Income, ZIP code drive disparities in outcomes after cardiac surgery
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Adults living in ZIP codes with a lower median household income are at greater risk for increased hospital length of stay after cardiac surgery compared with patients living in areas with a higher median income, researchers reported.
In a database analysis of more than 340,000 patients, researchers also observed that the relationship between socioeconomic status and mortality was “not as robust” as that observed with length of stay, noting that aortic valve replacement was the only procedure associated with median household income quartile, primary payer status and in‐hospital mortality. However, patients with Medicare had higher odds for in‐hospital mortality compared with those with private insurance.
“The influence of socioeconomic status on patient outcomes is directly related to a patient’s ability to access affordable health insurance,” Benjamin Seadler, MD, a resident in the department of surgery at the Medical College of Wisconsin, and colleagues wrote in the Journal of Cardiac Surgery. “Primary payer status often correlates with a patient’s socioeconomic standing. Uninsured and underinsured patients are at increased risk for postoperative mortality, morbidity and greater hospital length of stay. The influence of health insurance status on patient outcomes has led to primary payer status being viewed in some centers as a perioperative risk factor. The field of cardiac surgery continues to evolve, especially in the area of minimally invasive and endovascular operations. We must monitor how these new technologies are being implemented and promote equal access to standard of care.”
Seadler and colleagues analyzed baseline demographic data from 342,945 patients who underwent CABG, surgical AVR, transcatheter aortic valve replacement and combined AVR/CABG, using data from the National Inpatient Sample for 2019. Within each procedure group, researchers assessed odds for in‐hospital mortality and hospital length of stay, using age, sex, insurance, ZIP code, median household income and location as predictors.
Within the cohort, the CABG procedural group had the greatest proportion of patients in the lowest income quartile (28.3%) compared with patients who underwent other procedures. The most common form of insurance was Medicare (55.4%), followed by private insurance (30.7%). In‐hospital mortality occurred in 2.1% of patients and the mean length of stay was 9.7 days.
Researchers found that higher income was associated with decreased length of stay after surgical AVR and CABG and was moderately associated with decreased length of stay in TAVR and AVR/CABG. Having private insurance was associated with a decreased length of stay in patients undergoing CABG, surgical AVR, TAVR and AVR/CABG.
Female sex and increased age were associated with increased odds for mortality in TAVR, CABG and AVR/CABG. Having private insurance was associated with a decreased odds for mortality in patients undergoing surgical AVR.
“Our findings reinforce those of prior studies by showing that differences in inherent socioeconomic factors such as insurance status, geography, sex, age and median household income influence the outcomes of patients undergoing cardiac surgery,” the researchers wrote. “Outcomes improvements have been achieved in institutions that identify specific problems and make a commitment to change. A lesson learned from the existing literature is that not all socioeconomic factors are created equal: Interventions must target each factor specifically if we want all patients to receive equitable care.”
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