Contemporary socioeconomic-based disparities in cardiac surgery: Are we closing the disparities gap?

Center case volume is associated with Society of Thoracic Surgeons-defined failure to rescue in cardiac surgery

OBJECTIVE

Our understanding of the impact of a center's case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR.

METHODS

Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. After we excluded patients with missing Society of Thoracic Surgeons Predicted Risk of Mortality scores, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared with all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year.

RESULTS

A total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2%) developed an FTR complication, and 735 (13.8% of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th percentile cutoffs of 136 and 284 cases, respectively. Increasing center-level case volume was associated with significantly greater center-level major complication rates but lower mortality and FTR rates (all P values < .01). Observed-to-expected FTR was significantly associated with case volume (P = .040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (odds ratio, 0.87 per quartile; confidence interval, 0.799-0.946, P = .001).

CONCLUSIONS

Increasing center case volume is significantly associated with improved FTR rates. Assessment of low-volume centers' FTR performance represents an opportunity for quality improvement.

Socioeconomic disparities in procedural choice and outcomes after aortic valve replacement

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.