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Collins CM, Renshaw S, Olson MA, Poulose B, Collins CE. The effects of socioeconomic status on complex ventral hernia repair operative decision-making and outcomes. Surgery 2024:S0039-6060(24)00399-4. [PMID: 39019732 DOI: 10.1016/j.surg.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/02/2024] [Accepted: 06/10/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Patients from low socioeconomic backgrounds have greater rates of morbidity and mortality across disease processes. The Distressed Communities Index identified several socioeconomic components that were used to create a Distressed Communities Index score for every ZIP code, then broken into quintiles from prosperous to distressed. We aimed to explore whether socioeconomic distress as defined by the Distressed Communities Index affects the outcome of complex ventral hernia repair in the elderly population. METHODS Retrospective analysis was performed using the Abdominal Core Health Collaborative data. Included were adults aged 65+ years undergoing elective complex ventral hernia repair from 2013 to 2021. Primary outcomes were postoperative outcomes and composite hernia recurrence by Distressed Communities Index quintile. The Cox proportional hazards model was used for composite recurrence, and logistic regression was used for postoperative outcomes. RESULTS A total of 4,172 patients were included. Patients in distressed communities were more likely to identify as female or racial minority and had greater body mass index and American Society of Anesthesiologists class. Lower Distressed Communities Index quintile was associated with larger hernia (P = .012), open repair (P = .019), and 30-day complication (P = .05). There was no association between time to recurrence and Distressed Communities Index quintile (P = .24). After adjusted analysis, there was no significant difference for readmission, reoperation, recurrence, and complications. CONCLUSION Patients from more distressed communities presented in worse clinical status with larger hernias. This likely contributed to greater rates of open repair and complications. However, when adjusted for these variables, outcomes were similar across Distressed Communities Index quintile. This supports the efficacy of complex hernia repair across socioeconomic classes.
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Affiliation(s)
- Courtney M Collins
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Savannah Renshaw
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Molly A Olson
- Department of Population Health Services, Weill Cornell Medicine, New York, NY
| | - Benjamin Poulose
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Courtney E Collins
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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2
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Dyas AR, Carmichael H, Bronsert MR, Stuart CM, Garofalo DM, Henderson WG, Colborn KL, Schulick RD, Meguid RA, Velopulos CG. Social vulnerability is associated with higher risk-adjusted rates of postoperative complications in a broad surgical population. Am J Surg 2024; 229:26-33. [PMID: 37775458 DOI: 10.1016/j.amjsurg.2023.09.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/08/2023] [Accepted: 09/22/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE The purpose of this study was to determine if an association between Social Vulnerability Index (SVI) and risk-adjusted complications exists in a broad spectrum of surgical patients. SUMMARY BACKGROUND DATA Growing evidence supports the impact of social circumstances on surgical outcomes. SVI is a neighborhood-based measure accounting for sociodemographic factors putting communities at risk. METHODS This was a multi-hospital, retrospective cohort study including a sample of patients within one healthcare system (2012-2017). Patient addresses were geocoded to determine census tract of residence and estimate SVI. Patients were grouped into low SVI (score<75) and high SVI (score≥75) cohorts. Perioperative variables and postoperative outcomes were tracked and compared using local ACS-NSQIP data. Multivariable logistic regression was performed to generate risk-adjusted odds ratios of postoperative complications in the high SVI cohort. RESULTS Overall, 31,224 patients from five hospitals were included. Patients with high SVI were more likely to be racial minorities, have 12/18 medical comorbidities, have high ASA class, be functionally dependent, be treated at academic hospitals, and undergo emergency operations (all p < 0.05). Patients with high SVI had significantly higher rates of 30-day mortality, overall morbidity, respiratory, cardiac and infectious complications, urinary tract infections, postoperative bleeding, non-home discharge, and unplanned readmissions (all p < 0.05). After risk-adjustment, only the associations between high SVI and mortality and unplanned readmission became non-significant. CONCLUSIONS High SVI was associated with multiple adverse outcomes even after risk adjustment for preoperative clinical factors. Targeted preventative interventions to mitigate risk of these specific complications should be considered in this high-risk population.
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Affiliation(s)
- Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Heather Carmichael
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christina M Stuart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Denise M Garofalo
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - William G Henderson
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kathryn L Colborn
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA; Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Catherine G Velopulos
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO, USA
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3
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Sakowitz S, Bakhtiyar SS, Mallick S, Curry J, Ascandar N, Benharash P. Impact of Community Socioeconomic Distress on Survival Following Heart Transplantation. Ann Surg 2024; 279:376-382. [PMID: 37641948 DOI: 10.1097/sla.0000000000006088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
OBJECTIVE The aim of this study was to assess the impact of community-level socioeconomic deprivation on survival outcomes following heart transplantation. BACKGROUND Despite growing awareness of socioeconomic disparities in the US health care system, significant inequities in outcomes remain. While recent literature has increasingly considered the effects of structural socioeconomic deprivation, the impact of community socioeconomic distress on outcomes following heart transplantation has not yet been elucidated. METHODS All adult heart transplant recipients from 2004 to 2022 were ascertained from the Organ Procurement and Transplantation Network. Community socioeconomic distress was assessed using the previously validated Distressed Communities Index, a metric that represents education level, housing vacancies, unemployment, poverty rate, median household income, and business growth by zip code. Communities in the highest quintile were considered the Distressed cohort (others: Non-Distressed ). Outcomes were considered across 2 eras (2004-2018 and 2019-2022) to account for the 2018 UNOS Policy Change. Three- and 5-year patient and graft survival were assessed using Kaplan-Meier and Cox proportional hazards models. RESULTS Of 36,777 heart transplants, 7450 (20%) were considered distressed . Following adjustment, distressed recipients demonstrated a greater hazard of 5-year mortality from 2004 to 2018 [hazard ratio (HR)=1.10, 95% confidence interval (CI): 1.03-1.18; P =0.005] and 3-year mortality from 2019 to 2022 (HR=1.29, 95% CI: 1.10-1.51; P =0.002), relative to nondistressed . Similarly, the distressed group was associated with increased hazard of graft failure at 5 years from 2004 to 2018 (HR=1.10, 95% CI: 1.03-1.18; P =0.003) and at 3 years from 2019 to 2022 (HR=1.31, 95% CI: 1.11-1.53; P =0.001). CONCLUSIONS Community-level socioeconomic deprivation is linked with inferior patient and graft survival following heart transplantation. Future interventions are needed to address pervasive socioeconomic inequities in transplantation outcomes.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
- Department of Surgery, University of Colorado, Aurora, CO
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
| | - Nameer Ascandar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, Los Angeles, CA
- Department of Surgery, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, CA
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4
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Suzuki T, Mizuno A, Yasui H, Noma S, Ohmori T, Rewley J, Kawai F, Nakayama T, Kondo N, Tsukada YT. Scoping Review of Screening and Assessment Tools for Social Determinants of Health in the Field of Cardiovascular Disease. Circ J 2024; 88:390-407. [PMID: 38072415 DOI: 10.1253/circj.cj-23-0443] [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] [Indexed: 02/23/2024]
Abstract
BACKGROUND Despite the importance of implementing the concept of social determinants of health (SDOH) in the clinical practice of cardiovascular disease (CVD), the tools available to assess SDOH have not been systematically investigated. We conducted a scoping review for tools to assess SDOH and comprehensively evaluated how these tools could be applied in the field of CVD. METHODS AND RESULTS We conducted a systematic literature search of PubMed and Embase databases on July 25, 2023. Studies that evaluated an SDOH screening tool with CVD as an outcome or those that explicitly sampled or included participants based on their having CVD were eligible for inclusion. In addition, studies had to have focused on at least one SDOH domain defined by Healthy People 2030. After screening 1984 articles, 58 articles that evaluated 41 distinct screening tools were selected. Of the 58 articles, 39 (67.2%) targeted populations with CVD, whereas 16 (27.6%) evaluated CVD outcome in non-CVD populations. Three (5.2%) compared SDOH differences between CVD and non-CVD populations. Of 41 screening tools, 24 evaluated multiple SDOH domains and 17 evaluated only 1 domain. CONCLUSIONS Our review revealed recent interest in SDOH in the field of CVD, with many useful screening tools that can evaluate SDOH. Future studies are needed to clarify the importance of the intervention in SDOH regarding CVD.
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Affiliation(s)
- Takahiro Suzuki
- Department of Cardiovascular Medicine, St. Luke's International Hospital
| | - Atsushi Mizuno
- Department of Cardiovascular Medicine, St. Luke's International Hospital
- Leonard Davis Institute for Health Economics, University of Pennsylvania
| | - Haruyo Yasui
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Satsuki Noma
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Jeffrey Rewley
- Leonard Davis Institute for Health Economics, University of Pennsylvania
- The MITRE Corporation
| | - Fujimi Kawai
- Department of Academic Resources, St. Luke's International University
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health
| | - Naoki Kondo
- Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University
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Akinyemi O, Ogundare T, Weldeslase T, Andine T, Fasokun M, Odusanya E, Hughes K, Mallory W, Luo G, Cornwell E. The association between community-level economic deprivation and incidences of emergency department visits on account of attempted suicides in Maryland. Front Public Health 2024; 12:1353283. [PMID: 38384877 PMCID: PMC10879598 DOI: 10.3389/fpubh.2024.1353283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 01/24/2024] [Indexed: 02/23/2024] Open
Abstract
Background Suicide is a major cause of mortality in the United States, accounting for 14.5 deaths per 100,000 population. Many emergency department (ED) visits in the United States are due to attempted suicides. Suicide attempts predict subsequent completed suicides. Socioeconomic factors, such as community-level socioeconomic deprivation, significantly affect many traditional risk factors for attempted suicides and suicides. Aim To determine the association between community-level socioeconomic deprivation and ED visits for attempted suicide in Maryland. Methods A retrospective analysis of attempted suicides in the Maryland State Emergency Department Database from January 2018 to December 2020. Community-level socioeconomic deprivation was measured using the Distress Community Index (DCI). Multivariate regression analyses were conducted to identify the association between DCI and attempted suicides/self-harm. Results There were 3,564,987 ED visits reported in the study period, with DCI data available for 3,236,568 ED visits; 86.8% were younger than 45 years, 64.8% were females, and 54.6% non-Hispanic Whites. Over the study period, the proportion of ED visits due to attempted suicide was 0.3%. In the multivariate logistic regression, compared to prosperous zones, those in comfortable (OR = 0.80, 95% CI: 0.73-0.88, p < 0.01), Mid-Tier (OR = 0.76, 95%CI:0.67-0.86, p < 0.01), At-Risk (OR = 0.77; 95%CI: 0.65-0.92, p < 0.01) and Distressed zones (OR = 0.53; 95% CI:0.42-0.66, p < 0.01) were less likely to visit the ED for attempted suicide. Conclusion Prosperous communities had the highest rate of attempted suicides, with the risk of attempted suicide increasing as individuals move from the least prosperous to more prosperous areas.
