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

Read at the 101st Annual Meeting of The American Association for Thoracic Surgery: A Virtual Learning Experience, April 30-May 2, 2021.
https://doi.org/10.1016/j.jtcvs.2022.02.061Get rights and content

Abstract

Objective

Female sex and lower income residence location are associated with worse health care outcomes. In this study we analyzed the national, contemporary status of socioeconomic disparities in cardiac surgery.

Methods

Adult patients within the Nationwide Readmissions Database who underwent coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), mitral valve (MV) replacement, MV repair, or ascending aorta surgery from 2016 to 2018 were included. Sex and median household income quartile (MHIQ) were compared within each surgery group. Primary outcome was 30-day mortality. Multivariable analysis was adjusted for patient characteristics and hospital-level factors.

Results

A weighted total of 358,762 patients were included. Fewer women underwent CABG (22.3%), SAVR (32.2%), MV repair (37.5%), and ascending aorta surgery (29.7%). In adjusted analysis, female sex was independently associated with higher 30-day mortality rates after CABG (adjusted odds ratio [aOR], 1.6), SAVR (aOR, 1.4), MV repair (aOR, 1.8), and ascending aorta surgery (aOR, 1.2; all P < .03). The lowest MHIQ was independently associated with higher 30-day mortality rates after CABG (aOR, 1.4), SAVR (aOR, 1.5), MV replacement (aOR, 1.3), and ascending aorta surgery (aOR, 1.8; all P < .004) compared with the highest quartile. Women were less likely to receive care at urban and academic hospitals for CABG compared with men. Patients of lower MHIQ received less care at urban and academic institutions for all surgeries.

Conclusions

Despite advances in the techniques and safety, women and patients of lower socioeconomic status continue to have worse outcomes after cardiac surgery. These persistent disparities warrant the need for root cause analysis.

Section snippets

Data Source

In our study we used data from the Nationwide Readmissions Database (NRD)—a publicly available, deidentified data set that contains nationally representative information on hospital readmissions for all ages, which when weighted represents 35 million discharges annually.18 The extent of the clinical data available within NRD is limited to International Classification of Diseases (ICD) diagnosis and procedure codes. Furthermore, data are deidentified and thus specific geographic or hospital data

Patient Characteristics

A weighted total of 358,762 patients met inclusion criteria. A total of 187,296 patients underwent CABG, 109,110 SAVR, 31,009 MVR, 5579 MV repair, and 25,768 ascending aorta surgery. Baseline characteristics were largely similar among cardiac procedures (Table E3).

In comparing characteristics according to patient sex, female patients were the minority for most procedures (22.3% for CABG, 32.2% for SAVR, 37.5% MV repair, and 29.7% for ascending aorta surgery). Female patients had higher mean HES

Discussion

In this study we characterized the current state of socioeconomic disparities in cardiac surgery by conducting, to our knowledge, the largest and most contemporary nationally representative study to date with several important findings (Figure 3). First, female patients are undergoing fewer CABG, SAVR, MV repair, and ascending aorta surgeries than males patients, and when they do receive surgery they have more comorbidities and more often have urgent procedures. Second, female sex was an

Conclusion

Despite advances in cardiovascular surgical care, and health policy initiatives implemented in the past decade to close the disparities gap in cardiac surgery, women and patients of lower MHIQs continue to have worse outcomes after cardiac surgery on a national level. Future research should be focused on root-cause analysis for each procedure type, with a greater focus on sex-specific management guidelines and reevaluation of our approach to health policy to combat structural barriers to care.

References (38)

  • M. Katz et al.

    Gender-related differences on short- and long-term outcomes of patients undergoing transcatheter aortic valve implantation

    Catheter Cardiovasc Interv

    (2017)
  • S.H. Bots et al.

    Sex differences in coronary heart disease and stroke mortality: a global assessment of the effect of ageing between 1980 and 2010

    BMJ Glob Health

    (2017)
  • M.J. Leening et al.

    Sex differences in lifetime risk and first manifestation of cardiovascular disease: prospective population based cohort study

    BMJ

    (2014)
  • S. Chatterjee et al.

    Differential presentation in acuity and outcomes based on socioeconomic status in patients who undergo thoracoabdominal aortic aneurysm repair

    J Thorac Cardiovasc Surg

    (Published online July 27, 2020.)
  • V.R. Taqueti

    Sex differences in the coronary system

    Adv Exp Med Biol

    (2018)
  • N.L. Cook et al.

    Differences in specialist consultations for cardiovascular disease by race, ethnicity, gender, insurance status, and site of primary care

    Circulation

    (2009)
  • J.Z. Ayanian et al.

    Differences in the use of procedures between women and men hospitalized for coronary heart disease

    N Engl J Med

    (1991)
  • R. Blankstein et al.

    Female gender is an independent predictor of operative mortality after coronary artery bypass graft surgery: contemporary analysis of 31 Midwestern hospitals

    Circulation

    (2005)
  • G. Filardo et al.

    Excess short-term mortality in women after isolated coronary artery bypass graft surgery

    Open Heart

    (2016)
  • Cited by (0)

    View full text