Operative and late coronary artery bypass grafting outcomes in matched African-American versus Caucasian patients: evidence of a late survival-Medicaid association

Low socioeconomic status adversely influences outcomes after coronary artery bypass grafting

OBJECTIVES

Although socioeconomic status (SES) is believed to affect patient outcomes after coronary artery bypass grafting (CABG), readmission data are sparse. In a national cohort, we analyzed the influence of SES on readmission, resource utilization, and mortality after CABG.

METHODS

We queried the Nationwide Readmissions Database to identify patients who underwent isolated CABG from January 2016 through December 2018. We derived low, middle, and high SES from International Classification of Diseases, 10th Revision, Clinical Modification codes, patient demographics, and neighborhood-level factors. The effect of SES on risk-adjusted outcomes was assessed with multivariable analysis.

RESULTS

Of 523,042 patients who underwent CABG, the 134,039 (25.6%) with low SES were more likely than patients with middle (n = 305,572 [58.4%]) or high SES (n = 83,431 [16%]) to be female, younger, from rural areas, and admitted urgently. Patients with low SES were also less likely to be treated at teaching hospitals and had higher Elixhauser comorbidity scores (P < .001 for all). After risk adjustment, patients with low SES had 46% greater odds of in-hospital mortality at the index operation (odds ratio, 1.464; 95% CI, 1.299-1.650) than patients with high SES. Patients with low SES had the longest index hospital length of stay (P < .001). Low SES was associated with greater odds of readmission at 30 days (odds ratio, 1.229; 95% CI, 1.170-1.292), 90 days (odds ratio, 1.281; 95% CI, 1.223-1.341), and within a calendar year (hazard ratio, 1.234; 95% CI, 1.193-1.278) than high SES.

CONCLUSIONS

Patients with low SES have greater adjusted odds of mortality and readmission after CABG than patients with high SES.

Risk predictors of race disparity in patients undergoing coronary artery bypass grafting: a propensity-matched analysis

OBJECTIVES

The aim of this study was to compare long-term prognosis after isolated coronary artery bypass grafting between white and black patients and to investigate risk factors for poorer outcomes among the latest.

METHODS

All consecutive 4766 black and white patients undergoing isolated coronary artery bypass grafting between May 2005 and June 2021 at our institution were included. Primary outcomes were long-term incidence of all-cause death and major adverse cardiovascular and cerebrovascular events in black versus white patients. A propensity-matched analysis was used 2 compare groups.

RESULTS

After matching, 459 patients were included in each black and white groups while groups were correctly balanced. The mean age was 70.4 vs 70.6 years old (P = 0.7) in black and white groups, respectively. Intraoperatively, mean operating room time and blood product transfusion, were higher in the black group while incidence of extubation in the operating room was higher in the white one. Postoperatively, hospital length of stay was higher in the black cohort. Thirty-day all-cause mortality was not different among groups. The median follow-up time was 4 years. Primary outcome of all-cause death was higher in the black versus the white, respectively. Major adverse cardiovascular and cerebrovascular events incidence was twice higher in the black compared to the white cohort (7.6% vs 3.7%, P = 0.013). Risk predictors for all-cause death and major adverse cardiovascular and cerebrovascular events in blacks were creatinine level, chronic obstructive pulmonary disease, ejection fraction <50% and preoperative atrial fibrillation.

CONCLUSIONS

Racial disparities persist in a high-volume centre. Despite no preoperative difference, black minority has a higher incidence of major adverse cardiovascular and cerebrovascular events.

Medicare and Medicaid insurance status is associated with increased allogeneic red blood cell transfusion in cardiac surgery patients: 2007-2018

BACKGROUND AND AIM

Allogeneic red blood cell (RBC) transfusion and health insurance status are independently associated with perioperative morbidity. The aim of this study was to evaluate the effect of insurance status on allogeneic and autologous transfusion risk in cardiac surgery patients.

METHODS

We conducted a retrospective observational study of data spanning 2007-2018 from six states from the State Inpatient Databases. Patients were cohorted by medical insurance type. Rates and risk-adjusted odds ratios (aOR) were calculated for allogenic and autologous RBC transfusions. Interactions between insurance and race/ethnicity were assessed.

