Impact of socioeconomic deprivation on incidence and outcomes of acute type A aortic dissection repair in New Zealand

Race and Socioeconomic Disparities in Proximal Aortic Surgery

BACKGROUND

Substantial socioeconomics-based disparities exist in cardiac surgery. Although there are robust data for revascularization and valve procedures, the effect of race and socioeconomic status on proximal aortic surgery is not well studied. This study analyzed the impact of race and socioeconomic status on in-hospital outcomes after proximal aortic surgery.

METHODS

All adult patients who underwent proximal aortic surgery for aortic dissection or thoracic aneurysm from the 2016 to 2018 National Inpatient Sample were included. Primary outcomes included in-hospital mortality and in-hospital composite morbidity (stroke, pulmonary embolus, major bleeding, acute kidney injury, or permanent pacemaker insertion). Adjusted outcomes were assessed with multivariable analysis.

RESULTS

A weighted total of 32,895 patients were included; 25,461 (77.4%) classified as White, 3224 (9.8%) Black, 2039 (6.2%) Hispanic, and 2171 (6.6%) other. Black and Hispanic patients had significantly lower median household income, higher proportion of self-pay insurance status, younger age, higher comorbidity burden, and a higher proportion of urgent or emergency procedures compared with White patients. There was no significant difference in observed in-hospital mortality by patient race, but non-White patients had significantly higher composite morbidity. On adjusted analysis, there was no difference in in-hospital mortality, but non-White race was an independent predictor of in-hospital morbidity (adjusted odds ratio, 1.6; 95% CI, 1.4-1.8; P < .001).

CONCLUSIONS

Patients of non-White race who undergo proximal aortic surgery have less insurance coverage, more urgent procedures, and a higher comorbidity burden than White patients, disparities that translate to significantly higher morbidity in non-White. A greater focus on nonfatal outcome differentials and improving access to care likely will improve aortic surgery disparities.

The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch

Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.

The association of socioeconomic deprivation with access and survival after hematopoietic stem cell transplantation in New Zealand

BACKGROUND

Socioeconomic deprivation (SED) is a risk factor for reduced survival of hematopoietic stem cell transplant (HSCT) recipients. This study aimed to evaluate access and long-term survival of HSCT recipients.

METHODS

This was a hospital HSCT Registry-based retrospective cohort study. Patients who underwent HSCT from January 2010 to June 2020 were identified. HSCT recipients younger than 16 years of age, patients who reported their residential address as a post office box or the Department of Corrections, and those who left the country after HSCT were excluded from the study. HSCT recipients with the 2018 New Zealand deprivation index (NZDep2018) deciles 8, 9, and 10 were assigned to the higher SED group and those with NZDep2018 deciles from 1 to 7 were allocated to the lower SED group. The total number of New Zealanders in the higher and lower SED strata was obtained from the 2018 Census.

RESULTS

Eight hundred fifty-one HSCT recipients met the eligibility criteria. HSCT recipients from the higher and lower SED strata of the New Zealand population had similar access to HSCT (odds ratio = .9; 95% confidence interval (CI): .77-1.04; p = .155). Mortality in the higher and lower SED groups of HSCT recipients was 9.6/100 person-years (95% CI: 7.7-12/100 person-years) and 8.1/100 person-years (95% CI: 6.9-9.4/100 person-years), respectively. The mortality ratio was 1.2 (95% CI: .9-1.6), p = .098. Both groups had similar survival.

CONCLUSION

New Zealand residents from the higher and lower SED strata have similar access to HSCT. SED is not associated with reduced survival in adult HSCT recipients.

Disparities in surgical outcomes for low socioeconomic status patients in Australia

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.

Socioeconomic disparities in surveillance and follow-up of patients with thoracic aortic aneurysm

BACKGROUND

Thoracic aortic aneurysm (TAA) is a significant risk factor for aortic dissection and rupture. Guidelines recommend referral of patients to a cardiovascular specialist for periodic surveillance imaging with surgical intervention determined primarily by aneurysm size. We investigated the association between socioeconomic status (SES) and surveillance practices in patients with ascending aortic aneurysms.

METHODS

We retrospectively reviewed records of 465 consecutive patients diagnosed between 2013 and 2016 with ascending aortic aneurysm ≥4 cm on computed tomography scans. Primary outcomes were clinical follow-up with a cardiovascular specialist and aortic surveillance imaging within 2 years following index scan. We stratified patients into quartiles using the area deprivation index (ADI), a validated percentile measure of 17 variables characterizing SES at the census block group level. Competing risks analysis was used to determine interquartile differences in risk of death before follow up with a cardiovascular specialist.

RESULTS

Lower SES was associated with significantly lower rates of surveillance imaging and referral to a cardiovascular specialist. On competing risks regression, the ADI quartile with lowest SES had lower hazard of follow-up with a cardiologist or cardiac surgeon before death (hazard ratio: 0.46 [0.34, 0.62], p < .001). Though there were no differences in aneurysm size at time of surgical repair, patients in the lowest socioeconomic quartile were more frequently symptomatic at surgery than other quartiles (92% vs. 23%-38%, p < .001).

CONCLUSION

Patients with lower SES receive less timely follow-up imaging and specialist referral for TAAs, resulting in surgical intervention only when alarming symptoms are already present.

The risk factors and outcomes of preoperative hepatic dysfunction in patients who receive surgical repair for acute type A aortic dissection

Background

Hepatic dysfunction (HD) is a common complication that can occur after surgical repair of acute type A aortic dissection (ATAAD) and is associated with poor prognosis. However, the incidence of early preoperative HD and the associated risk factors in patients with ATAAD have not been fully elucidated.

Methods

A total of 984 ATAAD patients who received surgical repair within 48 hours of symptom onset at our department from January 2014 to December 2019 were retrospectively analyzed. Patients were divided into the non-HD group and the HD groups according to the Model of End-Stage Liver Disease (MELD) score before surgery. The clinical parameters and clinical outcomes of the 2 groups were collected and compared.

Results

Preoperative HD was detected in 268 patients (27.2%). The incidence of in-hospital complications, including the need for dialysis (34.0% vs. 9.2%; P<0.001), was significantly higher in patients with HD compared to patients without HD (69.8% vs. 51.0%; P<0.001). Patients with HD had a higher 30-day mortality rate compared to patients without HD (20.1% vs. 8.4%; P<0.001). Multivariate analysis demonstrated that preoperative cardiac tamponade, preoperative serum creatinine levels, and serum troponin T levels upon admission were independent predictors for preoperative HD in patients with ATAAD. Interestingly, even though preoperative HD was associated with an increased 30-day mortality rate, it did not significantly affect the long-term mortality rate (log-rank P=0.259).

Conclusions

Early HD before surgery was commonly observed in patients with ATAAD and was associated with increased in-hospital complications after surgery, but did not significantly affect long-term survival.