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Yamaguchi K, Newhall K, Edman NI, Zettervall SL, Sweet MP. Living in high-poverty areas is associated with reduced survival in patients with thoracoabdominal aortic aneurysms. J Vasc Surg 2024:S0741-5214(24)00953-4. [PMID: 38608968 DOI: 10.1016/j.jvs.2024.03.452] [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: 01/14/2024] [Revised: 03/01/2024] [Accepted: 03/31/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVES Studies have demonstrated that socioeconomic status, insurance, race, and distance impact clinical outcomes in patients with abdominal aortic aneurysms. The purpose of this study was to assess if these factors also impact clinical outcomes in patients with thoracoabdominal aortic aneurysms (TAAAs). METHODS We conducted a retrospective review of patients with TAAAs confirmed by computed tomography imaging between 2009 and 2019 at a single institution. Patients' zip codes were mapped to American Community Survey Data to obtain geographic poverty rates. We used the standard U.S. Census definition of high-poverty concentration as >20% of the population living at 100% of the poverty rate. Our primary outcome was overall survival, stratified by whether the patient underwent repair. RESULTS Of 578 patients, 575 had zip code data and were analyzed. In both the nonoperative (N = 268) and operative (N = 307) groups, there were no significant differences in age, race, comorbidities, clinical urgency, surgery utilization, or surgery modality between patients living in high-poverty areas (N = 95, 16.4%) vs not. In the nonoperative group, patients from high-poverty areas were more likely to have aneurysm due to dissection (37.5% vs 17.6%, P = .03). In multivariate analyses, patients from high-poverty zip codes had significantly worse nonoperative survival (hazard ratio [HR]: 1.9, 95% confidence interval [CI]: 1.1-3.3, P = .03). In the repair group, high poverty was also a significant predictor of reduced postoperative survival (HR: 1.65, 95% CI: 1-2.63, P = .04). Adding the Gagne Index, these differences persisted in both groups (nonoperative: HR: 1.93, 95% CI: 1.01-3.70, P = .05; operative: HR: 1.62, 95% CI: 1.03-2.56, P = .04). In Kaplan-Meier analysis, the difference in postoperative survival began approximately 1.5 years after repair. Private insurance was predictive of improved postoperative survival (HR: 0.42, 95% CI: 0.18-0.95, P = .04) but reduced nonoperative survival (HR: 2.05, 95% 1.01-4.14, P = .04). Data were insufficient to determine if race impacted survival discretely from poverty status. These results were found after adjusting for age, race, sex, maximum aortic diameter, coronary artery disease, distance from the hospital, insurance, and active smoking. Interestingly, in multivariate regression, traveling greater than 100 miles was correlated with increased surgery utilization (odds ratio: 1.58, 95% CI: 1.08-2.33, P = .02) and long-term survival (HR: 0.61, 95% CI: 0.41-0.92, P = .02). CONCLUSIONS Patients with TAAAs living in high-poverty areas had significantly more dissections and suffered a nearly doubled risk of mortality compared with patients living outside such areas. These data suggest that these disparities are attributed to the overall impacts of poverty and highlight the pressing need for research into TAAA disparities.
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Affiliation(s)
| | - Karina Newhall
- Division of Vascular Surgery, University of Rochester School of Medicine and Dentistry, Rochester
| | - Natasha I Edman
- University of Washington School of Medicine and University of Washington Medical Scientist Training Program, Seattle, WA
| | | | - Matthew P Sweet
- Division of Vascular Surgery, University of Washington, Seattle, WA.
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Newell P, Zogg C, Asokan S, Reed A, Vinholo TF, Harloff M, Hirji S, Kerolos M, Kaneko T, Sabe A. Race and Socioeconomic Disparities in Proximal Aortic Surgery. Ann Thorac Surg 2024; 117:761-768. [PMID: 37031768 DOI: 10.1016/j.athoracsur.2023.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Substantial socioeconomics-based disparities exist in cardiac surgery. Although there are robust data for revascularization and valve procedures, the effect of race and socioeconomic status on proximal aortic surgery is not well studied. This study analyzed the impact of race and socioeconomic status on in-hospital outcomes after proximal aortic surgery. METHODS All adult patients who underwent proximal aortic surgery for aortic dissection or thoracic aneurysm from the 2016 to 2018 National Inpatient Sample were included. Primary outcomes included in-hospital mortality and in-hospital composite morbidity (stroke, pulmonary embolus, major bleeding, acute kidney injury, or permanent pacemaker insertion). Adjusted outcomes were assessed with multivariable analysis. RESULTS A weighted total of 32,895 patients were included; 25,461 (77.4%) classified as White, 3224 (9.8%) Black, 2039 (6.2%) Hispanic, and 2171 (6.6%) other. Black and Hispanic patients had significantly lower median household income, higher proportion of self-pay insurance status, younger age, higher comorbidity burden, and a higher proportion of urgent or emergency procedures compared with White patients. There was no significant difference in observed in-hospital mortality by patient race, but non-White patients had significantly higher composite morbidity. On adjusted analysis, there was no difference in in-hospital mortality, but non-White race was an independent predictor of in-hospital morbidity (adjusted odds ratio, 1.6; 95% CI, 1.4-1.8; P < .001). CONCLUSIONS Patients of non-White race who undergo proximal aortic surgery have less insurance coverage, more urgent procedures, and a higher comorbidity burden than White patients, disparities that translate to significantly higher morbidity in non-White. A greater focus on nonfatal outcome differentials and improving access to care likely will improve aortic surgery disparities.
