Racial and Ethnic Disparities in Access to Minimally Invasive Mitral Valve Surgery

Does socioeconomic status influence the choice of surgical technique in abdominal rectal cancer surgery?

AIM

This study aimed to estimate the impact of socioeconomic status on the probability of receiving open (OPEN) or minimally invasive surgery (MIS) for curative abdominal rectal cancer resection.

METHODS

All patients diagnosed with rectal cancer clinical Stage I-III during the period 2010-2021 who underwent curative abdominal resection surgery, MIS or OPEN, were included. Patients were identified in the Colorectal Cancer Database, a register-linkage based on the Swedish Colorectal Cancer Register and linked to several national Swedish health-related and demographic registers. Socioeconomic factors, sex, patient and tumour characteristics, number of previous surgical procedures and category of hospital were collected. Exposures were level of education (categorized as 6-9, 10-12, >12 years), household income (quartiles 1-4) and country of birth (Sweden, Nordic countries outside Sweden, Europe outside the Nordic countries, outside Europe), and outcome was MIS or OPEN. Multivariable logistic regression models were fitted for each exposure, adjusted for age, sex, cT and cN, level of tumour, and number of previous abdominal surgical procedures.

RESULTS

A total of 13 778 patients were included of whom 43.6% underwent MIS (n = 6007) and 56.4% OPEN (n = 7771). Highest level of education (OR for highest vs. lowest level of education 1.15; 95% CI 1.03-1.29) and highest household income quartile (OR for highest vs. lowest household income quartile 1.27; 95% CI 1.12-1.44) increased the likelihood of receiving MIS.

CONCLUSION

Despite the tax-financed healthcare system in Sweden, rectal cancer patients with the highest level of education and the highest household income had an increased probability of receiving MIS.

Rates of Minimally Invasive Surgery After Introduction of Robotic-Assisted Surgery for Common General Surgery Operations

Importance

Many patients who would benefit from minimally invasive surgery (MIS) have open surgery; robotic-assisted surgery (RAS) addresses some of the limitations of laparoscopic surgery and could increase rates of MIS across different patient populations.

Objective

To determine whether the introduction of RAS increases MIS rates and whether increases are seen across different patient populations undergoing common general surgery procedures.

Design

A retrospective cohort study was performed to compare rates of MIS in the year before and after the index date for hospitals that did and did not introduce RAS. Generalized estimating equation regression models were used to compare rates in MIS over time.

Setting

PINC AI Healthcare Database, an all-payor discharge database of hospitals in the United States.

Participants

Hospitals that performed cholecystectomy, inguinal hernia repair, ventral hernia repair, and colorectal resection from 2016 to 2022.

Exposure

RAS hospitals performing at least 1 common general surgery procedure using RAS.

Main Outcome and Measure

The primary analysis examined rates of MIS, defined as the rate of common general surgeries that were minimally invasive (laparoscopic or RAS) in a hospital. The secondary analysis examined MIS rates for common general surgeries, across age, sex, race, ethnicity, and payor.

Results

Of 408 hospitals included in the study, 153 (38%) introduced RAS for common general surgeries. The relative MIS rate for hospitals that introduced RAS compared with hospitals that did not went from 1.08 (95% confidence interval [CI], 1.02-1.14; P < 0.01) before the index date to 1.15 (95% CI, 1.09-1.22; P < 0.01) after the index date (P interaction < 0.01), indicating a larger increase in MIS rates among hospitals introducing RAS. MIS rates increased significantly more in hospitals that introduced RAS across patient age, sex, ethnicity, race, and payor compared with hospitals that did not introduce RAS.

Conclusions and Relevance

Hospitals that introduced RAS for common general surgery procedures were associated with an increase in MIS rates across different patient populations compared with hospitals that did not introduce RAS.

Clinical Trial Diversity, Equity, and Inclusion: Roadmap of the Cardiothoracic Surgical Trials Network

BACKGROUND

There is a recognized lack of diversity among patients enrolled in cardiovascular interventional and surgical trials. Diverse patient representation in clinical trials is necessary to enhance generalizability of findings, which may lead to better outcomes across broader populations. The Cardiothoracic Surgical Trials Network (CTSN) recently developed a plan of action to increase diversity among participating investigators and trial participants and is the focus of this review.

METHODS

A review of literature and enrollment data from CTSN trials was conducted.

RESULTS

CTSN completed more than a dozen major clinical trials (2008-2022), enrolling >4000 patients, of whom 30% were women, 11% were non-White, and 5.6% were Hispanic. CTSN also completed trials of hospitalized patients with coronavirus disease 2019, wherein enrollment was more diverse, with 42% women, and 58% were Asian, Black, Hispanic, or from another underrepresented racial group. The discrepancy in diversity of enrollment between cardiac surgery trials and coronavirus disease trials highlights the need for a more comprehensive understanding of (1) the prevalence of underlying disease requiring cardiac interventions across broad populations, (2) differences in access to care and referral for cardiac surgery, and (3) barriers to enrollment in cardiac surgery trials.