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Affiliation(s)
- Oluwasegun Akinyemi
- Clive O Callender Department of Surgery, Howard University College of Medicine, Washington, DC, United States
| | - Temitope Ogundare
- Department of Psychiatry, Boston Medical Center, Boston, MA, United States
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Terhas Weldeslase
- Department of Surgery, Howard University College of Medicine, Washington, DC, United States
| | - Tsion Andine
- Department of Surgery, Howard University College of Medicine, Washington, DC, United States
| | - Mojisola Fasokun
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Eunice Odusanya
- Department of Surgery, Howard University College of Medicine, Washington, DC, United States
| | - Kakra Hughes
- Department of Surgery, Howard University College of Medicine, Washington, DC, United States
| | - Williams Mallory
- Department of Surgery, Howard University College of Medicine, Washington, DC, United States
| | - Guoyang Luo
- Department of Obstetrics and Gynecology, Howard University College of Medicine, Washington, DC, United States
| | - Edward Cornwell
- Department of Surgery, Howard University College of Medicine, Washington, DC, United States
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Natour AK, Shepard A, Nypaver T, Weaver M, Peshkepija A, Kafri O, Kabbani L. Socioeconomic status is not associated with unfavorable outcomes in patients with acute limb ischemia. Vascular 2024; 32:118-125. [PMID: 36117451 DOI: 10.1177/17085381221124994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Whether socioeconomic status (SES) is associated with health outcomes in patients with acute limb ischemia (ALI) is largely unknown. We aimed to determine whether SES is associated with worse presentations and outcomes for patients with ALI. METHODS We performed a retrospective medical record review of patients who presented with ALI between April 2016 and October 2020 at a single tertiary care center. SES was quantified using individual variables (median household income, level of education, and employment) and a composite endpoint, the neighborhood deprivation index (NDI). The NDI is a standardized and reproducible index that uses census tract data (higher number indicates lower SES status). The NDI summarizes 8 domains of socioeconomic deprivation. ALI severity was categorized using the Rutherford classification. The association between SES and the severity of ALI at presentation and between SES and other health outcomes were analyzed using bivariate analysis of variance, independent t test, and multivariate logistic regression. RESULTS During the study period, 278 patients were treated for ALI, of whom 211 had complete SES data available. The mean age was 64 years, 55% were men, and 57% were White. The Rutherford classification of disease severity was grade 1, 2a, 2b, and 3 for 6%, 54%, 32%, and 8% of patients, respectively. Patients with a low SES status per the NDI were more likely to have a history of peripheral arterial disease and chronic kidney disease at presentation. The ALI etiology (thrombotic vs embolic) was not associated with SES. No significant differences were seen between SES and the severity of ALI at presentation (p = 0.96) or the treatment modality (p = 0.80). No associations between SES and 30-day or 1-year mortality were observed (mean NDI, 0.15 vs 0.26, p = 0.58, and 0.20 vs 0.26, p = 0.71, respectively) or between SES and 30-day or 1-year limb loss (mean NDI, 0.06 vs 0.30, p = 0.18, and 0.1 vs 0.32, p = 0.17, respectively). Lower SES (higher NDI) was associated with increased 30-day readmission (mean NDI, 0.49 vs 0.15, p = 0.021). However, this association was not significant on multivariate analysis (odds ratio 1.4, 95% CI 0.9-2.1, p = 0.06). CONCLUSIONS SES was not associated with the severity of ALI at patient presentation. Although SES was associated with the presence of peripheral arterial disease and chronic kidney disease at presentation, SES was not a predictor of short-term or 1-year limb loss and mortality. Overall, ALI presentation and treatment outcomes were independent of SES.
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Affiliation(s)
| | | | - Timothy Nypaver
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Mitchell Weaver
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Andi Peshkepija
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Omar Kafri
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Loay Kabbani
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
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Thompson MP, Hou H, Stewart JW, Pagani FD, Hawkins RB, Keteyian SJ, Sukul D, Likosky DS. Relationship Between Community-Level Distress and Cardiac Rehabilitation Participation, Facility Access, and Clinical Outcomes After Inpatient Coronary Revascularization. Circ Cardiovasc Qual Outcomes 2023; 16:e010148. [PMID: 37855157 PMCID: PMC10953712 DOI: 10.1161/circoutcomes.123.010148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Although disparities in cardiac rehabilitation (CR) participation are well documented, the role of community-level distress is poorly understood. This study evaluated the relationship between community-level distress and CR participation, access to CR facilities, and clinical outcomes. METHODS A retrospective cohort study was conducted on a 100% sample of Medicare beneficiaries undergoing inpatient coronary revascularization between July 2016 and December 2018. Community-level distress was defined using the Distressed Community Index quintile at the beneficiary zip code level, with the first and fifth quintiles representing prosperous and distressed communities, respectively. Outpatient claims were used to identify any CR use within 1 year of discharge. Beneficiary and CR facility zip codes were used to describe access to CR facilities. Adjusted logistic regression models evaluated the association between Distressed Community Index quintiles, CR use, and clinical outcomes, including one-year mortality, all-cause hospitalization, and acute myocardial infarction hospitalization. RESULTS A total of 414 730 beneficiaries were identified, with 96 929 (23.4%) located in the first and 67 900 (16.4%) in the fifth quintiles, respectively. Any CR use was lower for beneficiaries in distressed compared with prosperous communities (26.0% versus 46.1%, P<0.001), which was significant after multivariable adjustment (odds ratio, 0.41 [95% CI, 0.40-0.42]). A total of 98 458 (23.7%) beneficiaries had a CR facility within their zip code, which increased from 16.3% in prosperous communities to 26.6% in distressed communities. Any CR use was associated with absolute reductions in mortality (-6.8% [95% CI, -7.0% to -6.7%]), all-cause hospitalization (-5.9% [95% CI, -6.3% to -5.6%]), and acute myocardial infarction hospitalization (-1.3% [95% CI, -1.5% to -1.1%]), which were similar across each Distressed Community Index quintiles. CONCLUSIONS Although community-level distress was associated with lower CR participation, the clinical benefits were universally received. Addressing barriers to CR in distressed communities should be considered a significant priority to improve survival after coronary revascularization and reduce disparities.
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Affiliation(s)
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI
| | - James W Stewart
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | | | | | - Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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8
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Johns AJ, Luce MS, Kaneski MJ, Lowery RA, Jachniewicz B, Salas A, McCreary R, Russell RM, Lyo V, Ali MR, Ahmed SM. The long weight: association between distressed communities index and long-term weight outcomes following bariatric surgery. Surg Endosc 2023; 37:7218-7225. [PMID: 37369948 PMCID: PMC10462541 DOI: 10.1007/s00464-023-10158-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/20/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Socioeconomic status (SES) is multifactorial, and its effect on post-bariatric weight recurrence is unclear. Distressed Community Index (DCI) is a composite SES score measuring community economic well-being. This study aims to evaluate the effect of DCI on long-term post-bariatric weight outcomes. METHODS Retrospective analysis of patients undergoing primary laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy between 2015 and 2020 was performed. All weights in the electronic medical record (EMR), including non-bariatric visits, were captured. Patients were stratified into low tier (LT) and high tier (HT) DCI groups. RESULTS Of 583 patients, 431 (73.9%) were HT and 152 (26.1%) were LT. Average bariatric follow up was 1.78 ± 1.6 years and average postoperative weight in the EMR was 3.96 ± 2.26 years. Rates of bariatric follow up within the last year were similar (13.8% LT vs 16.2% HT, p = 0.47). LT had higher percent total body weight loss (%TWL; 26% LT vs 23% HT, p < 0.01) and percent excess weight loss (%EWL; 62% vs 57%, p = 0.04) at 1 year on univariate analysis. On multivariate linear regression adjusting for baseline characteristics and surgery type, there were no differences in %EWL between groups at 1 year (p = 0.22), ≥ 3 years (p = 0.53) or ≥ 5 years (p = 0.34) postop. While on univariate analysis LT only trended towards greater percentage of patients with > 15% increase from their 1-year weight (33.3% LT vs 21.0% HT, p = 0.06), on multivariate analysis this difference was significant (OR 2.0, LT 95%CI 1.41-2.84). There were no differences in the percentage of patients with > 15% decrease in %EWL from 1 to 3 + years postop between groups (OR 0.98, LT 95% CI 0.72-1.35). CONCLUSIONS While low tier patients had similar weight loss at 1 year, they were twice as likely to have weight recurrence at ≥ 3 years. Further studies are needed to identify factors contributing to greater weight recurrence among this population.
