventions to reduce and eliminate disparities remain a gap in the field of paediatric cardiac critical care. The Pediatric Cardiac Critical Care Consortium (PC4) established the Equity, Diversity, and Inclusion (EDI) Committee in 2020 to promote an equity lens to its aim of improving paediatric cardiac critical care quality and outcomes across North America. The PC4 EDI Committee is working to increase research, quality improvement, and programming efforts to work towards health equity. It also aims to promote health equity considerations in PC4 research. In addition to a focus on patient outcomes and research, the committee aims to increase the inclusion of Black, Indigenous, and People of Color (BIPOC) members in the PC4 collaborative. The following manuscript outlines the development, structure, and aims of the PC4 EDI Committee and describes an analysis of social determinants of health in published PC4 research.
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Affiliation(s)
- Yuen Lie Tjoeng
- Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA, USA
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - David K Werho
- Division of Pediatric Cardiology, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA
| | - Claudia Algaze
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Pooja Nawathe
- Division of Pediatric Critical Care, Guerin Children's, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Solange Benjamin
- Division of Pediatric Cardiology, Levine Children's Hospital, Charlotte, NC, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, C. S. Mott Children's Hospital, University of Michigan. Ann Arbor, MI, USA
| | - Titus Chan
- Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA, USA
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
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7
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Preventza O, Akpan-Smart E, Simpson KK, Cornwell LD, Amarasekara H, Green SY, Chatterjee S, LeMaire SA, Coselli JS. The intersection of community socioeconomic factors with gender on outcomes after thoracic aortic surgery. J Thorac Cardiovasc Surg 2023; 166:1572-1582.e10. [PMID: 36396474 DOI: 10.1016/j.jtcvs.2022.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/23/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We evaluated the relationship among community socioeconomic factors (poverty, income, and education), gender, and outcomes in patients who underwent ascending aortic, root, and arch surgery. METHODS For 2634 consecutive patients, we associated patients' ZIP codes with community socioeconomic factors. The composite adverse outcome comprised death, persistent neurological injury, and renal failure necessitating dialysis at discharge. Multivariable analysis and Kaplan-Meier survival curves were used. Men and women from the full cohort and from the elective patients were propensity matched. RESULTS Median follow-up was 3.6 years (interquartile range, 1.2-9.3). Men lived in areas characterized by less poverty (P = .03), higher household income (P = .01), and more education (P = .02) than women; likewise, in the elective cohort, all community socioeconomic factors favored men (P ≤ .009). Female gender predicted composite adverse outcome (P = .006). In the propensity-matched women and men (820 pairs), the composite adverse outcome rates were 14.2% and 11%, respectively (P = .06). In 583 propensity-matched pairs of elective patients, men had less composite adverse outcome (P = .02), operative mortality (P = .04), and renal (P = .02) and respiratory failure (P = .0006). The 5- and 10-year survivals for these men and women were 74.2% versus 71.4% and 50.2% versus 48.2%, respectively (P = .06). All community socioeconomic factors in both propensity-matched groups nonsignificantly favored men. CONCLUSIONS This study is among the first to examine the association among community socioeconomic factors, gender, and outcomes in patients who undergo proximal aortic surgery. Female gender predicted a composite adverse outcome. In the elective patients, most adverse outcomes were significantly less in men. In the propensity-matched patients, all community socioeconomic factors favored men, although not significantly. Larger studies with patient-level socioeconomic information are needed.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
| | | | - Katherine K Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Hiruni Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, 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; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
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8
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Lobdell KW, Crotwell S, Watts LT, LeNoir B, Frederick J, Skipper ER, Russell GB, Habib R, Maxey T, Rose GA. Remote monitoring following adult cardiac surgery: A paradigm shift? JTCVS OPEN 2023; 15:300-310. [PMID: 37808027 PMCID: PMC10556943 DOI: 10.1016/j.xjon.2023.07.003] [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: 02/24/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 10/10/2023]
Abstract