CONCLUSIONS

Committed to diversity, CTSN's multifaceted action plan includes developing site-specific enrollment targets, collecting social determinants of health data, understanding reasons for nonparticipation, recruiting sites that serve diverse populations, emphasizing greater diversity among clinical trial teams, and implicit bias training. The CTSN will prospectively assess how these interventions influence enrollment as we work to ensure trial participants are more representative of the communities we serve.

Measuring hospital inpatient Procedure Access Inequality in the United States

Geographic disparities in access to inpatient procedures are a significant issue within the US healthcare system. This study introduces the Procedure Access Inequality (PAI) index, a standardized metric to quantify these disparities while adjusting for disease prevalence. Using data from the Healthcare Cost and Utilization Project State Inpatient Databases, we analyzed inpatient procedure data from 18 states between 2016 and 2019. The PAI index reveals notable variability in access inequality across different procedures, with minimally invasive and newer procedures exhibiting higher inequality. Key findings indicate that procedures such as skin grafts and minimally invasive gastrectomy have the highest PAI scores, while cesarean sections and percutaneous coronary interventions have the lowest. The study highlights that higher inequality is associated with greater market concentration and in particular, fewer hospitals offering these procedures. These findings emphasize the need for targeted policy interventions to address procedural access disparities to promote more equitable healthcare delivery across the United States.

Socioeconomic disparities in midterm outcomes after repair for degenerative mitral regurgitation

OBJECTIVE

The influence of socioeconomic disparities on survival after mitral repair is poorly defined. We examined the association between socioeconomic disadvantage and midterm outcomes of repair in Medicare beneficiaries with degenerative mitral regurgitation.

METHODS

US Centers for Medicare and Medicaid Services data were used to identify 10,322 patients undergoing isolated first-time repair for degenerative mitral regurgitation between 2012 and 2019. Zip code-level socioeconomic disadvantage was dichotomized with the Distressed Communities Index, which incorporates education level, poverty, unemployment, housing security, median income, and business growth; those with Distressed Communities Index score ≥80 were classified as distressed. The primary outcome was survival, censored at 3 years. Secondary outcomes included cumulative incidences of heart failure readmission, mitral reintervention, and stroke.

RESULTS

Of the 10,322 patients undergoing degenerative mitral repair, 9.7% (n = 1003) came from distressed communities. Patients from distressed communities underwent surgery at lower volume centers (11 vs 16 cases/year) and traveled further for surgical care (40 vs 17 miles) (both P values < .001). At 3 years, unadjusted survival (85.4%; 95% CI, 82.9%-87.5% vs 89.7%; 95% CI, 89.0%-90.4%) and cumulative incidence of heart failure readmission (11.5%; 95% CI, 9.6%-13.7% vs 7.4%; 95% CI, 6.9%-8.0%) were worse in patients from distressed communities (all P values < .001), whereas mitral reintervention rates were similar (2.7%; 95% CI, 1.8%-4.0% vs 2.8%; 95% CI, 2.5%-3.2%; P = .75). After adjustment, community distress was independently associated with 3-year mortality (hazard ratio, 1.21; 95% CI, 1.01-1.46) and heart failure readmissions (hazard ratio, 1.28; 95% CI, 1.04-1.58).

CONCLUSIONS

Community-level socioeconomic distress is associated with worse outcomes in degenerative mitral repair among Medicare beneficiaries.

Racial, ethnic, and sex disparities in the utilization and outcomes of tricuspid valve surgery

Background

Data on racial/ethnic and sex disparities in the utilization and outcomes of tricuspid valve surgery (TVS) in the United States are scarce. The authors aimed to evaluate the impact of race/ethnicity and sex on the utilization and outcomes of TVS.

Methods

The authors analyzed the National Inpatient Sample database from 2016 to 2020 to identify hospitalizations for TVS. Racial/ethnic and sex disparities in TVS outcomes were determined using logistic regression models.

Results

Between 2016 and 2020, 19 395 hospitalizations for TVS were identified. The utilization rate (number of surgeries/100,000 hospitalizations) was lower in Black and Hispanic patients compared with White patients for surgical tricuspid valve repair (STVr) (331 versus 493 versus 634, P<0.01) and surgical tricuspid valve replacement (STVR) (312 versus 601 versus 728, P<0.01). Similarly, the utilization rate was lower for women compared with men for STVr (1021 versus 1364, P<0.01) and STVR (930 versus 1,316, P<0.01). Compared to White men undergoing TVS, all women had lower odds of acute kidney injury [adjusted odds ratio (aOR) 0.65, 95% CI 0.55-0.78] and higher odds of blood transfusion (aOR 1.30, 95% CI 1.07-1.59), and Black men had higher odds of blood transfusion (aOR 1.59, 95% CI 1.08-2.35). In-hospital mortality and other surgical complications were similar between all groups (all P>0.05).