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Affiliation(s)
- Alexandra J Johns
- Department of Surgery, University of California, Davis, 2335 Stockton Blvd, 6thFloor, Sacramento, CA, 95817, USA
| | - M Siobhan Luce
- Department of Surgery, University of California, Davis, 2335 Stockton Blvd, 6thFloor, Sacramento, CA, 95817, USA
| | - Mason J Kaneski
- Division of Foregut, Metabolic, and General Surgery, University of California, Davis, Sacramento, USA
| | - Ryan A Lowery
- University of California, Davis Health, Sacramento, USA
| | | | - Angela Salas
- University of California, Davis Health, Sacramento, USA
| | | | | | - Victoria Lyo
- Department of Surgery, University of California, Davis, 2335 Stockton Blvd, 6thFloor, Sacramento, CA, 95817, USA
- Division of Foregut, Metabolic, and General Surgery, University of California, Davis, Sacramento, USA
- Center for Metabolic and Alimentary Science, University of California, Davis, Sacramento, USA
| | - Mohammed R Ali
- Department of Surgery, University of California, Davis, 2335 Stockton Blvd, 6thFloor, Sacramento, CA, 95817, USA
- Division of Foregut, Metabolic, and General Surgery, University of California, Davis, Sacramento, USA
- Center for Metabolic and Alimentary Science, University of California, Davis, Sacramento, USA
| | - Shushmita M Ahmed
- Department of Surgery, University of California, Davis, 2335 Stockton Blvd, 6thFloor, Sacramento, CA, 95817, USA.
- Division of Foregut, Metabolic, and General Surgery, University of California, Davis, Sacramento, USA.
- Center for Metabolic and Alimentary Science, University of California, Davis, Sacramento, USA.
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9
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Akingba AG, Chow WB, Rowe VL. Lower Extremity Bypass. Surg Clin North Am 2023; 103:767-778. [PMID: 37455036 DOI: 10.1016/j.suc.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
The original description of the lower extremity bypass (LEB) provided surgeons with a reliable method of limb revascularization. The tenets of the operation have formed the foundation for the advances of surgical care. A careful evaluation of the chronic limb-threatening ischemia patient due to the numerous comorbid conditions is paramount to obtain the best possible outcomes. Use of all adjuncts including judicious target vessels control, completion imaging, and vein harvesting techniques to ensure optimal outcomes because a functioning LEB remains a key to successful limb salvage.
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Affiliation(s)
- Ajibola George Akingba
- DC VAMC, Uniformed Services University of Health Sciences, 50 Irving Street, Washington, DC 20422, USA
| | - Warren Bryan Chow
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at UCLA, 200 Peter Morton Medical Building, Suite 526, Los Angeles, CA 90095, USA
| | - Vincent Lopez Rowe
- Division of Vascular Surgery and Endovascular Therapy, David Geffen School of Medicine at UCLA, 200 Peter Morton Medical Building, Suite 526, Los Angeles, CA 90095, USA.
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10
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Rali AS, Larson EE, Tran LE, Rahaman ZM, Charles LJ, Stokes JW, Chin C, Hilton A, Gannon WD, Bacchetta MD, Shah AS. Area Deprivation Index and Distress Community Index Scores Are Not Associated With Short-Term and Long-Term Extracorporeal Life Support Outcomes. ASAIO J 2023; 69:583-587. [PMID: 36807257 DOI: 10.1097/mat.0000000000001888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Distressed Communities Index (DCI) and Area Deprivation Index (ADI) are two composite ranking scores that report community level socioeconomic status (SES) by ZIP codes. The objective of this study was to evaluate the impact of SES as estimated by DCI and ADI scores on short-term and long-term outcomes after extracorporeal life support (ECLS) at a quaternary medical center. All patients on ECLS between January 1, 2015 and August 31, 2020 (N = 428) at Vanderbilt University Medical Center in Nashville, Tennessee, had their ADI and DCI scores calculated. Primary outcome was mortality during index hospitalization, and secondary outcome was survival to end of study follow-up. There was no significant difference in primary outcome between the top 25% ADI vs . bottom 75% ADI (53.8% vs . 50.6%; p = 0.56) or between top 25% DCI vs . bottom 75% DCI (56.1 vs . 49.2; p = 0.21). Adjusted odds ratio for the primary outcome with ADI and DCI was 1.13 (95% CI, 0.63-2.0; p = 0.67) and 1.28 (95% CI, 0.70-2.34; p = 0.41), respectively. Additionally, there was no significant difference in long-term survival curves based on their ADI or DCI scores. In conclusion, SES as estimated by baseline DCI and ADI scores does not appear to impact short- or long-term survival post-ECLS at a large volume center. http://links.lww.com/ASAIO/A951.
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Affiliation(s)
- Aniket S Rali
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emilee E Larson
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lena E Tran
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Zakiur M Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lawrence J Charles
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John W Stokes
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Clifford Chin
- Vanderbilt University School of Medical, Nashville, Tennessee
| | - Alistair Hilton
- Vanderbilt University School of Medical, Nashville, Tennessee
| | - Whitney D Gannon
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew D Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Julien HM, Wang Y, Curtis JP, Johnston-Cox H, Eberly LA, Wang GJ, Nathan AS, Fanaroff AC, Khatana SAM, Groeneveld PW, Secemsky EA, Eneanya ND, Vora AN, Kobayashi T, Barbery C, Chery G, Kohi M, Kirksey L, Armstrong EJ, Jaff MR, Giri J. Racial Differences in Presentation and Outcomes After Peripheral Arterial Interventions: Insights From the NCDR-PVI Registry. Circ Cardiovasc Interv 2023; 16:e011485. [PMID: 37339237 DOI: 10.1161/circinterventions.121.011485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 05/03/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND We assess the rates of device use and outcomes by race among patients undergoing lower extremity peripheral arterial intervention using the American College of Cardiology National Cardiovascular Data Registry-Peripheral Vascular Intervention (PVI) registry. METHODS Patients who underwent PVI between April 2014 and March 2019 were included. Socioeconomic status was evaluated using the Distressed Community Index score for patients' zip codes. Multivariable logistic regression was used to assess factors associated with utilization of drug-eluting technologies, intravascular imaging, and atherectomy. Among patients with Centers for Medicare and Medicaid Services data, we compared 1-year mortality, rates of amputation, and repeat revascularizations. RESULTS Of 63 150 study cases, 55 719 (88.2%) were performed in White patients and 7431 (11.8%) in Black patients. Black patients were younger (67.9 versus 70.0 years), had higher rates of hypertension (94.4% versus 89.5%), diabetes (63.0% versus 46.2%), less likely to be able to walk 200 m (29.1% versus 24.8%), and higher Distressed Community Index scores (65.1 versus 50.6). Black patients were provided drug-eluting technologies at a higher rate (adjusted odds ratio, 1.14 [95% CI, 1.06-1.23]) with no difference in atherectomy (adjusted odds ratio, 0.98 [95% CI, 0.91-1.05]) or intravascular imaging (adjusted odds ratio, 1.03 [95% CI, 0.88-1.22]) use. Black patients experienced a lower rate of acute kidney injury (adjusted odds ratio, 0.79 [95% CI, 0.72-0.88]). In Centers for Medicare and Medicaid Services-linked analyses of 7429 cases (11.8%), Black patients were significantly less likely to have surgical (adjusted hazard ratio, 0.40 [95% CI, 0.17-0.96]) or repeat PVI revascularization (adjusted hazard ratio, 0.42 [95% CI, 0.30-0.59]) at 1 year compared with White patients. There was no difference in mortality (adjusted hazard ratio [0.8-1.4]) or major amputation (adjusted hazard ratio, 2.5 [95% CI, 0.8-7.6]) between Black and White patients. CONCLUSIONS Black patients presenting for PVI were younger, had higher prevalence of comorbidities and lower socioeconomic status. After adjustment, Black patients were less likely to have surgical or repeat PVI revascularization after the index PVI procedure.
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Affiliation(s)
- Howard M Julien
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
- Penn Cardiovascular Center for Health Equity and Social Justice, Philadelphia (H.M.J., L.A.E.)
| | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (Y.W., J.P.C.)
- Center of Outcome Research and Evaluation Yale New Haven Health System, CT (Y.W., J.P.C.)
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (Y.W., J.P.C.)
- Center of Outcome Research and Evaluation Yale New Haven Health System, CT (Y.W., J.P.C.)
| | - Hillary Johnston-Cox
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Lauren A Eberly
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Penn Cardiovascular Center for Health Equity and Social Justice, Philadelphia (H.M.J., L.A.E.)
| | - Grace J Wang
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Ashwin S Nathan
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Alexander C Fanaroff
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
| | - Eric A Secemsky
- Department of Medicine, Harvard Medical School, Boston, MA (E.A.S.)
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.A.S.)
| | - Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
| | - Amit N Vora
- University of Pittsburgh Medical Center-Pinnacle, Wormleysburg, PA (A.N.V.)
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
| | - Carlos Barbery
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Godefroy Chery
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Maureen Kohi
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill (M.K.)
| | - Lee Kirksey
- Division of Vascular Surgery, Cleveland Clinic, OH (L.K.)
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO (E.J.A.)
- University of Colorado School of Medicine, Aurora (E.J.A.)
| | - Michael R Jaff
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston (M.R.J.)
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
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Kolossváry E, Farkas K, Karahan O, Golledge J, Schernthaner GH, Karplus T, Bernardo JJ, Marschang S, Abola MT, Heinzmann M, Edmonds M, Catalano M. The importance of socio-economic determinants of health in the care of patients with peripheral artery disease: A narrative review from VAS. Vasc Med 2023; 28:241-253. [PMID: 37154387 PMCID: PMC10265288 DOI: 10.1177/1358863x231169316] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Socio-economic determinants of health (SDoH) include various nonmedical factors in the socio-economic sphere with a potentially significant impact on health outcomes. Their effects manifest through several mediators/moderators (behavioral characteristics, physical environment, psychosocial circumstances, access to care, and biological factors). Various critical covariates (age, gender/sex, race/ethnicity, culture/acculturation, and disability status) also interact. Analyzing the effects of these factors is challenging due to their enormous complexity. Although the significance of SDoH for cardiovascular diseases is well documented, research regarding their impact on peripheral artery disease (PAD) occurrence and care is less well documented. This narrative review explores to what extent SDoH are multifaceted in PAD and how they are associated with its occurrence and care. Additionally, methodological issues that may hamper this effort are addressed. Finally, the most important question, whether this association may contribute to reasonable interventions aimed at SDoH, is analyzed. This endeavor requires attention to the social context, a whole systems approach, multilevel-thinking, and a broader alliance that reaches out to more stakeholders outside the medical sphere. More research is needed to justify the power in this concept to improve PAD-related outcomes like lower extremity amputations. At the present time, some evidence, reasonable consideration, and intuitive reasoning support the implementation of various interventions in SDoH in this field.