Background The Perfect Care (PC) initiative engages, educates, and enrolls adult cardiac surgery patients into a transformational program that includes an app for appointment scheduling, tracking biometric data and patient-reported outcomes, audiovisual visits, and messaging, paired with a digital health kit (consisting of a fitness tracker, scale, and sphygmomanometer). PC aims to reduce postoperative length of stay (LOS) as well as 30-day readmission and mortality. Methods This was a retrospective review of patients who underwent coronary artery bypass (CAB), valve, or combined CAB and valve procedures at either of the 2 participating hospitals between April 2018 and March 2022. Patients who participated in the PC quality improvement initiative were compared to propensity-matched controls (1:1 matching). The evaluation focused on postoperative LOS and a novel composite measure comprising 30-day readmission and mortality. Results Remote monitoring (PC) was associated with a shorter postoperative LOS, lower combined rate of 30-day readmission and mortality, and less variation compared to matched non-PC controls. Conclusions Integrated improvements in postoperative remote monitoring of adult cardiac surgery patients may reduce time in the hospital and post-acute care facilities. Future prioritized efforts include the development of additional, personalized biometric monitoring devices, use of biometric data to augment risk assessment, and investigation of the value of remote monitoring on various patient risk profiles to address potential disparities in care.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Thomas Maxey
- Sanger Heart & Vascular Institute, Charlotte, NC
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9
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Development of a Novel Society of Thoracic Surgeons Adult Congenital Mortality Risk Model. Ann Thorac Surg 2023:S0003-4975(23)00032-2. [PMID: 36696938 DOI: 10.1016/j.athoracsur.2023.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/29/2022] [Accepted: 01/08/2023] [Indexed: 01/23/2023]
Abstract
BACKGROUND Operative mortality risk models for adults with congenital heart disease (ACHD) undergoing cardiac operations are essential, given the growing population of these patients, yet they are currently unavailable. Existing adult Society of Thoracic Surgeons (STS) models exclude congenital procedures, whereas existing congenital models exclude operations for acquired disease. We aimed to develop an STS mortality risk model for ACHD patients undergoing cardiac operations. METHODS Leveraging a comprehensive list of diagnostic and procedure codes, ACHD patients who underwent cardiac operations were identified from the STS Adult Cardiac Surgery Database (versions: v2.73, v2.81, and v2.9) between 2011 and 2019. The model was developed and validated in the ACHD population using a 60/40 development/validation split. Univariate analyses and clinical expertise informed the addition of ACHD-relevant procedure and diagnosis variables to existing STS adult risk model variables. Model performance was assessed overall and in 38 subgroups based on patient demographics, procedures, and diagnoses. RESULTS Forty-seven procedure and diagnosis variables relevant to ACHD were added to existing STS adult risk model variables. The derived ACHD model for operative mortality was well calibrated within demographic, procedural, and diagnosis subgroups and the overall ACHD population, and discrimination in the validation cohort was excellent (C statistic, 0.815) compared with the model using only existing STS adult risk model variables (C statistic, 0.79; P < .0001). CONCLUSIONS A novel, high-performing STS ACHD mortality risk model has been developed on the basis of contemporary patient data. The ACHD risk model represents an important expansion of the STS portfolio. Implementation with an online risk calculator is planned.
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Editor's Choice: The Biggest Challenges in Cardiothoracic Surgery. Ann Thorac Surg 2022; 114:1099-1103. [PMID: 36168192 DOI: 10.1016/j.athoracsur.2022.08.021] [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: 08/22/2022] [Indexed: 12/31/2022]
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11
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Chikwe J. Editor's Choice: Strength in Numbers. Ann Thorac Surg 2022; 113:1401-1404. [PMID: 35459448 DOI: 10.1016/j.athoracsur.2022.03.007] [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: 03/15/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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12
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Shahian DM, Badhwar V, O'Brien SM, Habib RH, Han J, McDonald DE, Antman MS, Higgins RSD, Preventza O, Estrera AL, Calhoon JH, Grondin SC, Cooke DT. Social Risk Factors in Society of Thoracic Surgeons Risk Models Part 2: Review of Empirical Studies in Cardiac Surgery and Risk Model Recommendations. Ann Thorac Surg 2022; 113:1718-1729. [PMID: 34998735 DOI: 10.1016/j.athoracsur.2021.11.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/28/2021] [Accepted: 11/02/2021] [Indexed: 11/17/2022]
Affiliation(s)
- David M Shahian
- Division of Cardiac Surgery, Department of Surgery, and Center for Quality and Safety, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Jane Han
- The Society of Thoracic Surgeons, Chicago, Illinois
| | | | | | - Robert S D Higgins
- Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, Maryland
| | - Ourania Preventza
- Baylor College of Medicine, Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, Texas
| | - Anthony L Estrera
- McGovern Medical School at UTHealth, Memorial Hermann Heart and Vascular Institute, Houston, Texas
| | - John H Calhoon
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Sean C Grondin
- Cumming School of Medicine, University of Calgary, and Foothills Medical Centre, Calgary, Alberta, Canada
| | - David T Cooke
- Division of General Thoracic Surgery, UC Davis Health, Sacramento, California
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