Gender Disparities in Disease-specific Health Status in Postoperative Patients with Peripheral Arterial Disease

Gender, Racial and Ethnic Disparities in Iatrogenic Vascular Injuries among the Ten Most Frequent Surgical Procedures in the United States

OBJECTIVE

Iatrogenic vascular injuries (IaVI's) appear to be increasing, with disparate prevalence across gender, race and ethnicity. We aim to assess the risk of IaVI's across these characteristics.

METHODS

Using the Nationwide Inpatient Sample for the years 2008 to 2015, we identified rates of IaVI's among the top ten most frequently performed inpatient procedures in the United States. Joint point regression was employed to examine the trends in the rates of IaVI's. We also calculated the adjusted odds ratios for IaVI's using survey logistic regression.

RESULTS

During the eight-year study period, a total of 29,877,180 procedures were performed (33.6% hip replacement, 14% knee arthroplasty, 11.2% cholecystectomy, 10.3% spinal fusion, 8.9% lysis of adhesions, 8% colorectal resection, 7.9% partial bone excision, 5% appendectomy, 0.6% percutaneous coronary angioplasty, 0.6% laminectomy). A total of 194,031 (0.65%) IaVI's were associated with these procedures. The incidence of IaVI's increased over time with an average annual percentage change (AAPC) of 4.2% (95% CI: 3.1, 5.4; P < 0.01). More females (105,747; 54.5%) than males (88,284; 45.5%) suffered IaVI's during their hospital admission (P < 0.01). Patients 70 years of age and older had the highest incidence of IaVI's (12,244,082; 34.3%; P ≤ 0.01). Among the ten index procedures, Non-Hispanic (NH) Whites underwent the highest proportion of procedures (14.1 procedures/100 hospitalizations; P < 0.01) and cholecystectomy was associated with the highest rate of IaVI's (19.4 per 1000 hospitalizations, P ≤ 0.01). Overall, patients from the lowest income quartile were least likely to suffer IaVI's (0.83 95% CI 0.79-0.88, P < 0.01) compared to the highest income quartile. All form of healthcare coverage increased the odds of IaVI's: Medicaid (1.07 95% CI 1.07-1.13, P < 0.01); Private insurance (1.35 95% CI 1.3-1.39, P < 0.01); Self-pay or no charge (1.45 95% CI 1.38-1.52, P < 0.01). IaVI's increased the odds of in-hospital mortality in all groups (1.25 95% CI 1.14-1.35, P < 0.01) and more pronounced in NH-Blacks (1.51 95% CI 1.15-1.99, P < 0.01). In the overall cohort, urban teaching hospitals observed the highest odds of in-hospital mortality (1.11 95% CI 1.07-1.15, P < 0.01).

CONCLUSION

Between 2008 to 2015, IaVI's rates for the top ten most frequently performed inpatient procedures increased by 33.6% (4.2% annually; P < 0.01). The elderly, females, and Hispanics more frequently had hospitalizations complicated by IaVI's. Overall, IaVI's independently increased the adjusted odds of mortality by 25%. IaVI's were most fatal among Blacks, about 50% elevated risk of death compared to NH-Whites. These benchmarks will be critical to future efforts to reduce IaVI, and associated healthcare disparities.

Relationship Between Depressive Symptoms and Health Status in Peripheral Artery Disease: Role of Sex Differences

Background

The association of depressive symptoms with health status in peripheral artery disease (PAD) is understudied. No reports of differential impact on women have been described.

Methods and Results

The PORTRAIT (Patient‐Centered Outcomes Related to Treatment Practices in Peripheral Artery Disease Investigating Trajectories) registry enrolled 1243 patients from vascular specialty clinics with new or worsening PAD symptoms. Depressive symptoms were assessed at baseline and 3 months using the 8‐Item Patient Health Questionnaire (score ≥10 indicating clinically relevant depressive symptoms). Disease‐specific and generic health status were measured by Peripheral Artery Questionnaire and EQ‐5D Visual Analogue Scale at baseline and 3, 6, and 12 months. An adjusted general linear model for repeated measures was constructed for baseline and 3‐, 6‐, and 12‐month health status outcomes by depressive symptoms at baseline. Differences by sex were tested with interaction effects. The mean age was 67.6±9.4 years with 38% (n=470) women. More women than men (21.1% versus 12.9%; P<0.001) presented with severe depressive symptoms. In the adjusted model, patients with depressive symptoms had worse health status at each time point (all P<0.0001). Results were similar for EQ‐5D Visual Analogue Scale scores. The magnitude in 1‐year change in health status scores did not differ by sex. Depressive symptoms explained 19% of the association between sex differences in 1‐year Peripheral Artery Questionnaire summary scores.

Conclusions

Women with PAD have a high burden of depressive symptoms. Depressive symptoms were associated with a strikingly worse disease‐specific health status recovery path over the year following PAD diagnosis in men and women. Developing and testing interventions to address depressive symptoms in PAD are urgently needed.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01419080.