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Affiliation(s)
- Endre Kolossváry
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- Department of Angiology, St Imre University Teaching Hospital, Budapest, Hungary
| | - Katalin Farkas
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- Department of Angiology, St Imre University Teaching Hospital, Budapest, Hungary
| | - Oguz Karahan
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- Department of Cardiovascular Surgery, Medical School of Alaaddin Keykubat University, Alanya/Antalya, Diyarbakir, Turkey
| | - Jonathan Golledge
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- James Cook University & Townsville University Hospital, Townsville, QLD, Australia
| | - Gerit-Holger Schernthaner
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Karplus
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- Department of Vascular Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Jonathan James Bernardo
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- Department of Vascular Medicine, St Luke’s Medical Center, Quezon, NCR, Philippines
| | - Sascha Marschang
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- Department Managing Committee, VAS-European Independent Foundation in Angiology/Vascular Medicine, Bruxelles, Belgium
| | - Maria Teresa Abola
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- University of the Philippines College of Medicine–Philippine, Philippine Heart Center, Quezon, Philippines
| | - Monica Heinzmann
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- Angiology Unit, Allende Sanatorium, Nueva, Cordóba, Argentina
| | - Michael Edmonds
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- King’s College Hospital, Diabetic Foot Clinic, London, UK
| | - Mariella Catalano
- VAS-European Independent Foundation in Angiology/Vascular Medicine
- VAS-International Consortium – International PAD Strategic Network
- Inter-University Research Center on Vascular Disease, Department Biomedical and Clinical Science, University of Milan, Milan, Italy
- Department of Biomedical and Clinical Sciences L Sacco Hospital, Inter-University Research Center on Vascular Disease, University of Milan, Milan, Italy
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Radtka JF, Zil-E-Ali A, Medina D, Aziz F. Patients from distressed communities are more likely to be symptomatic at endovascular aneurysm repair and have an increased risk of being lost to long-term follow-up. J Vasc Surg 2023; 77:1087-1098.e3. [PMID: 36343872 DOI: 10.1016/j.jvs.2022.10.053] [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: 06/24/2022] [Revised: 10/17/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has become the preferred modality to repair abdominal aortic aneurysms (AAAs). However, the effect of the distressed communities index (DCI) on the outcomes of EVAR is still unknown. In the present study, we investigated the effect of DCI on the postoperative outcomes after EVAR. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was used for the present study. Patients who had undergone EVAR from 2003 to 2021 were selected for analysis. The study cohort was divided into two groups according to their DCI score. Patients with DCI scores ranging from 61 to 100 were assigned to group I (DCI >60), and those with DCI scores ranging from 0 to 60 were assigned to group II (DCI ≤60). The primary outcomes included the 30-day and 1-year mortality and major adverse cardiovascular events at 30 days. Regression analyses were performed to study the postoperative outcomes. P values ≤ .05 were deemed statistically significant for all analyses in the present study. RESULTS A total of 60,972 patients (19.5% female; 80.5% male) had undergone EVAR from 2003 to 2021. Of these patients, 18,549 were in group I (30.4%) and 42,423 in group II (69.6%). The mean age of the study cohort was 73 ± 8.9 years. Group I tended to be younger (mean age, 72.6 vs 73.7 years), underweight (3.5% vs 2.5%), and African American (10.8% vs 3.5%) and were more likely to have Medicaid insurance (3.6% vs 1.9%; P < .05 for all). Group I had had more smokers (87.3% vs 85.3%), a higher rate of comorbidities, including hypertension (84.5% vs 82.9%), diabetes (21.7% vs 19.7%), coronary artery disease (30.3% vs 28.6%), chronic obstructive pulmonary disease (36.9% vs 31.8%), and moderate to severe congestive heart failure (2.6% vs 2%; P < .05 for all). The group I patients were more likely to undergo EVAR for symptomatic AAAs (11.1% vs 7.9%; P < .001; adjusted odds ratio [aOR], 1.25; 95% confidence interval [CI], 1.15-1.37; P < .001) with a higher risk of mortality at 30 days (aOR, 3.98; 95% CI, 2.23-5.44; P < .001) and 1 year (aOR, 1.74; 95% CI, 1.43-2.13; P < .001). A higher risk of being lost to follow-up (28.9% vs 26.3%; P < .001) was also observed in group I. CONCLUSIONS Patients from distressed communities who require EVAR tended to have multiple comorbidities. These patients were also more likely to be treated for symptomatic AAAs, with a higher risk of mortality. An increased incidence of lost to long-term follow-up was also observed for this population. Surgeons and healthcare systems should consider these outcomes and institute patient-centered approaches to ensure equitable healthcare.
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Affiliation(s)
- John F Radtka
- Division of Vascular Surgery, Pennsylvania State University College of Medicine, Hershey, PA
| | - Ahsan Zil-E-Ali
- Division of Vascular Surgery, Pennsylvania State University College of Medicine, Hershey, PA.
| | - Daniela Medina
- Office of Medical Education, Pennsylvania State University College of Medicine, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Pennsylvania State University College of Medicine, Hershey, PA
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Vilariño-Rico J, Fariña-Casanova X, Martínez-Gallego EL, Hernández-Lahoz I, Rielo-Arias F, Pértega S, Encisa JM, García-Colodro JM, Fernández-Noya J. The Influence of the Socioeconomic Status and the Density of the Population on the Outcome After Peripheral Artery Disease. Ann Vasc Surg 2023; 89:269-279. [PMID: 36404448 DOI: 10.1016/j.avsg.2022.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Low socioeconomic status (SES) and living in a rural environment are associated with poorer health and a higher number of amputations among the population at large. The purpose of this study is to determine the influence of low SES and of the degree of urbanization on the short-term and long-term results of patients after revascularization for peripheral artery disease. METHODS An observational retrospective follow-up study of 770 patients operated on for peripheral artery disease at three university centers in north-western Spain from January 2015 to December 2016. The events studied were Rutherford classification of severity upon admission, direct amputation, amputations in the follow-up period, new revascularization procedures, major adverse cardiovascular events (MACE), and overall mortality. Mean personal income and income of the household associated with the street in which each patient lived and the degree of urbanization in three areas as per Eurostat criteria: densely populated areas, intermediate density areas, and thinly populated areas. Comorbidity, surgical, and follow-up variables were also collected. Descriptive analysis and Cox regression were used. Approval was obtained from the regional ethics committee. RESULTS Median follow-up was 47.5 months. MACE occurred in 21.5% of the series and overall mortality was 47.0%. Living in a thinly populated area is associated with a lower risk of MACE (adjusted subhazard ratio = 0.60; 95% confidence interval [CI]: 0.39-0.91). Overall survival is lower in intermediate density area patients (adjusted Hazard Ratio = 1.46; 95% CI: 1.07-2.00). The third quartile of mean personal and household income is associated with a higher risk of major amputation at follow-up (adjusted Odds Ratio 1.92, 95% CI: 1.05-3.52 and adjusted Odds Ratio 1.93, 95% CI: 1.0.3-3.61, respectively). CONCLUSIONS Patients who live in a densely populated area run a higher risk of MACE. SES is neither associated with worse outcomes after surgery nor with MACE in long-term follow-up.
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Affiliation(s)
- Jorge Vilariño-Rico
- Angiology and Vascular Surgery Service, A Coruña University Hospital Complex, A Coruña, Spain.
| | | | | | | | | | - Sonia Pértega
- Clinical Epidemiology and Biostatistics Unit, A Coruña University Hospital Complex, A Coruña, Spain
| | - José Manuel Encisa
- Angiology and Vascular Surgery Service, Vigo Hospital Complex, Vigo, Spain
| | | | - Jorge Fernández-Noya
- Angiology and Vascular Surgery Service, A Coruña University Hospital Complex, A Coruña, Spain
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15
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Hughes K, Olufajo OA, White K, Roby DH, Fryer CS, Wright JL, Sehgal NJ. The Relationship Between Peripheral Arterial Disease Severity and Socioeconomic Status. Ann Vasc Surg 2023; 92:33-41. [PMID: 36736719 DOI: 10.1016/j.avsg.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although socioeconomic disparities in outcomes of peripheral artery disease (PAD) have been well studied, little is known about relationship between severity of PAD and socioeconomic status. The objective of this study was to examine this relationship. METHODS Patients who had operations for severe PAD (rest pain or tissue loss) were identified in the National Inpatient Sample, 2005-2014. They were stratified by the median household income (MHI) quartiles of their residential ZIP codes. Other characteristics such as race/ethnicity and insurance type were extracted. Factors associated with more severe disease (tissue loss) were evaluated using multivariable regression analyses. RESULTS There were 765,175 patients identified; 34% in the first MHI quartile and 18% in the fourth MHI quartile. Compared to patients in the first quartile, those in the fourth quartile were more likely White (69% vs. 42%, P < 0.001), more likely ≥65 years old (75% vs. 62%, P < 0.001), and were less likely to undergo amputations (25% vs. 34%, P < 0.001). After adjusting for patient characteristics, the fourth quartile was associated with more severe disease [Odds ratio: 1.19, 95% confidence interval (CI): 1.11-1.27] compared to the first quartile. CONCLUSIONS While higher MHI was associated with higher PAD severity, patients with high MHI were less likely to undergo amputations indicating a disparity in the choice of treatment for PAD. Increased efforts are necessary to reduce socioeconomic disparities in the treatment of severe PAD.
