Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review

Diversity presentations at cardiothoracic surgery meetings: Opportunity to align our actions with our values

OBJECTIVE

Substantial efforts have been directed toward identifying and addressing cardiothoracic surgical disparities in both patient care and our workforce. We aimed to characterize the presence over time of diversity and disparities-related content at cardiothoracic surgical society meetings.

METHODS

Annual meeting program books from the American Association for Thoracic Surgery and the Society of Thoracic Surgeons from 2013 to 2023 were manually reviewed to identify abstract presentations, invited talks, and dedicated sessions related to diversity, equity, or social determinants of health. Relevant presentations were further categorized as issues in the surgical workforce versus patient care. Applicable presentations and sessions were quantified in each domain and proportions compared with the χ2 test.

RESULTS

Of 7812 presentations over 11 years, 167 (2.1%) were related to issues of diversity. These included 118 abstracts, among which 19 (16.1%) covered workforce diversity issues whereas 99 (83.9%) addressed patient care inequities. Among 48 invited disparities talks, 28 (58.3%) related to workforce challenges and 20 (41.7%) explored variabilities in patient care. Seventeen complete sessions were dedicated to diversity and disparities, with 9 (52.9%) addressing those in the workforce and 8 (47.1%) related to patient care. Comparing the first 5 years with the final 5 years of study, the proportion of talks (abstracts and invited) related to diversity and inclusion increased 3-fold.

CONCLUSIONS

Recent years have shown an explosion in cardiothoracic surgery meeting content focused on diversity but still account for a diminutive proportion of overall content. These data highlight an opportunity to further align scholarly activity with our values.

Classifying Race in Out-of-Hospital Cardiac Arrest and Potential Disparities: A Retrospective Cohort Study

BACKGROUND

Although racial disparities have been described in resuscitation, little is known about potential bias in race classification of out-of-hospital cardiac arrest (OHCA).

METHODS

We conducted a retrospective cohort study of adults treated by emergency medical services (EMS) for nontraumatic OHCA in King County, WA between January 1, 2018, and December 31, 2021. We assessed agreement using κ and evaluated patterns of missingness between EMS-assessed race versus comprehensive race classification from hospital and death records. Using multivariable logistic regression adjusting for Utstein data elements, we analyzed the association between race and OHCA survival across different sources.

RESULTS

Among 5909 eligible OHCA patients, the average age was 64.0 years, 35.4% were female, and 16.1% survived to hospital discharge. Based on comprehensive race classification, 68.7% were White, 12.8% Black, 12.1% Asian, 2.5% multiracial, 2.3% Native Hawaiian/other Pacific Islander, and 1.6% American Indian/Alaska Native. EMS did not classify race in 43.7%. The κ coefficient between EMS and comprehensive race classification was 0.88 (95% CI, 0.86-0.90), though agreement varied substantially by specific race and was lowest among American Indian/Alaska Native (39.5%). Missingness in EMS records varied according to race and was greater among those classified as American Indian/Alaska Native (60.8%), Native Hawaiian/other Pacific Islander (58.8%), Asian (57.8%), or multiracial (54.1%) compared with White (40.6%) or Black (40.4%). In multivariable models using EMS-classified race, the odds ratio (OR) of survival was not significantly different for any race group compared with the White race, that is, OR. However, when using comprehensive race classification, OR of survival was significantly lower among Native Hawaiian/other Pacific Islander (OR, 0.57 [95% CI, 0.33-0.97]) and among multiracial (OR, 0.40 [95% CI, 0.20-0.75]) compared with White race.

CONCLUSIONS

In adult OHCA, race misclassification and missingness influenced its association with survival. Efforts should continue to evaluate best practices to classify race correctly and comprehensively.

National Trends in Racial and Ethnic Disparities in Mortality from Mechanical Complications of Cardiac Valves and Grafts (1999-2020)

Background: The volume of cardiac valve and coronary artery revascularization procedures is rising in the United States. This cross-sectional study explores ethnic disparities in mortality in cardiac surgery attributed to mechanical failures of implantable heart valves and coronary artery grafts. Methods: We used the CDC Wide-Ranging Online Data for Epidemiologic Research Multiple Causes of Death database to identify patients whose single cause of death was categorized by complications of cardiovascular prosthetic devices, implants, and grafts (ICD-10 code T82) between 1999 and 2020. The Joinpoint software (version 5.2.0, National Cancer Institute) was used to construct log-linear regression models to estimate the average annual percent changes in age-adjusted mortality (per 100,000). These patterns were compared and stratified by sex, age (0-44, 44-64, and 65 years or older), and US census regions between White, Black, Hispanic, non-Hispanic, American Indian, Alaskan Native, Asian American, and Pacific Islanders. Results: Age-adjusted mortality due to mechanical failures of cardiac implants and grafts declined across ethnicities from 2.21 (95% CI 2.16-2.27) in 1999 to 0.88 (95% CI 0.85-0.91) in 2020. Black populations (1.31 [95% CI 1.20-1.42]), both men (1.56 [95% CI 1.37-1.74]) and women (1.02 [95% CI 0.90-1.15]) experienced higher mortality in 2020 compared to all other ethnicities. This disparity was pronounced in younger groups (age 0-64), wherein age-adjusted mortality among Black populations (0.18 [95% CI 0.13-0.25]) more than doubled that of White populations (0.08 [95% CI 0.06-0.10]). Conclusions: Over the last two decades, age-adjusted mortality due to mechanical complications of cardiovascular implants has declined significantly. However, Black men and women, particularly younger patients, continue to experience higher death rates compared to other ethnicities.