Assessment of the Quality of Nursing Care of Postoperative Pain in Patients Undergoing Vascular Procedures

PURPOSE

The purpose of this study was to evaluate the quality of nursing care of postoperative pain management in patients who underwent vascular procedures.

DESIGN

A survey using patient questionnaires.

METHODS

The sample was composed of 100 patients, aged 52 to 86 years, admitted to the Clinic of Cardiac and Vascular Surgery, University Clinical Centre, Gdansk, Poland. The study included the use of an interview questionnaire, that is,.e. a standardized research tool-the Strategic and Clinical Quality Indicators in Postoperative Pain Management scale and a questionnaire designed to record sociodemographic characteristics.

FINDINGS

Analysis of the data indicated that the most numerous group of patients were men (80%). The total mean score obtained with the Strategic and Clinical Quality Indicators in Postoperative Pain Management scale was 59.2 points (range, 14 to 70) meaning that the high quality of nursing care in each area was not provided. The results of this research revealed areas for improvement in postoperative pain management on the subscales: communication (12.9 points), action (15.3 points), and environment (12.5 points).

CONCLUSIONS

The overall level of quality of nursing care in terms of postoperative pain management as reported by patients after vascular procedures was not fully satisfying, and nursing care should improve. This indicates the need to educate nurses in postoperative pain management, its monitoring and prophylaxis, and communication techniques with patients. Our study indicates that gender, place of residence, education level, and satisfaction with pain management influence the assessment of the quality of care.

Peripheral Arterial Disease in Women: an Overview of Risk Factor Profile, Clinical Features, and Outcomes

Purpose of Review

Peripheral arterial disease (PAD) is the third most common manifestation of cardiovascular disease (CVD), following coronary artery disease (CAD) and stroke. PAD remains underdiagnosed and under-treated in women.

Recent Findings

Women with PAD experience more atypical symptoms and poorer overall health status. The prevalence of PAD in women increases with age, such that more women than men have PAD after the age of 40 years. There is under-representation of PAD patients in clinical trials in general and women in particular. In this article, we address the lack of women participants in PAD trials. We then present a comprehensive overview of the epidemiology/risk factor profile, clinical features, treatment, and outcomes.

Summary

PAD is prevalent in women and its global burden is on the rise despite a decline in global age-standardized death rate from CVD. The importance of this issue has been underlined by the American Heart Association’s (AHA) “Call to Action” scientific statement on PAD in women. Large-scale campaigns are needed to increase awareness among physicians and the general public. Furthermore, effective treatment strategies must be implemented.

Impact of Gender Disparities on Short-Term and Long-Term Patient Reported Outcomes and Satisfaction Measures After Elective Lumbar Spine Surgery: A Single Institutional Study of 384 Patients

BACKGROUND

There is a paucity of data determining the impact that gender disparities have on spine outcomes, particularly perception of health and satisfaction. The aim of this study was to determine whether there is a difference in 3-month and 1-year patient-reported outcomes and satisfaction after elective lumbar spine surgery.

METHODS

This was a retrospectively analyzed study from a maintained prospective database of 384 patients who underwent elective lumbar spine surgery. Patients were categorized by gender (men, n = 199; women, n = 185). Patient-reported outcome instruments (Oswestry disability index, visual analogue scale-back pain/leg pain, EuroQol visual analogue scale, and EuroQol 5 dimensions questionnaire) were completed before surgery, then at 3 and 12 months after surgery along with patient satisfaction measures.

RESULTS

Baseline patient demographics, comorbidities, and operative variables were similar between both cohorts. The female cohort had a slightly longer hospital stay than male cohort (P = 0.007). Baseline patient-reported outcome measures were different between both cohorts, with female patients having more Oswestry disability index (23.8 vs. 20.4; P ≤ 0.0001) and visual analogue scale-back pain (7.2 vs. 6.2; P = 0.0004), and a lower EuroQol 5 dimensions questionnaire (0.34 vs. 0.49; P = 0.0001) compared with the male cohort. At 1-year follow-up, the male cohort had a significantly more mean change in visual analogue scale-leg pain (-3.9 vs. -2.8; P = 0.04) and trended to have more mean change in visual analogue scale-back pain (-3.4 vs. -2.5; P = 0.06) and EuroQol visual analogue scale (8.6 vs. 3.4; P = 0.054) scores compared with the female cohort. At 1-year a significantly more portion in the male cohort found that surgery met their expectations compared with the female cohort (65.0% vs. 49.5%; P = 0.02).

CONCLUSIONS

Our study suggests that there may be differences in perception of health, pain, and disability between men and women at baseline, short-term and long-term follow-up that may influence overall patient satisfaction.