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Affiliation(s)
- Kakra Hughes
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD; Department of Surgery, Howard University College of Medicine, Washington, DC.
| | - Olubode A Olufajo
- Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Kellee White
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD
| | - Dylan H Roby
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD
| | - Craig S Fryer
- Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park, MD
| | - Joseph L Wright
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD; University of Maryland Capital Region Health, Cheverly, MD
| | - Neil J Sehgal
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD
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Association between patient-surgeon race and gender concordance and patient-reported outcomes following breast cancer surgery. Breast Cancer Res Treat 2023; 198:167-175. [PMID: 36622543 DOI: 10.1007/s10549-022-06858-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/30/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Surgeon- and patient-related factors have been shown to influence patient experiences, quality of life (QoL), and surgical outcomes. We examined the association between patient-surgeon race and gender concordance with QoL after breast reconstruction. METHODS We conducted a retrospective cross-sectional analysis of patients who underwent lumpectomy or mastectomy followed by breast reconstruction over a 3-year period. We created the following categories with respect to the race and gender of a patient-surgeon triad: no, intermediate, and perfect concordance. Multivariable regression was used to correlate postoperative global (SF-12) and condition-specific (BREAST-Q) QoL performance with patient-level covariates, gender and race concordance. RESULTS We identified 375 patients with a mean (± SD) age of 57.6 ± 11.9 years, median (IQR) body mass index of 27.5 (24.0, 32.0), and median morbidity burden of 3 (2, 4). The majority of encounters were of intermediate concordance for gender (70%) and race (52%). Compared with gender-discordant triads, intermediate gender concordance was associated with higher SF-Mental scores (β, 2.60; 95% CI, 0.21-4.99, p = 0.003). Perfect race concordance (35% of encounters) was associated with significantly higher adjusted SF-Physical scores (β, 2.14; 95% CI, 0.50-4.22, p = 0.045) than the race-discordant group. There were no significant associations observed between race or gender concordance and BREAST-Q performance. CONCLUSION Race-concordant relationships following breast cancer surgery were more likely to have improved global QoL. Perfect gender concordance was not associated with variation in QoL outcomes. Policy-level interventions are needed to facilitate personalized care and optimize breast cancer surgery outcomes.
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Hassan AM, Nguyen HT, Corkum JP, Liu J, Kapur SK, Chu CK, Tamirisa N, Offodile AC. Area Deprivation Index is Associated with Variation in Quality of Life and Psychosocial Well-being Following Breast Cancer Surgery. Ann Surg Oncol 2023; 30:80-87. [PMID: 36085393 DOI: 10.1245/s10434-022-12506-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/18/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neighborhood-level factors have been shown to influence surgical outcomes through material deprivation, psychosocial mechanisms, health behaviors, and access to resources. To date, no study has examined the relationship between area-level deprivation (ADI) and post-mastectomy outcomes. METHODS A cross-sectional survey of adult female breast cancer patients who underwent lumpectomy or mastectomy between January 2018 to June 2019 was carried out. Patient-specific characteristics and ADI information were abstracted and correlated with postoperative global- (SF-12) and condition-specific (BREAST-Q) quality-of-life performance via multivariable regression. Patients were classified into three ADI terciles: 0-39 (low deprivation), 40-59 (moderate deprivation), and 60-100 (high deprivation). RESULTS A total of 564 consecutive patients were identified, being mostly white (75%) with mean age of 60.2 ± 12.4 years, median body mass index of 27.8 [interquartile range (IQR) 24.3-32.2) kg/m2, median Charlson Comorbidity Index of 3 (IQR 2-5), and mean ADI of 42.3 ± 25.7. African American and Hispanic patients and those with high BMI were more likely to reside in highly deprived neighborhoods (p = 0.003 and p < 0.001). In adjusted models, patients in highly deprived neighborhoods had significantly lower mean SF-12 physical (44.9 [95% CI, 43.8-46.0] versus 44.9 [95% CI, 43.7-46.1] versus 46.3 [95% CI, 45.3-47.3], p = 0.03) and BREAST-Q psychosocial well-being scores (63.5 [95% CI, 59.32-67.8] versus 69.3 [95% CI, 65.1-73.6] versus 69.7 [95% CI, 66.4-73.1], p = 0.01) relative to moderate- and low-deprivation groups. CONCLUSIONS Patients residing in the most deprived neighborhoods were identified to have worse psychological well-being and quality-of-life. The ADI should be incorporated into the shared decision-making process and perioperative counseling to engender value-based and personalized care, especially for vulnerable populations.
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Affiliation(s)
- Abbas M Hassan
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huan T Nguyen
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Joseph P Corkum
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Liu
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sahil K Kapur
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carrie K Chu
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nina Tamirisa
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anaeze C Offodile
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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18
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Villarreal ME, Jalilvand A, Schubauer K, Kellet W, DiDonato C, Roberts L, Helkin A, Scarlet S, Wisler J. Comorbidities Matter as Distressed Communities Index Fails to Predict Mortality in Necrotizing Soft Tissue Infection. Surg Infect (Larchmt) 2022; 23:801-808. [DOI: 10.1089/sur.2022.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Anahita Jalilvand
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kathryn Schubauer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Whitney Kellet
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Courtney DiDonato
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Luke Roberts
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alex Helkin
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sara Scarlet
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jonathan Wisler
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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19
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Ramadan OI, Santos T, Stoecker JB, Belkin N, Jackson BM, Schneider DB, Rice J, Wang GJ. The Differential Impact of Medicaid Expansion on Disparities in Outcomes Following Peripheral Vascular Intervention. Ann Vasc Surg 2022; 86:135-143. [PMID: 35460861 DOI: 10.1016/j.avsg.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Peripheral artery disease (PAD) disproportionately affects nonwhite, Hispanic/Latino, and low socioeconomic status patients, who are less likely to have insurance and routine healthcare visits. Medicaid expansion (ME) has improved insurance rates and access to care, potentially benefitting these patients. We sought to assess the impact of ME on disparities in outcomes after peripheral vascular intervention (PVI) for PAD. METHODS A retrospective analysis of prospectively-collected Vascular Quality Initiative PVI procedures between 2011 and 2019 was conducted. The sample was restricted to first-record procedures in adults under the age 65 in states that expanded Medicaid on January 1, 2014 (ME group) or had not expanded before January 1, 2019 (non-expansion [NE] group). ME and NE groups were compared between pre-expansion (2011-2013) and post-expansion (2014- 2019) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors and clinical center and year fixed effects. Our primary outcome was 1-year major amputation. Secondary outcomes included trends in presentation, 30-day mortality, 1-year mortality, and 1-year primary and secondary patency. Outcomes were stratified by race and ethnicity. RESULTS We examined 34,313 PVI procedures, including 20,378 with follow-up data. Rates of Medicaid insurance increased post-expansion in ME and NE states (ME 16.7% to 23.0%, P < 0.001; NE 10.0% to 11.9%, P = 0.013) while rates of self-pay decreased in ME states only (ME 4.6% to 1.8%, P < 0.001; NE 8.1% to 8.4%, P = 0.620). Adjusted difference-in-differences analysis revealed lower odds of urgent/emergent PVI among all patients and all nonwhite patients in ME states post-expansion compared to NE states (all: odds ratio [OR] 0.53 [95% confidence interval 0.33-0.87], P = 0.011; nonwhite: OR 0.41 [0.19-0.88], P = 0.023). No differences were observed for 1-year major amputation (OR 0.70 [0.43-1.14], P = 0.152), primary patency (OR 0.93 [0.63-1.38], P = 0.726), or secondary patency (OR 1.29 [0.69-2.41], P = 0.431). Odds of 1-year mortality were higher in ME states post-expansion compared to NE states (OR 2.50 [1.07-5.87], P = 0.035), although 30-day mortality was not different (OR 2.04 [0.60-6.90], P = 0.253). Notably, odds of 1-year major amputation among Hispanic/Latino patients decreased in ME states post-expansion compared to NE states (OR 0.11 [0.01-0.86], P = 0.036). CONCLUSIONS ME was associated with lower odds of 1-year major amputation among Hispanic/Latino patients who underwent PVI for PAD. ME was also associated with lower odds of urgent/emergent procedures among patients overall and nonwhite patients specifically. However, 1-year mortality increased in the overall cohort. Further study is needed to corroborate our findings that ME may have benefits for certain underserved populations with PAD.
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Affiliation(s)
- Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Tatiane Santos
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; The Wharton School at the University of Pennsylvania, Philadelphia, PA
| | - Jordan B Stoecker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Nathan Belkin
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Benjamin M Jackson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Darren B Schneider
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jayne Rice
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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20
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Su AY, Vinogradsky A, Wang AS, Ning Y, Abrahams E, Bacchetta M, Kurlansky P, Rosenzweig EB, Takeda K. Impact of Sex, Race, and Socioeconomic Status on Survival after Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension. Eur J Cardiothorac Surg 2022; 62:6637515. [PMID: 35809067 DOI: 10.1093/ejcts/ezac364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/04/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Pulmonary thromboendarterectomy (PTE) is a definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH). Demographic-based disparities in PTE outcomes have not been well studied. METHODS We reviewed all patients who underwent PTE for CTEPH between 2009 and 2019 at our institution, tracking demographic information including self-identified race, preoperative characteristics, and 2-year survival. Socioeconomic status (SES) was assessed using the zip code-linked Distressed Communities Index, a validated holistic measure of community well-being. Survival was estimated using Kaplan-Meier method and factors associated with mortality were estimated using Cox regression. RESULTS Of 235 PTE patients, 101 (42.9%) were white and 87 (37.0%) were black. White patients had a higher median age at surgery (57 vs. 51 years, P = 0.035) and a lower degree of economic distress (33.6 vs. 61.2 percentile, P < 0.001). Regarding sex, 106 (45.1%) patients were male and 129 (53.6%) were female. Male patients had a higher median age (59 vs. 50 years, P = 0.004), greater rates of dyslipidaemia (34% vs. 20.2%, P = 0.025), a lower ejection fraction (55% vs. 57%, P = 0.046), and longer cross-clamp (77 vs. 67.50 min, P = 0.004) and circulatory arrest times (42 vs. 37.50 min, P = 0.007). No difference was observed in unadjusted 2-year survival after PTE between patients stratified by race and sex (P = 0.35). After adjustment for clinically relevant variables, neither SES, sex, or race were associated with mortality in Cox proportional hazard analysis. CONCLUSIONS Sex, SES, and race were not associated with adverse outcomes after PTE in our single center experience.