Applying a health equity lens to the perioperative anesthetic management for coronary artery bypass grafting

BACKGROUND

Disparities in healthcare based on race, ethnicity, and socioeconomic status (SES) remain a public health crisis, especially in perioperative anesthetic management. This study applies a health equity lens to intraoperative pain and postoperative nausea and vomiting (PONV) for patients undergoing coronary artery bypass grafting (CABG).

METHODS

This retrospective cohort study included 1404 adult patients who underwent coronary artery bypass grafting (CABG) between 2017 and 2022 at a single, multi-site, academic healthcare system. The primary outcomes were PONV as well as moderate-to-severe post-operative pain. Secondary outcomes were administration of prophylactic antiemetics, compliance with guideline-recommended antiemetic prophylaxis, and opioid morphine milligram equivalents (MME) administered intraoperatively. Independent variables included patient race and ethnicity, healthcare payor type, and community-level SES (using Area Deprivation Index [ADI]). Multivariable logistic regression models that controlled for relevant covariates were utilized.

RESULTS

The findings showed no significant disparities in experiencing PONV, post-operative pain, or receiving high opioid MME based on race, ethnicity, payor type, and ADI. There were also no differences in the receipt of antiemetics nor compliance with guideline-recommended antiemetic prophylaxis.

CONCLUSIONS

Our study did not find racial, ethnic, or SES disparities in intraoperative anesthetic pain management, postoperative pain, nor PONV management. Applying a health equity lens to quality outcomes during the perioperative period is necessary to ensure equitable care among diverse populations.

Racial, ethnic, and sex disparities in the utilization and outcomes of tricuspid valve surgery

Background

Data on racial/ethnic and sex disparities in the utilization and outcomes of tricuspid valve surgery (TVS) in the United States are scarce. The authors aimed to evaluate the impact of race/ethnicity and sex on the utilization and outcomes of TVS.

Methods

The authors analyzed the National Inpatient Sample database from 2016 to 2020 to identify hospitalizations for TVS. Racial/ethnic and sex disparities in TVS outcomes were determined using logistic regression models.

Results

Between 2016 and 2020, 19 395 hospitalizations for TVS were identified. The utilization rate (number of surgeries/100,000 hospitalizations) was lower in Black and Hispanic patients compared with White patients for surgical tricuspid valve repair (STVr) (331 versus 493 versus 634, P<0.01) and surgical tricuspid valve replacement (STVR) (312 versus 601 versus 728, P<0.01). Similarly, the utilization rate was lower for women compared with men for STVr (1021 versus 1364, P<0.01) and STVR (930 versus 1,316, P<0.01). Compared to White men undergoing TVS, all women had lower odds of acute kidney injury [adjusted odds ratio (aOR) 0.65, 95% CI 0.55-0.78] and higher odds of blood transfusion (aOR 1.30, 95% CI 1.07-1.59), and Black men had higher odds of blood transfusion (aOR 1.59, 95% CI 1.08-2.35). In-hospital mortality and other surgical complications were similar between all groups (all P>0.05).

Conclusions

Significant racial/ethnic and sex disparities exist in the utilization of TVS in the United States. Further studies are needed to understand the reasons for these disparities and to identify effective strategies for their mitigation.

Racial and Ethnic Disparities in Peri-and Post-operative Cardiac Surgery

Purpose of Review

Despite efforts to curtail its impact on medical care, race remains a powerful risk factor for morbidity and mortality following cardiac surgery. While patients from racial and ethnic minority groups are underrepresented in cardiac surgery, they experience a disproportionally elevated number of adverse outcomes following various cardiac surgical procedures. This review provides a summary of existing literature highlighting disparities in coronary artery bypass surgery, valvular surgery, cardiac transplantation, and mechanical circulatory support.

Recent Findings

Unfortunately, specific causes of these disparities can be difficult to identify, even in large, multicenter studies, due to the complex relationship between race and post-operative outcomes. Current data suggest that these racial/ethnic disparities can be attributed to a combination of patient, socioeconomic, and hospital setting characteristics.

Summary

Proposed solutions to combat the mechanisms underlying the observed disparate outcomes require deployment of a multidisciplinary team of cardiologists, anesthesiologists, cardiac surgeons, and experts in health care equity and medical ethics. Successful identification of at-risk populations and the implementation of preventive measures are necessary first steps towards dismantling racial/ethnic differences in cardiac surgery outcomes.