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Affiliation(s)
- Paige Newell
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Boston, Massachusetts
| | - Cheryl Zogg
- Yale School of Medicine, New Haven, Connecticut
| | - Sainath Asokan
- Boston University School of Medicine, Boston, Massachusetts
| | - Alexander Reed
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thais Faggion Vinholo
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Morgan Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mariam Kerolos
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ashraf Sabe
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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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 2024:S0022-5223(24)00093-X. [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] [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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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: 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: 05/16/2022] [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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Thoracoabdominal Aortic Disease and Repair: JACC Focus Seminar, Part 3. J Am Coll Cardiol 2022; 80:845-856. [PMID: 35981828 DOI: 10.1016/j.jacc.2021.05.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/03/2021] [Accepted: 05/25/2021] [Indexed: 11/21/2022]
Abstract
Thoracoabdominal aortic disease is a rare but life-threatening condition that requires expert multidisciplinary collaborative management. Intervention is indicated in patients with symptomatic aneurysms or when an aneurysm reaches a certain threshold of diameter or rate of expansion. The strategies for spinal cord and end-organ protection have evolved over several decades, resulting in improved outcomes after repair. Open repair, although invasive, provides definitive and durable repair. Endovascular approaches are rapidly evolving, and the results with fenestrated and branched endografts are promising. Both open repair and endovascular repair require highly specialized expertise, and outcomes are best when repair is undertaken in an elective setting by a dedicated team. Patients with degenerative thoracoabdominal aortic aneurysms and chronic dissections should be followed up closely and referred for elective repair when indicated.
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Vervoort D, Chung JCY, Ouzounian M. Access to Thoracic Aortic Care: Challenges and Opportunities in Universal Health Coverage Systems. Can J Cardiol 2022; 38:726-728. [PMID: 35272002 DOI: 10.1016/j.cjca.2022.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/02/2022] Open
Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario.
| | - Jennifer C Y Chung
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario
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7
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Pichert M, Geirsson A, Assi R. Surgery for aortic dissection: An international case for universal coverage? J Card Surg 2021; 36:2044. [PMID: 33682946 DOI: 10.1111/jocs.15455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Matthew Pichert
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Roland Assi
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Abstract
Thoracoabdominal aortic aneurysms, although rare, continue to be associated with high morbidity and mortality in the modern era of vascular surgery, and knowledge of this disease is essential for those in clinical practice. Given the clinically silent nature of the disease, it is difficult to determine disease incidence, with most epidemiologic recommendations not made based on evidence regarding those diagnosed with the disease, but extrapolated from data on surgical outcomes. It appears that although men are more likely to develop thoracoabdominal aortic aneurysms, the distribution is not as skewed as in abdominal aortic aneurysms. Current evidence suggests that Black and Hispanic patients continue to have disproportionately poor disease outcomes, mostly attributed to later presentation and undergoing interventions at lower-volume centers. Although select patients meet criteria for disease screening based on personal or family history of aneurysmal disease, general population screening has not been recommended by any professional organization to date. Vascular surgeons need to continue to be at the forefront of thoracoabdominal aortic aneurysm management, especially as care becomes centered around comprehensive "aortic care centers" and as more endovascular therapies become available.
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Affiliation(s)
- Jordan B Stoecker
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4th Floor, Philadelphia, PA 19104.
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, 3400 Spruce Street, Maloney 4th Floor, Philadelphia, PA 19104.
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Hawkins RB, Mehaffey JH. Commentary: Socioeconomic impact on aortic surgery: Is it about the individual, the community, or the surgeon? J Thorac Cardiovasc Surg 2020; 163:2000-2001. [PMID: 32859424 DOI: 10.1016/j.jtcvs.2020.07.079] [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: 07/25/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
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10
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Bozinovski J. Commentary: Access to top-notch care. J Thorac Cardiovasc Surg 2020; 163:1999-2000. [PMID: 33268113 DOI: 10.1016/j.jtcvs.2020.07.056] [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: 07/17/2020] [Revised: 07/17/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Affiliation(s)
- John Bozinovski
- Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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