The relationship between socio-economic status, geography, symptomatic carotid territory disease and carotid endarterectomy

Impact of neighborhood social disadvantage on carotid artery disease presentation, management, and discharge outcomes

OBJECTIVE

Recent studies have highlighted that race and socioeconomic status serve as important determinants of disease presentation and perioperative outcomes in carotid artery disease. However, these investigations only focus on individual factors of social disadvantage, and fail to account for community factors that may drive disparities. Area Deprivation Index (ADI) is a validated measure of neighborhood adversity that offers a more comprehensive assessment of social disadvantage. We examined the impact of ADI ranking on carotid artery disease severity, management, and postoperative outcomes.

METHODS

We identified patients who underwent carotid endarterectomy (CEA), transfemoral carotid artery stenting (tfCAS), and transcarotid artery revascularization (TCAR) in the Vascular Quality Initiative registry between 2016 and 2020. Patients were assigned ADI scores of 1 to 100 based on zip codes and grouped into quintiles, with higher quintiles reflecting increasing adversity. Outcomes assessed included disease presentation, intervention type, and discharge patterns. Logistic regression was used to evaluate independent associations between ADI quintiles and these outcomes.

RESULTS

Among 91,904 patients undergoing carotid revascularization, 9811 (10.7%) were in the lowest ADI quintile (Q1), 18,905 (20.6%) in Q2, 25,442 (27.7%) in Q3, 26,099 (28.4%) in Q4, and 11,647 (12.7%) in Q5. With increasing ADI quintiles, patients were more likely to present with symptomatic disease (Q5, 52.1% vs Q1, 46.6%; P < .001), and stroke vs transient ischemic attack (Q5, 63.1% vs Q1, 53.5%; P < .001); they also more frequently underwent CAS vs CEA (Q5, 46.4% vs Q1, 33.9%; P < .001), and specifically tfCAS vs TCAR (Q5, 54.2% vs Q1, 33.9%; P < .001). In adjusted analyses, higher ADI quintiles remained as independent risk factors for presenting with symptomatic disease and stroke and undergoing CAS and tfCAS. Across ADI quintiles, patients were more likely to experience death (Q5, 0.8% vs Q1, 0.4%; P < .001), stroke/death (Q5, 2.1% vs Q1, 1.6%; P = .001), failure to discharge home (Q5, 11.5% vs Q1, 8.0%; P < .001) and length of stay >2 days (Q5, 33.3% vs Q1, 26.3%; P < .001) following revascularization.

CONCLUSIONS

Among carotid revascularization patients, those with greater neighborhood social disadvantage had greater disease severity and more frequently underwent tfCAS. These patients also had higher rates of death and stroke/death, were less frequently discharged home, and had prolonged hospital stays. Greater efforts are needed to ensure that patients in higher ADI quintiles undergo better carotid surveillance and are treated appropriately for their carotid artery disease.

Socio-demographic factors and their impact on the number of resections for patients with recurrent glioblastoma

Glioblastoma multiforme (GBM) is the most aggressive malignant brain tumour. Having a second or subsequent operation at recurrence may be a positive prognostic factor for survival. Recent studies suggest that socio-demographic variables may influence survival, raising the question whether surgical care differs based on these variables. We examined the relationship between selected socio-demographic variables and the number of repeat operations undergone by patients with recurrent GBM. Data from all patients diagnosed with GBM between 2001 and 2011 was obtained from a clinical database maintained across two institutions (one public, one private). The clinical and socio-demographic factors for patients who received one operation were compared to those who had two or more operations, using chi-squared analyses to determine statistical differences between groups. Socioeconomic status was measured using the Index of Relative Socioeconomic Advantage and Disadvantage scores. Of 553 patients, 449 (81%) had one operation and 104 (19%) had ≥2 operations. Patients who had ≥2 operations were significantly younger (median 55 years versus 64 years, p<0.001), less likely to have multifocal (p=0.043) or bilateral (p=0.037) disease and more likely to have initial macroscopic resection (p=0.006), than those who had only one operation. Socioeconomic status did not significantly differ between the groups (p=0.31). Similarly, there was no significant difference between the number of operations in patients from regional versus city residence and public versus private hospital. This is reassuring as it suggests similar surgical management options are available for patients regardless of socio-demographic background.