Conclusions

Significant racial/ethnic and sex disparities exist in the utilization of TVS in the United States. Further studies are needed to understand the reasons for these disparities and to identify effective strategies for their mitigation.

Racial and Ethnic Disparities in Peri-and Post-operative Cardiac Surgery

Purpose of Review

Despite efforts to curtail its impact on medical care, race remains a powerful risk factor for morbidity and mortality following cardiac surgery. While patients from racial and ethnic minority groups are underrepresented in cardiac surgery, they experience a disproportionally elevated number of adverse outcomes following various cardiac surgical procedures. This review provides a summary of existing literature highlighting disparities in coronary artery bypass surgery, valvular surgery, cardiac transplantation, and mechanical circulatory support.

Recent Findings

Unfortunately, specific causes of these disparities can be difficult to identify, even in large, multicenter studies, due to the complex relationship between race and post-operative outcomes. Current data suggest that these racial/ethnic disparities can be attributed to a combination of patient, socioeconomic, and hospital setting characteristics.

Summary

Proposed solutions to combat the mechanisms underlying the observed disparate outcomes require deployment of a multidisciplinary team of cardiologists, anesthesiologists, cardiac surgeons, and experts in health care equity and medical ethics. Successful identification of at-risk populations and the implementation of preventive measures are necessary first steps towards dismantling racial/ethnic differences in cardiac surgery outcomes.

Using the Social Vulnerability Index to Analyze Statewide Health Disparities in Cholecystectomy

INTRODUCTION

Addressing the effects of social determinants of health in surgery has become a national priority. We evaluated the utility of the Social Vulnerability Index (SVI) in determining the likelihood of receiving cholecystectomy for cholecystitis in Texas.

METHODS

A retrospective study of adults with cholecystitis in the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Data Public Use Data File from 2016 to 2019. Patients were stratified into SVI quartiles, with the lowest quartile as low vulnerability, the middle two as average vulnerability, and the highest as high vulnerability. The relative risk (RR) of undergoing surgery was calculated using average vulnerability as the reference category and subgroup sensitivity analyses.

RESULTS

A total of 67,548 cases were assessed, of which 48,603 (72.0%) had surgery. Compared with the average SVI groups, the low vulnerability groups were 21% more likely to undergo cholecystectomy (RR = 1.21, 95% confidence interval [CI] 1.18-1.24), whereas the high vulnerability groups were 9% less likely to undergo cholecystectomy (RR = 0.91, 95% CI 0.88-0.93). The adjusted model showed similar results (RR = 1.05, 95% CI 1.04-1.06 and RR = 0.97, 95% CI 0.96-0.99, for low and high vulnerability groups, respectively). These results remained significant after stratifying for age, sex, ethnicity, and insurance status. However, the differences between low, average, and high vulnerability groups diminished in rural settings, with lower surgery rates in all groups.

CONCLUSIONS

Patients with higher SVI were less likely to receive an elective cholecystectomy. SVI is an effective method of identifying social determinants impacting access to and receipt of surgical care.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2023 Update on Procedure Data and Research

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database is one of the largest and most comprehensive contemporary clinical databases in use. It now contains >9 million procedures from 1010 participants and 3651 active surgeons. Using audited data collection, it has provided the foundation for multiple risk models, performance metrics, health policy decisions, and a trove of research studies to improve the care of patients in need of cardiac surgical procedures. This annual report provides an update on the current status of the database and summarizes the development of new risk models and the STS Online Risk Calculator. Further, it provides insights into current practice patterns, such as the change in the demographics among patients undergoing aortic valve replacement, the use of minimally invasive techniques for valve and bypass surgery, or the adoption of surgical ablation and left atrial appendage ligation among patients with atrial fibrillation. Lastly, an overview of the research conducted using the STS Adult Cardiac Surgery Database and future directions for the database are provided.

Racial and Ethnic Disparities in Perioperative Health Care Among Patients Undergoing Cardiac Surgery: JACC State-of-the-Art Review

There has been little progress in reducing health care disparities since the 2003 landmark Institute of Medicine's report Unequal Treatment. Despite the higher burden of cardiovascular disease in underrepresented racial and ethnic groups, they have less access to cardiologists and cardiothoracic surgeons, and have higher rates of morbidity and mortality with cardiac surgical interventions. This review summarizes existing literature and highlights disparities in cardiovascular perioperative health care. We propose actionable solutions utilizing multidisciplinary perspectives from cardiology, cardiac surgery, cardiothoracic anesthesiology, critical care, medical ethics, and health disparity experts. Applying a health equity lens to multipronged interventions is necessary to eliminate the disparities in perioperative health care among patients undergoing cardiac surgery.