‘Disparities gap’ drives worse outcomes for women, low-income adults after cardiac surgery
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Women and adults who reside in low-income areas are more likely to die 30 days after cardiac surgery compared with men and those living in higher-income ZIP codes, according to a nationwide database analysis.
“In the field of cardiac surgery, there have been reported disparities but they were separated by individual surgeries,” Tsuyoshi Kaneko, MD, a cardiac surgeon at Brigham and Women's Hospital and an assistant professor of surgery at Harvard Medical School, told Healio. “There are analyses looking at disparities that are restricted to CABG or valve surgeries, but nothing that looks at the entire field. That led to our question: Is this disparity real in the field of cardiac surgery?”
Kaneko and colleagues analyzed data from 358,762 adults who underwent CABG, surgical aortic valve replacement, mitral valve replacement, mitral valve repair or ascending aortic surgery between 2016 and 2018, using data from the Nationwide Readmissions Database. Researchers compared patient sex and median household income quartiles, based on patient ZIP code. The primary outcome was 30-day mortality.
“Although race and ethnicity are important socioeconomic factors, they are not included in the Nationwide Readmissions Database and thus could not be included in this study,” the researchers wrote.
The findings were published in The Journal of Thoracic and Cardiovascular Surgery.
Fewer women underwent CABG (22.3%), surgical AVR (32.2%), mitral valve repair (37.5%) and ascending aorta surgery (29.7%). In analyses stratified by sex, women had higher in-hospital mortality, in-hospital morbidities and fewer home discharges than men across all five surgery categories (P < .001).
Compared with men, women had higher 30-day mortality after CABG (4.1% vs. 2.5%) surgical AVR (4.8% vs. 3.5%), mitral valve repair (5.5% vs. 3.7%) and ascending aorta surgery (9.4% vs. 6.2%; P for all < .005). Female sex was independently associated with higher 30-day mortality after CABG (adjusted OR = 1.6), surgical AVR (aOR = 1.4), mitral valve repair (aOR = 1.8) and ascending aorta surgery (aOR = 1.2; P for all < .03).
Compared with patients in the highest median household income quartile, those in the lowest quartile were more likely to die 30 days after CABG (aOR = 1.4), surgical AVR (aOR = 1.5), mitral valve replacement (aOR = 1.3) and ascending aorta surgery (aOR = 1.8; P for all < .004).
Additionally, researchers found that women were less likely to receive care at urban and academic hospitals for CABG compared with men, whereas patients in the lowest income quartile were less likely to receive care at urban and academic institutions for all surgeries.
“We must understand the problem before we look for answers,” Kaneko told Healio. “Our question was, is there a disparity in cardiac surgery? The next question is, why is this happening? This nationwide database is not perfect — it is mainly based on billing codes and the data are not granular. The next step is to take further actions to identify what may be the exact causes behind this. There are clues, based on our analysis, but they are just not detailed enough. For example, we lack race data, and ZIP codes have limitations. We hope this spurs people to find out why these disparities exist.”
For more information:
Tsuyoshi Kaneko, MD, can be reached at tkaneko2@bwh.harvard.edu.
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