Relationship between socioeconomic deprivation or urban/rural residence and visual acuity before cataract surgery in Northern Scotland

PURPOSE

To evaluate the influence of socioeconomic factors on visual acuity before cataract surgery. 


METHODS

The medical case notes of 240 consecutive patients listed for cataract surgery from January 1, 2010, at Grampian University Hospital, Aberdeen, were reviewed retrospectively. Patients with ocular comorbidity were excluded. Demographics, postal codes, and visual acuity were recorded. Scottish Index of Multiple Deprivation was used to determine the deprivation rank. Home location was classified as urban or rural. The effect of these parameters on preoperative visual acuity was investigated using chi-square tests or Fisher exact test as appropriate. 


RESULTS

A total of 184 patients (mean 75 years) were included. A total of 127 (69%) patients had visual acuity of 6/12 or better. An association was found between affluence and preoperative visual acuity of 6/12 or better (χ2trend = 4.97, p = 0.03), with a significant rising trend across quintile of deprivation. There was no evidence to suggest association between geographical region and preoperative visual acuity (p = 0.63). 


CONCLUSION

Affluence was associated with good visual acuity (6/12 or better) before cataract surgery. There was no difference in preoperative visual acuity between rural and urban populations.

Methicillin-resistant Staphylococcus aureus in surgical patients: identification of high-risk populations for the development of targeted screening programmes

INTRODUCTION

Methicillin-resistant Staphylococcus aureus (MRSA)-related hospital-acquired infection (HAI) in surgical patients is associated with high morbidity, mortality and financial cost. The identification and characterisation of populations of patients who are at high risk of developing MRSA infection or colonisation could inform the design of more effective strategies to prevent HAIs and reduce transmission of MRSA.

PATIENTS AND METHODS

An analysis of historical discharge data for the whole of 2005 (7145 surgical in-patients) was performed, for all patients admitted to general surgery at the Royal Infirmary of Edinburgh. Analysis specifically focused on MRSA laboratory data and coding data for patient demographics, medical co-morbidities, and progress of in-patient stay.

RESULTS

A total of 134 (1.88%) individual patients with colonisation or infection by MRSA were identified from indicated laboratory testing. Univariate analysis identified a significant association of concurrent MRSA-positive status with patients aged over 60 years (P < 0.01), a duration of inpatient stay > 7 days (P < 0.01), presence of a malignant neoplasm (P < 0.01), circulatory disease (P < 0.01), respiratory disease (P < 0.01), central nervous system disease (P < 0.01), renal failure (P < 0.01), and concurrent admission to ITU/HDU (P < 0.01). Multivariate analysis suggested MRSA colonisation or infection was strongest in those with co-morbid malignancy (P < 0.0001) or admission to ITU/HDU (P < 0.0001).

CONCLUSIONS

This large observational study has identified cancer patients as a UK surgical patient subpopulation which is at significantly higher risk of colonisation by MRSA. These data could inform the development of focused hospital in-patient screening protocols and provide a means to stratify patient risk.

Cross-sectional analysis of baseline data to identify the major determinants of carotid intima-media thickness in a European population: the IMPROVE study

AIMS

The 'IMPROVE study' was designed to investigate whether cross-sectional carotid artery intima-media thickness (IMT) and overall IMT progression are predictors of new vascular events in European individuals at high risk of cardiovascular diseases. This paper reports the results of the baseline analyses aimed at identifying the major determinants of increased carotid IMT (C-IMT).

METHODS AND RESULTS

IMPROVE is a prospective, multicentre, longitudinal, observational study. A total of 3711 subjects (age range 54-79 years) with at least three vascular risk factors (VRFs) were recruited in seven centres in Finland, France, Italy, the Netherlands, and Sweden. Collected variables included clinical, biochemical, genetic, socioeconomic, psychological, nutritional, and educational data, personal and family history of diseases, drug intake, and physical activity. By multiple linear regression analysis, C-IMT was positively associated with latitude, age, gender, pulse pressure, pack-years, and hypertension, and inversely with educational level (all P < 0.0001 for IMT(mean-max)). Latitude was the strongest independent determinant of C-IMT (partial r(2) for IMT(mean-max) = 0.109, P < 0.0001) and alone accounted for nearly half of the variation explained by the regression model (partial r(2) for IMT(mean-max) = 0.243, P < 0.0001). The geographical gradient for C-IMT paralleled the well-known north-to-south cardiovascular mortality gradient (r(2) for IMT(mean) = 0.96).