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Affiliation(s)
- Austin Y Su
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
| | - Alice Vinogradsky
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
| | - Amy S Wang
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
| | - Yuming Ning
- Center of Innovation and Outcomes Research, Department of Surgery, Columbia University
| | - Elizabeth Abrahams
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Matthew Bacchetta
- Departments of Thoracic and Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paul Kurlansky
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
| | - Erika B Rosenzweig
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY
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21
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Greenberg AL, Lin JA, Colley A, Finlayson E, Bongiovanni T, Wick EC. Characteristics and Procedures Among Adults Discharged to Hospice After Gastrointestinal Tract Surgery in California. JAMA Netw Open 2022; 5:e2220379. [PMID: 35793086 PMCID: PMC9260472 DOI: 10.1001/jamanetworkopen.2022.20379] [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] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Hospice care is associated with improved quality of life and goal-concordant care. Limited data suggest that provision of hospice services after surgery is suboptimal; however, literature in this domain is in its nascency, leaving gaps in our understanding of patients who enroll in hospice after surgery. OBJECTIVE To characterize the transition to hospice after gastrointestinal tract surgery and identify areas that warrant further attention and intervention. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients discharged to hospice after a surgical hospitalization for a digestive disorder in California-licensed hospitals between January 1, 2015, and December 31, 2019. Data were analyzed from August 1 to November 30, 2021. EXPOSURES Patient age, race and ethnicity, principal language, payer, and Distressed Community Index (DCI). MAIN OUTCOMES AND MEASURES Admission type and most common diagnoses and procedures for surgical hospitalizations that resulted in discharge to hospice, annual hospitalization trend for 3 years preceding hospice enrollment, and most common diagnoses for patients who were readmitted after hospice enrollment were summarized. Age, race and ethnicity, principal language, payer, and DCI were compared between patients who were readmitted after hospice enrollment and those who were not. RESULTS Of 2688 patients with surgical hospitalizations resulting in discharge to hospice (mean [SD] age, 73.2 [14.7] years; 1459 women [54.3%]), 2389 (88.9%) had urgent or emergent discharges. The most common diagnoses were cancer (primary and metastatic; 1541 [57.3%]) and bowel obstruction (563 [20.9%]). The most common procedures were bowel resection, fecal diversion, inferior vena cava filter, gastric bypass, and paracentesis. In the 3 years preceding hospice enrollment, this cohort had a mean (SD) of 2.21 (2.77) hospitalizations per patient (1537 of 5953 surgical [25.8%]). Of these, 3594 of 5953 total (60.4%) and 840 of 1537 surgical (54.7%) hospitalizations were within 1 year of hospice enrollment. Three hundred and sixty-eight patients (13.7%) were readmitted after hospice enrollment, with infection being the most common readmission diagnosis. Readmitted patients were more likely to be younger (mean [SD] age, 69.7 [16.4] vs 73.8 [14.3] years; P < .001), to speak a principal language other than English (62 of 368 [16.8%] vs 292 of 2320 [12.6%]; P = .02), to be insured through Medicaid (70 of 368 [19.0%] vs 223 of 2320 [9.6%]; P < .001), and to be from a community with higher DCI (198 of 360 [55.0%] vs 1117 of 2269 [49.2%]; P = .04) and were less likely to be White (195 of 368 [53.0%] vs 1479 of 2320 [63.8%]; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest multiple opportunities for advance care planning in this surgical cohort, with a particular focus on emergent care. Further study is needed to understand the reasons for rehospitalization after hospice discharge and identify ways to improve communication and decision-making support for patients who choose to enroll in hospice care. Given the frequent antecedent interactions with the health care system among this population, longitudinal and tailored approaches may be beneficial to promote equitable end-of-life care; however, further research is needed to clarify barriers and understand differing patient needs.
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Affiliation(s)
| | - Joseph A. Lin
- Department of Surgery, University of California, San Francisco
| | - Alexis Colley
- Department of Surgery, University of California, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
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22
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de Jager E, Gunnarsson R, Ho YH. Disparities in surgical outcomes for low socioeconomic status patients in Australia. ANZ J Surg 2022; 92:1026-1032. [PMID: 35388595 PMCID: PMC9322460 DOI: 10.1111/ans.17675] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/16/2022] [Accepted: 03/20/2022] [Indexed: 01/14/2023]
Abstract
Background There are disparities in surgical outcomes for patients of low socioeconomic status globally, including in countries with universal healthcare systems. There is limited data on the impact of low socioeconomic status on surgical outcomes in Australia. This study examines surgical outcomes by both self‐reported unemployment and neighbourhood level socioeconomic status in Australia. Methods A retrospective administrative data review was conducted at a tertiary care centre over a 10‐year period (2008–2018) including all adult surgical patients. Multivariable logistic regression adjusting for year, age, sex and Charlson Comorbidity Index was performed. Results 106 197 patients underwent a surgical procedure in the decade examined. The overall adverse event rates were mortality (1.13%), total postoperative complications (10.9%), failure to rescue (0.75%) and return to theatre (4.31%). Following multivariable testing, unemployed and low socioeconomic patients had a higher risk of postoperative mortality (OR 2.06 (1.50–2.82), OR 1.37 (1.15–1.64)), all complications (OR 1.43 (1.31–1.56), OR 1.21 (1.14–1.28)), failure to rescue (OR 2.03 (1.39–2.95), OR 1.38 (1.11–1.72)) and return to theatre (OR 1.42 (1.27–1.59), OR 1.24 (1.14–1.36)) (P < 0.005 for all). Conclusions Despite universal healthcare, there are disparities in surgical adverse events for patients of low socioeconomic status in Australia. Disparities in surgical outcomes can stem from three facets: a patient's access to healthcare (the severity of disease at the time of presentation), variation in perioperative care delivery, and social determinants of health. Further work is required to pinpoint why these disparities are present and to evaluate the impact of strategies that aim to reduce disparities.
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Affiliation(s)
- Elzerie de Jager
- College of Medicine and Dentistry, The James Cook University, Townsville, Queensland, Australia
| | - Ronny Gunnarsson
- General Practice/Family medicine, School of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden.,Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden.,Primary Health Care Clinic for Homeless people, Närhälsan, Region Västra Götaland, Sweden
| | - Yik-Hong Ho
- College of Medicine and Dentistry, The James Cook University, Townsville, Queensland, Australia.,Townsville Clinical School, The Townsville Hospital, Townsville, Queensland, Australia
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23
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Rogers MP, DeSantis AJ, Janjua HM, Kulshrestha S, Kuo PC, Lozonschi L. Outcomes of Transcatheter and Surgical Aortic Valve Replacement in Distressed Socioeconomic Communities. Cureus 2022; 14:e23643. [PMID: 35510019 PMCID: PMC9057310 DOI: 10.7759/cureus.23643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/30/2022] [Indexed: 11/26/2022] Open
Abstract
Objective Patients of low socioeconomic status have an increased risk of complications following cardiac surgery. We aimed to identify disparities in patients undergoing aortic valve replacement using the Distressed Communities Index (DCI), a comparative measure of community well-being. The DCI incorporates seven distinct socioeconomic indicators into a single composite score to depict the economic well-being of a community. Methods The Healthcare Cost and Utilization Project State Inpatient Database (HCUP-SID) for Florida and Washington was queried to identify patients undergoing surgical and transcatheter aortic valve replacement (surgical aortic valve replacement [SAVR], transcatheter aortic valve replacement [TAVR]) between 2012-2015. Patients undergoing TAVR and SAVR were propensity-matched and stratified based on the quintile of DCI score. A distressed community was defined as those in quintiles 4 and 5 (at-risk and distressed, respectively); a non-distressed community was defined as those in quintiles 1 and 2 (prosperous and comfortable, respectively). Outcomes following aortic valve replacement were compared across groups in distressed communities. Propensity score matching was used to balance baseline covariates between groups. Results A total of 27,591 patients underwent aortic valve replacement. After propensity matching, 5,331 patients were identified in each TAVR and SAVR group. Distressed TAVR patients had lower rates of postoperative pneumonia (7.6% vs. 3.8%, p<0.001), sepsis (3.6% vs. 1.9%, p<0.05), and cardiac complications (15.4% vs. 7.5%, p<0.001) when compared to highly distressed SAVR patients. When comparing distressed SAVR and TAVR and low distressed SAVR and TAVR groups, no significant difference was found in postoperative outcomes, except distressed TAVR experienced more cases of UTI. Conclusions Highly distressed TAVR patients had lower incidences of postoperative sepsis, pneumonia, and cardiac complications when compared to the highly distressed SAVR cohort. Patients undergoing TAVR in highly distressed communities had an increased incidence of postoperative urinary tract infection. DCI may be a useful adjunct to current risk scoring systems.
