Gender-, Income-Based Disparities Still Exist in Outcomes Following Cardiac Surgery

Despite advances in care and emphasis on reducing disparities in care, data from a new study suggests socioeconomic- and gender-based disparities still exist when examining outcomes following cardiac surgery.

In what investigators are calling the largest, contemporary national study on socioeconomic disparities in cardiac surgery, results of the study, which leveraged data from the Nationwide Readmissions Database, provide insight into these disparities, including an increased risk of 30-day mortality following CABG, SAVR, mitral valve repair, and ascending aorta surgery among female patients and those of lower socioeconomic status.

“Despite advances in cardiovascular surgical care, and health policy initiatives implemented in the last decade to close the disparities gap in cardiac surgery, females and patients of lower median household income quartiles (MHIQs) continue to have worse outcomes following cardiac surgery on a national level,” wrote investigators. “Future research should be focused on root cause analysis for each procedure type, with a greater focus on sex-specific management guidelines and re-evaluating our approach to health policy to combat structural barriers to care.”

Led by Tsuyoshi Kaneko, MD, surgical director of the structural heart program at Brigham, and Women’s Hospital, the present study was conducted with the intent of producing a comprehensive overview of contemporary trends in outcomes following cardiac surgery based on sex and income using data from a nationally representative database. Together with colleagues from Brigham and Women’s Hospital, the Center for Surgery and Public Health, and Boston University School of Medicine, the study used the Nationwide Readmissions Database.

A publicly available, deidentified dataset, the Nationwide Readmissions Database provided investigators with information related to 358,762 patients for inclusion in their study. Of the 358,762 identified for inclusion, 187,296 patients underwent CABG, 109,110 underwent SAVR, 31,009 underwent mitral valve replacement, 5,579 underwent mitral valve repair, and 25,768 underwent ascending aorta surgery. Investigators noted females were the minority for most procedures, with women representing just 22.3%, 32.2%, 37.5%, and 29.7% of those undergoing CABG, SAVR, mitral valve repair, and ascending aorta surgery, respectively.

For the purpose of analysis, investigators included patients aged 18 years or older who underwent CABG, SAVR, mitral valve replacement, mitral valve repair, or repair or replacement of the ascending aorta from 2016-2018. Investigators noted those who underwent concomitant procedures were included within both procedure cohorts and all patients were identified using ICD-10 procedure codes. Using multivariable analysis adjusted for patient characteristics and hospital-level factors, investigators hoped to assess the risk of 30-day mortality based on patient sex and MHIQ. Secondary outcomes of interest for the study included incidence of postoperative complications, including stroke, renal failure, pacemaker implantation, complete heart block, cardiac arrest, major bleeding, and home discharge. Investigators also noted an exploratory analysis was planned to identify characteristics of hospital providing care to determine if significant differences in site of care were associated with disparate outcomes.

In adjusted analyses, results indicated female sex was independently associated with increased 30-day mortality following CABG (aOR, 1.60 [95% CI, 1.48-1.57]; p <.001), SAVR (aOR, 1.43 [95% CI, 1.32-1.55]; P <.001), mitral valve repair (aOR, 1.84 [95% CI, 1.17-2.87]; P=.008), and ascending aorta surgery (aOR, 1.19 [95% CI, 1.02-1.38]; P=.028). Compared to their counterparts in the highest quartile of MHIQ, being in the lowest quartile was associated with an increased risk of 30-day mortality among those undergoing CABG (aOR, 1.40 [905% CI, 1.25-1.58]; P <.001), SAVR (aOR, 1.45 [95% CI, 1.27-1.65]; P <.001), mitral valve repair (aOR, 1.26 [95% CI, 1.08-1.47]; P=.004), and ascending aorta surgery (aOR, 1.79 [95% CI, 1.42-2.23]; P <.001). Investigators pointed out women were significantly less likely to receive care at urban and academic hospitals for CABG compared to their male counterparts. Additionally, investigators noted those with lower MHIQ received less care at urban and academic institutions for all surgeries.

“Despite advances in the techniques and safety, females and patients of lower 69 socioeconomic status continue to have worse outcomes following cardiac surgery. These persistent 70 disparities warrant the need for root cause analysis,” wrote investigators in their conclusion.

This study, “Contemporary Socioeconomic Based Disparities in Cardiac Surgery: Are We Closing the Disparities Gap?” Was published in The Journal of Thoracic and Cardiovascular Surgery.