CONCLUSION

Latitude is an important determinant of C-IMT, which is not explained by between-country differences in established VRFs. Other unknown contributory mechanisms such as heritable, nutritional, or environmental factors may be important in the genesis of this geographical gradient.

Regional variation in the utilization of carotid endarterectomy

OBJECTIVE

In different regions of the United States, highly variable rates have been documented for a wide range of procedures, such as prostatectomy and caesarean section. It is generally held that this variation is due to inconsistent physician practice patterns or other nonmedical considerations. Only limited research has been conducted regarding vascular surgical operations. We examined national data on the utilization of carotid endarterectomy (CEA) to determine the extent and diversity of regional variations.

METHODS

Medicare discharge data quantified the per capita rate of CEA in 50 states and the District of Columbia in 2003. Multiple metrics pertaining to risk factors, socioeconomic status, access to care, provider density, and local health care capacity were quantified. We performed bivariate analysis, Pearson (PC) or Spearman (SC) correlations, and multiple regression modeling.

RESULTS

In 2003, 83,164 CEAs were performed on 28,767,985 enrollees. CEA rates were 28.9 +/- 7.8 per 10,000 (range, 5.6-44.7 per 10,000). The rate of CEA was highly correlated with the number of heart disease deaths (PC = 0.575, P < .0001), deaths by stroke (PC = 0.504, P = .0002), and percentage of adult smokers in a state (PC = 0.643, P < .0001). These three factors held the strongest association with variation in CEA rates. Statistically, they explained 51% of the variation in total number of CEAs (R(2) = 0.5074, P < .0001). Median annual income (PC = -0.608, P < .0001) and percentage of college degrees (PC = -0.606, P < .0001) displayed inverse relationships to CEA rates. Per capita hospital beds (SC = 0.540, P < .0001) and rural health care clinics (SC = 0.518, P < .0001) exhibited positive correlations. The number of physicians or vascular surgeons did not predict higher utilization of CEA.

CONCLUSION

The strongest correlations for CEA were three markers associated with atherosclerotic disease: percentage of adult smokers and deaths from heart disease or stroke. Geographic variation in this vascular procedure is chiefly associated with variance in markers of disease prevalence, not physician preference or other nonmedical factors. The increased utilization of carotid stenting, accompanied by the participation of a much wider range of medical specialists, may affect this relationship in the future.

Impact of socio-economic deprivation on death rates after surgery for upper gastrointestinal tract cancer

We hypothesised that socio-economic deprivation in England may be a prognostic factor for death after oesophagectomy or gastrectomy for cancer of the upper gastrointestinal tract. We analysed statistical data from hospital records linked to death records for patients who underwent operations for oesophageal and gastric cancer in England from April 1998 to March 2002. The patients were stratified into quintiles according to the index of multiple deprivation (IMD) (2000) for their place (ward) of residence. Age and sex standardised death rates at 30 and 90 days for each deprivation quintile were calculated. Following oesophagectomy, death rates showed a significant association with IMD. They increased with increasing levels of deprivation: the odds ratio for death, comparing highest with lowest quintile for deprivation, was 1.37 (95% confidence interval 1.03-1.85) at 30 days and 1.30 (1.04-1.64) at 90 days. Following gastrectomy, the death rates showed smaller and nonsignificant associations with IMD with odds ratios of 1.16 (0.84-1.62) and 1.10 (0.86-1.41), respectively. There is a significant association between social deprivation and death after oesophagectomy, but less of an association, if any, after gastrectomy in current UK practice.

Treatment of intermittent claudication: cilostazol

Intermittent claudication is a potentially disabling disorder that impairs quality of life and is a marker of underlying cardiovascular disease. Treatment involves secondary prevention and measures to improve walking. Cilostazol significantly increases walking distance and quality of life in claudicants.