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24
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Mentias A, Desai MY, Vaughan-Sarrazin MS, Rao S, Morris AA, Hall JL, Menon V, Hockenberry J, Sims M, Fonarow GC, Girotra S, Pandey A. Community-Level Economic Distress, Race, and Risk of Adverse Outcomes After Heart Failure Hospitalization Among Medicare Beneficiaries. Circulation 2022; 145:110-121. [PMID: 34743555 PMCID: PMC9172990 DOI: 10.1161/circulationaha.121.057756] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Socioeconomic disadvantage is a strong determinant of adverse outcomes in patients with heart failure. However, the contribution of community-level economic distress to adverse outcomes in heart failure may differ across races and ethnicities. METHODS Patients of self-reported Black, White, and Hispanic race and ethnicity hospitalized with heart failure between 2014 and 2019 were identified from the Medicare MedPAR Part A 100% Files. We used patient-level residential ZIP code to quantify community-level economic distress on the basis of the Distressed Community Index (quintile 5: economically distressed versus quintiles 1-4: nondistressed). The association of continuous and categorical measures (distressed versus nondistressed) of Distressed Community Index with 30-day, 6-month, and 1-year risk-adjusted mortality, readmission burden, and home time were assessed separately by race and ethnicity groups. RESULTS The study included 1 611 586 White (13.2% economically distressed), 205 840 Black (50.6% economically distressed), and 89 199 Hispanic (27.3% economically distressed) patients. Among White patients, living in economically distressed (versus nondistressed) communities was significantly associated with a higher risk of adverse outcomes at 30-day and 1-year follow-up. Among Black and Hispanic patients, the risk of adverse outcomes associated with living in distressed versus nondistressed communities was not meaningfully different at 30 days and became more prominent by 1-year follow-up. Similarly, in the restricted cubic spline analysis, a stronger and more graded association was observed between Distressed Community Index score and risk of adverse outcomes in White patients (versus Black and Hispanic patients). Furthermore, the association between community-level economic distress and risk of adverse outcomes for Black patients differed in rural versus urban areas. Living in economically distressed communities was significantly associated with a higher risk of mortality and lower home time at 1-year follow-up in rural areas but not urban areas. CONCLUSIONS The association between community-level economic distress and risk of adverse outcomes differs across race and ethnic groups, with a stronger association noted in White patients at short- and long-term follow-up. Among Black patients, the association of community-level economic distress with a higher risk of adverse outcomes is less evident in the short term and is more robust and significant in the long-term follow-up and rural areas.
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Affiliation(s)
- Amgad Mentias
- Heart, Thoracic and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Milind Y. Desai
- Heart, Thoracic and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Mary S Vaughan-Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA
| | - Shreya Rao
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | | | - Jennifer L. Hall
- Institute for Precision Cardiovascular Medicine, American Heart Association, Dallas, TX
| | - Venu Menon
- Heart, Thoracic and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Jason Hockenberry
- Department of Public Health (Health Policy), Yale School of Public Health, New Haven, CT
| | - Mario Sims
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Gregg C. Fonarow
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Saket Girotra
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA
- Division of Cardiovascular Diseases, Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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25
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Witrick B, Shi L, Mayo R, Hendricks B, Kalbaugh CA. The association between socioeconomic distress communities index and amputation among patients with peripheral artery disease. Front Cardiovasc Med 2022; 9:1021692. [PMID: 36407449 PMCID: PMC9668855 DOI: 10.3389/fcvm.2022.1021692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Background Socioeconomic factors have been shown to be associated with amputation in peripheral artery disease (PAD); however, analyses have normally focused on insurance status, race, or median income. We sought to determine whether community-level socioeconomic distress was associated with major amputation and if that association differed by race. Materials and methods Community-level socioeconomic distress was measured using the distressed communities index (DCI). The DCI is a zip code level compositive socioeconomic score (0-100) that accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies. A distressed community was defined as a zip code with DCI of 40 or greater. We calculated one-year risk of major amputation by DCI score for individuals with peripheral artery disease in South Carolina, 2012-2017. Treating death as competing event, we reported Fine and Gray subdistribution hazards ratios (sdHR), adjusted for patient demographic and clinical comorbidities associated with amputation. Further analyses were completed to identify potential differences in outcomes within strata of race and DCI. Results Among 82,848 individuals with peripheral artery disease, the one-year incidence of amputation was 3.5% (95% CI: 3.3%, 3.6%) and was significantly greater in distressed communities than non-distressed communities (3.9%; 95% CI: 3.8%, 4.1% vs. 2.4%; 95% CI: 2.2%, 2.6%). After controlling for death and adjusting for covariates, we found an increased hazard of amputation among individuals in a distressed community (sdHR: 1.25; 95% CI: 1.14, 1.37), which persisted across racial strata. However, regardless of DCI score, Black individuals had the highest incidence of amputation. Conclusion Socioeconomic status is independently predictive of limb amputation after controlling for demographic characteristics and clinical comorbidities. Race continues to be an important risk factor, with Black individuals having higher incidence of amputation, even in non-distressed communities, than White individuals had in distressed communities.
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Affiliation(s)
- Brian Witrick
- West Virginia Clinical and Translational Science Institute, Morgantown, WV, United States
- *Correspondence: Brian Witrick,
| | - Lu Shi
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Rachel Mayo
- Department of Public Health Sciences, Clemson University, Clemson, SC, United States
| | - Brian Hendricks
- West Virginia Clinical and Translational Science Institute, Morgantown, WV, United States
- Department of Epidemiology and Biostatistics, West Virginia University School of Public Health, Morgantown, WV, United States
| | - Corey A. Kalbaugh
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, IN, United States
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Social Deprivation and Peripheral Artery Disease. Can J Cardiol 2021; 38:612-622. [PMID: 34971734 DOI: 10.1016/j.cjca.2021.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/08/2021] [Accepted: 12/22/2021] [Indexed: 12/24/2022] Open
Abstract
The link between peripheral artery disease and socioeconomic status is complex. The objective of this narrative review is to explore this relationship in detail, including how social factors impact the development, management, and outcomes of peripheral artery disease. Although the current literature on this topic is limited, some patterns do emerge. Populations of low socioeconomic status appear to be at increased risk for the development of peripheral artery disease, due to factors such as increased prevalence of cardiovascular risk factors (i.e. cigarette smoking) and decreased access to care. However, variables that are more difficult to quantify, such as chronic stress and health literacy, also likely play a significant role. Among those who are living with peripheral artery disease, socioeconomic status can also affect disease management. Secondary prevention strategies, such as medication use, smoking cessation, and exercise therapy, are underutilized in socially deprived populations. This underutilization of evidence-based management leads to adverse outcomes in these groups, including increased rates of amputation and decreased post-operative survival. The recognition of the importance of social factors in prognosis is an important first step towards addressing this health disparity. Moving forward, interventions that help to identify those who are at high risk and help to improve access to care in populations of low socioeconomic status, will be critical to improving outcomes.
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Distressed Communities Index in Patients Undergoing Transcatheter Aortic Valve Implantation in an Affluent County in New York. J Interv Cardiol 2021; 2021:8837644. [PMID: 34497479 PMCID: PMC8407997 DOI: 10.1155/2021/8837644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 07/07/2021] [Accepted: 08/13/2021] [Indexed: 12/30/2022] Open
Abstract
Background The clinical impact of the distressed communities index (DCI), a composite measure of economic well-being based on the U.S. zip code, is becoming increasingly recognized. Ranging from 0 (prosperous) to 100 (distressed), DCI's association with cardiovascular outcomes remains unknown. We aimed to study the association of the DCI with presentation and outcomes in adults with severe symptomatic aortic stenosis (AS) undergoing transcatheter aortic valve intervention (TAVR) in an affluent county in New York. Methods The study population included 286 patients with severe symptomatic AS or degeneration of a bioprosthetic valve who underwent TAVR with a newer generation transcatheter heart valve (THV) from December 2015 to June 2018 at an academic tertiary medical center. DCI for each patient was derived from their primary residence zip code. Patients were classified into DCI deciles and then categorized into 4 groups. The primary and secondary outcomes of interest were 30-day, 1-year, and 3-year mortality, respectively. Results Among 286 patients studied, 26%, 28%, 28%, and 18% were categorized into DCI groups 1–4, respectively (DCI <10: n = 73; DCI 10–20: n = 81; DCI 20–30: n = 80; DCI >30: n = 52). Patients in group 4 were younger with worse kidney function compared to patients in groups 1 and 2. They also had smaller aortic annuli and were more likely to receive a smaller THV. No significant difference in hospital length of stay or distribution of in-hospital, 30-day, 1-year, and 3-year mortality was demonstrated. Conclusions While the DCI was associated with differences in the clinical and anatomic profile, it was not associated with differences in clinical outcomes in this prospective observational study of adults undergoing TAVR suggesting that access to care is the likely discriminator.
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Hughes K, Olufajo OA, White K, Roby DH, Fryer CS, Wright JL, Sehgal NJ. The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction. J Vasc Surg 2021; 75:168-176. [PMID: 34506895 DOI: 10.1016/j.jvs.2021.08.071] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 08/13/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Although it has been shown that patient socioeconomic status (SES) is associated with the surgical treatments chosen for severe peripheral arterial disease (PAD), the association between SES and outcomes of arterial reconstruction have not been well-studied. The objective of this study was to determine if SES is associated with outcomes following lower extremity arterial reconstruction. METHODS Patients 40 years and older who had surgical revascularization for severe lower extremity PAD were identified in the Nationwide Readmissions Database, 2010 to 2014. Measures of SES including median household income (MHI) quartiles of patients' residential ZIP codes were extracted. Factors associated with repeat revascularization, subsequent major amputations, hospital mortality, and 30-day all-cause readmission were evaluated using multivariable regression analyses. RESULTS Of the 131,529 patients identified, the majority (61%) were male, and the average age was 69 years. On unadjusted analyses, subsequent amputations were higher among patients in the lowest MHI quartile compared with patients in the highest MHI quartile (13% vs 10%; overall P < .001). On multivariable analyses, compared with patients in the lowest quartile, those in the highest quartile had lower amputation (adjusted odds ratio [aOR], 0.70; 95% confidence interval (CI), 0.63-0.77; overall P < .001) and readmission (aOR, 0.91; 95% CI, 0.84-0.99; overall P = .028) rates. However, subsequent revascularization (aOR, 1.04; 95% CI, 0.94-1.15) and mortality (aOR, 1.01; 95% CI, 0.79-1.28) rates were not different across the groups. CONCLUSIONS Lower SES is associated with disproportionally worse outcomes following lower extremity arterial reconstruction for severe PAD. These data suggest that improving outcomes of lower extremity arterial reconstruction may involve addressing socioeconomic disparities.