One year health status benefits following treatment for new onset or exacerbation of peripheral arterial disease symptoms: the importance of patients' baseline health status

OBJECTIVE/BACKGROUND

Limited information is available on expected health status gains following invasive treatment in peripheral arterial disease (PAD). One year health status outcomes following invasive treatment for PAD were compared, and whether pre-procedural health status was indicative of 1 year health status gains was evaluated.

METHODS

Pre-procedural and 1 year health status (Short Form-12, Physical Component Score [PCS]) was prospectively assessed in a cohort of 474 patients, enrolled from 2 Dutch vascular clinics (March 2006-August 2011), with new or exacerbation of PAD symptoms. One year treatment strategy (invasive vs. non-invasive) and clinical information was abstracted. Quartiles of baseline health status scores and mean 1 year health status change scores were compared by invasive treatment for PAD. The numbers needed to treat (NNT) to obtain clinically relevant changes in 1 year health status were calculated. A propensity weight adjusted linear regression analysis was constructed to predict 1 year PCS scores.

RESULTS

Invasive treatment was performed in 39% of patients. Patients with baseline health status scores in the lowest quartile undergoing invasive treatment had the greatest improvement (mean invasive 11.3 ± 10.3 vs. mean non-invasive 5.3 ± 8.5 [p = .001, NNT = 3]), whereas those in the highest quartile improved less (.8 ± 6.3 vs. -3.0 ± 8.2 [p = .025, NNT = 90]). Undergoing invasive treatment (p < .0001) and lower baseline health status scores (p < .0001) were independently associated with greater 1 year health status gains.

CONCLUSION

Substantial improvements were found in patients presenting with lower pre-procedural health status scores, whereas patients with higher starting health status levels had less to gain by an invasive strategy.

The persistence of gender and racial disparities in vascular lower extremity amputation: an examination of HCUP-NIS data (2002-2011)

The purpose of this study was to examine trends in racial and gender disparities in the severity of lower extremity amputation among individuals with peripheral artery disease (PAD) over the period of a decade (2002-2011). This is a longitudinal secondary analysis of data from the Healthcare Utilization Project Nationwide Inpatient Survey (HCUP-NIS) for the years 2002-2011. Level of amputation was determined from ICD-9-CM procedure and coded as either transfemoral (TF) or transtibial (TT). The main predictors were gender and race; covariates including age, race, income, insurance status and presence of vascular disease were incorporated as control variables in regression analysis. A total 121,587 cases of non-traumatic dysvascular amputations were identified. Female gender (odds ratio (OR) 1.35; 95% confidence interval (CI) 1.32, 1.39) and black race (OR 1.17; 95% CI 1.12, 1.23) are both significantly associated with increased odds for receiving TF amputation with no change in these odds over the decade of study. Other covariates with significant associations with TF amputation level include increased age (OR 1.03; 95% CI 0.99, 1.09), low income (OR 1.21; 95% CI 1.15, 1.27), Medicaid insurance (OR 1.36; 95% CI 1.29, 1.44), Medicare insurance (OR 1.27; 95% CI 1.21, 1.32), and cerebrovascular disease (OR 2.12; 95% CI 2.03, 2.23). In conclusion, although overall rates of amputation have decreased, disparities in level of amputation related to female gender and black race have not significantly changed over time. Higher-level amputation has significant consequences from a quality-of-life, medical and economic perspective.

Gender differences in health status and adverse outcomes among patients with peripheral arterial disease

BACKGROUND

Few studies have examined gender differences in health status and cardiovascular outcomes in patients with peripheral artery disease (PAD). This study assessed (1) self-reported health status at PAD diagnosis and 12-months later, and explored (2) whether outcomes in women with PAD differ with regard to long-term major adverse events.

METHODS AND RESULTS

A total of 816 patients (285 women) with PAD were enrolled from 2 vascular clinics in the Netherlands. Baseline clinical data and subsequent adverse events were recorded and patients completed the Short Form-12 (SF-12, Physical Component Score [PCS] and Mental Component Score [MCS]) upon PAD diagnosis and 12-months later. Women had similar ages and clinical characteristics, but poorer socio-economic status and more depressive symptoms at initial diagnosis, as compared with men. Women also had poorer physical (PCS: 37±10 versus 40±10, P=0.004) and mental (

MCS

47±12 versus 49±11, P=0.005) health status at the time of presentation. At 12-months, women still reported a poorer overall PCS score (41±12 versus 46±11, P=0.006) and MCS score (42±14 versus 49±12, P=0.002). Female gender was an independent determinant of a poorer baseline and 12-month PCS and MCS scores. However, there were no significant differences by gender on either mortality (unadjusted hazard ratio [HR]=0.93, 95% CI 0.60;1.44, P=0.74) or major adverse events (unadjusted HR=0.90, 95% CI 0.63;1.29, P=0.57), after a median follow-up of 3.2 years.

CONCLUSIONS

Women's physical and mental health status is compromised both at initial PAD diagnosis and at 12-month follow-up, despite experiencing a similar magnitude of change in their health scores throughout the first 12-months after diagnosis.