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Affiliation(s)
- Kakra Hughes
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Md; Department of Surgery, Howard University College of Medicine, Washington, DC.
| | - Olubode A Olufajo
- Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Kellee White
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Md
| | - Dylan H Roby
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Md
| | - Craig S Fryer
- Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park, Md
| | - Joseph L Wright
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Md; Executive Suite, University of Maryland Capital Region Health, Cheverly, Md
| | - Neil J Sehgal
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Md
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Tracci MC, Woo K, Sideman M. Primum Non Nocere-Avoiding Harm to Populations at Social Risk in the Design and Implementation of Value-Based Payment Programs. JAMA Surg 2021; 156:1024-1025. [PMID: 34379087 DOI: 10.1001/jamasurg.2021.3747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Margaret C Tracci
- Vascular and Endovascular Surgery, University of Virginia, Charlottesville
| | - Karen Woo
- Department of Surgery, University of California, Los Angeles, Los Angeles
| | - Matthew Sideman
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio
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Michaels AD, Meneveau MO, Hawkins RB, Charles EJ, Mehaffey JH. Socioeconomic risk-adjustment with the Area Deprivation Index predicts surgical morbidity and cost. Surgery 2021; 170:1495-1500. [PMID: 33722398 DOI: 10.1016/j.surg.2021.02.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/30/2021] [Accepted: 02/01/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND There is a strong association between socioeconomic status and surgical outcomes; however, the optimal method for socioeconomic risk-stratification remains elusive. We aimed to compare 2 metrics of socioeconomic ranking by ZIP code, the Distressed Communities Index, and the Area Deprivation Index and their association with surgical outcomes. METHODS This retrospective study included all general surgery cases performed at a single institution from 2005 to 2015. Each patient was assigned Distressed Communities Index and Area Deprivation Index scores based on ZIP code. Both indices are normalized composite measures of socioeconomic status derived from census data. Primary outcome was 30-day morbidity; secondary outcomes included long-term mortality and cost, stratified by socioeconomic status. The utility of the addition of each metric to the American College of Surgeons National Surgical Quality Improvement Program risk calculator was assessed. RESULTS The 9,843 patients had normally distributed Distressed Communities Index (47.3 ± 22.4) and Area Deprivation Index (35.4 ± 19.0). Patients who experienced any complication or readmission had significantly higher Distressed Communities Index (48.6 vs 47.1, P = .04) and Area Deprivation Index (37.2 vs 35.1, P = .002). Risk-adjusted models demonstrated that only Area Deprivation Index independently predicted postoperative complications (odds ratio 1.11, P = .02), improved the discrimination of risk-stratification when added to the American College of Surgeons National Surgical Quality Improvement Program risk calculator (area under curve 0.758-0.790, P = .02), and was associated with hospitalization cost ($1,811 ± 856/quartile, P = .03). CONCLUSION Area Deprivation Index provides improved socioeconomic risk-adjustment in this surgical population. The addition of Area Deprivation Index to risk-stratification tools would allow us to better inform our patients of their expected postoperative courses, more accurately account for the increased cost of providing their care, and identify patients and regions that are most in need of improvements in health and healthcare.
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Affiliation(s)
- Alex D Michaels
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Max O Meneveau
- Department of Surgery, University of Virginia Health, Charlottesville, VA
| | - Robert B Hawkins
- Department of Surgery, University of Virginia Health, Charlottesville, VA
| | - Eric J Charles
- Department of Surgery, University of Virginia Health, Charlottesville, VA
| | - J Hunter Mehaffey
- Department of Surgery, University of Virginia Health, Charlottesville, VA.
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Association of Socioeconomic Area Deprivation Index with Hospital Readmissions After Colon and Rectal Surgery. J Gastrointest Surg 2021; 25:795-808. [PMID: 32901424 PMCID: PMC7996389 DOI: 10.1007/s11605-020-04754-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Risk adjustment for reimbursement and quality measures omits social risk factors despite adversely affecting health outcomes. Social risk factors are not usually available in electronic health records (EHR) or administrative data. Socioeconomic status can be assessed by using US Census data. Distressed Communities Index (DCI) is based upon zip codes, and the Area Deprivation Index (ADI) provides more granular estimates at the block group level. We examined the association of neighborhood disadvantage using the ADI, DCI, and patient-level insurance status on 30-day readmission risk after colorectal surgery. METHODS Our 677 patient cohort was derived from the 2013-2017 National Surgical Quality Improvement Program at a safety net hospital augmented with EHR data to determine insurance status and 30-day readmissions. Patients' home addresses were linked to the ADI and DCI. RESULTS Our cohort consisted of 53.9% males and 63.8% Hispanics with a 22.9% 30-day readmission rate from the date of discharge; > 50% lived in highly deprived neighborhoods. Controlling for medical comorbidities and complications, ADI was associated with increased risk of 30 days from the date of discharge readmissions among patients living in medium (OR = 2.15, p = .02) or high (OR = 1.88, p = .03) deprived areas compared to less-deprived neighborhoods, but not insurance status or DCI. CONCLUSIONS The ADI identified patients living in deprived communities with increased readmission risk. Our results show that block-group level ADI can potentially be used in risk adjustment, to identify high-risk patients and to design better care pathways that improve health outcomes.
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Franco RDL, Iora PH, Dutra AC, Belczak SQ, Vissoci J, Staton C, Andrade L. Spatial inequalities of major lower limb amputation rates in Paraná state, Brazil. BMJ Open 2020; 10:e038980. [PMID: 33361072 PMCID: PMC7768970 DOI: 10.1136/bmjopen-2020-038980] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this observational cross-sectional study was to analyse the spatial distribution of major lower limb amputation (MLLA) rates and associate them to socioeconomic, demographic and public healthcare access-related variables in the State of Paraná, Brazil, from 2012 to 2017. METHOD Data on MLLA, revascularisation surgeries, diagnostic exams and healthcare coverage were obtained from the Brazilian Public Hospital Information System. Socioeconomic data were obtained from the Brazilian Institute of Geography and Statistics. Spatial autocorrelation of the MLLA rates was tested using Moran's I method. Multivariate spatial regression models using ordinary least squares regression (OLS) and geographically weighted regression (GWR) were used to identify the variables significantly correlated with MLLA. RESULTS A total of 5270 MLLA were included in the analysis. Mean MLLA rates were 24.32 (±18.22)/100 000 inhabitants, showing a positive global spatial autocorrelation (Moran's I=0.66; p<0.001). Queen contiguity matrix demonstrates that MLLA rates ranged from 7.6 to 46.6/100 000 with five large clusters of high MLLA rates. OLS showed that four of the nine studied variables presented significant spatial correlation with MLLA rates. Colour Doppler ultrasound showed a negative association (p<0.001), while revascularisation surgeries and illiteracy showed a positive correlation (p<0.01). GWR presented the best model (adjusted R2=0.77) showing that the predictors differentially affect the MLLA rates geographically. CONCLUSION The high MLLA rates in some regions of the state are influenced by the high rate of illiteracy and low utilisation rate of colour Doppler, indicating a social problem and difficulty in accessing health. On the other hand, the high rates of revascularisation surgeries are related to higher MLLA rates, possibly due to delayed access to specialised hospitals. This indicates that attention must be given to population access to public healthcare in the State of Paraná in order to ensure proper and timely medical attention.
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Affiliation(s)
| | | | | | | | - João Vissoci
- Division of Emergency Medicine, Duke University, Durham, North Carolina, USA
| | - Catherine Staton
- Division of Emergency Medicine, Duke University, Durham, North Carolina, USA
| | - Luciano Andrade
- Medicine Department, Universidade Estadual de Maringa, Maringa, Brazil
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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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Hawkins RB, Mehaffey JH, Charles EJ, Kern JA, Schneider EB, Tracci MC. Socioeconomically Distressed Communities Index independently predicts major adverse limb events after infrainguinal bypass in a national cohort. J Vasc Surg 2020; 70:1985-1993.e8. [PMID: 31761106 DOI: 10.1016/j.jvs.2019.03.060] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/24/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Socioeconomic status is a major determinant of not only quality of life, but also mortality and health care-related outcomes. We hypothesized that patients coming from distressed communities would have worse short- and long-term limb related outcomes after infrainguinal bypass. METHODS The infrainguinal bypass national Vascular Quality Initiative datasets for 2003 to 2018 were used. Clinical data were paired with the Distressed Communities Index (DCI) score before extraction. The DCI accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies at the zip code level, with a range of 0 (no distress) to 100 (severe distress). Severely distressed communities were defined as DCI greater than 75 for univariate analysis. Hierarchical multivariable modeling adjusted for baseline and operative risk factors, and clustering at the hospital level. RESULTS The 9711 patients who underwent infrainguinal bypass from severely distressed communities (out of 40,109 total) were younger, more likely to smoke, disproportionately African American, with more comorbid disease (all P < .05). Patients from less distressed communities had lower rates of critical limb ischemia (56% DCI ≤ 75 vs 60% DCI > 75; P < .0001) and prior amputation (4.7 vs 6.3%; P < .0001). There was no difference in in-hospital mortality (1.3% vs 1.3%; P = .906) or major adverse cardiovascular events (4.1% vs 3.7%; P = .097). However, patients from distressed communities had higher rates of major adverse limb events (MALE; 11.7% vs 14.4%; P < .0001), and the components amputation, thrombectomy, and revision. After risk adjustment, DCI remained an independent predictor of in-hospital MALE (odds ratio, 1.05 per 25 DCI points; 95% confidence interval [CI], 1.02-1.08; P = .001) and long-term MALE (hazard ration [HR] 1.02; 95% CI, 1.00-1.04; P = .045). DCI is predictive of long-term graft occlusion (HR, 1.04; 95% CI, 1.00-1.07; P = .028) and amputation (HR, 1.09; 95% CI, 1.06-1.12; P < .0001). CONCLUSIONS The DCI is an independent predictor of MALE after infrainguinal bypass. Patients from distressed communities are at an increased risk of long-term graft occlusion, which is disproportionately treated with amputation instead of surgical limb-saving alternatives. Socioeconomic factors impact vascular disease and surgical outcomes with disparities that warrant further investigation.
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Affiliation(s)
- Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va; Center for Health Policy, University of Virginia, Charlottesville, Va.
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va; Center for Health Policy, University of Virginia, Charlottesville, Va
| | - Eric J Charles
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
| | - John A Kern
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va; Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, Va
| | - Eric B Schneider
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, Va
| | - Margaret C Tracci
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, Va
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