RESULTS

A total of 710,296 cardiac surgery patients were included. Allogeneic infusions occurred in 34.7% of Medicare patients, 31.9% of Medicaid patients, 24.7% of privately insured patients, and 26.1% of uninsured patients. Autologous rates were 2.3%, 2.5%, 3.4%, and 2.6% for Medicare, Medicaid, privately insured, and uninsured patients, respectively. Medicare and Medicaid patients were more likely to receive allogeneic RBC than privately insured patients (Medicare: aOR: 1.42, 99% confidence interval [CI]: 1.40-1.44, p < .001, Medicaid: aOR: 1.18, 99% CI: 1.14-1.21, p < .001). Nonwhite Medicare patients showed higher odds of allogeneic transfusion compared with White patients with private insurance (Black Medicare: aOR 1.74, 99% CI: 1.65-1.83, p < .001, Hispanic Medicare: aOR 1.92, 99% CI: 1.84-2.00, p < .001).

CONCLUSION

Cardiac surgery patients with Medicare and Medicaid insurance demonstrate increased risk of allogeneic RBC transfusion; nonwhite patient groups are particularly vulnerable. Further research is needed to understand the causes and implications of these disparities, and to help ensure equitable care across patient groups.

Managing acute cholecystitis among Medicaid insured in New York State: opportunities to optimize care

BACKGROUND

Identifying sources of unnecessary cost within Medicaid will help focus cost containment efforts. This study sought to identify differences in surgical management and associated costs of cholecystitis between Medicaid and privately insured in New York State.

METHODS

The New York State all-payer mandatory discharge database from 2003 to 2013, had 297,635 patients with Medicaid (75,512) and privately (222,123) insurance who underwent cholecystectomy for cholecystitis. Patients were stratified by insurance. Four surgical management approaches were delineated based on cholecystectomy timing: primary, interval, emergency, and delayed cholecystectomy. Delayed cholecystectomy was defined as more than one hospital visit from diagnosis to definitive cholecystectomy. Medicaid and privately insured patients were propensity score matched. Surgical management approach and associated costs were compared between matched cohorts.

RESULTS

A greater proportion of Medicaid patients underwent delayed cholecystectomy compared to matched privately insured patients, 8.5 versus 4.8%; P < 0.001. Primary initial cholecystectomy was performed in fewer Medicaid compared to privately insured patients, 55.4 versus 66.0%, P < 0.001. Primary initial cholecystectomy was the cheapest surgical management approach, with the median cost of $3707, and delayed cholecystectomy was the most expensive, $12,212, P < 0.001. The median cost per Medicaid patient was $6170 versus $4804 per matched privately insured patient, P < 0.001. The annual predicted cost savings for New York State Medicaid would be $13,097,371, if the distribution of surgical management approaches were proportionally similar to private insurance.

CONCLUSIONS

Medicaid patients with cholecystitis were more frequently managed with delayed cholecystectomy than privately insured patients, which had substantial cost implications for the New York Medicaid Program.

Household Disposable Income and Long-Term Survival After Cardiac Surgery: A Swedish Nationwide Cohort Study in 100,534 Patients

BACKGROUND

Lower socioeconomic groups face higher mortality risk, possibly due to a higher burden of cardiovascular risk factors. The independent association between income and survival following cardiac surgery is not known.

OBJECTIVES

This study sought to investigate the association between household disposable income and long-term mortality after cardiac surgery.

METHODS

In a Swedish nationwide population-based analysis, we included all patients who underwent cardiac surgery between 1999 and 2012 using a large national registry. Information regarding income, education, marital status, medical history, and cardiovascular risk factors was obtained from data managed by the National Board of Health and Welfare and Statistics Sweden. The adjusted risk for all-cause mortality was estimated using Cox regression by quintiles of household disposable income.

RESULTS

We included 100,534 patients and, during a mean follow-up of 7.3 years, 29,176 (29%) patients died. There was a stepwise inverse association between household disposable income and all-cause mortality: the adjusted hazard ratio was 0.93 (95% confidence interval [CI]: 0.89 to 0.96), 0.87 (95% CI: 0.84 to 0.91), 0.78 (95% CI: 0.75 to 0.82), and 0.71 (95% CI: 0.67 to 0.75), for the second, third, fourth, and fifth income quintiles, respectively, compared to the first (and lowest) income quintile. The inverse association between income and mortality was consistent through the study period and in selected subgroups, although it was slightly attenuated in older patients.

CONCLUSIONS

We found a strong inverse association between income and mortality following cardiac surgery in Sweden that was independent of other socioeconomic status variables, comorbidities, and cardiovascular risk profile. Ways to better implement secondary prevention measures should be explored in low-income patient groups. (HeAlth-data Register sTudies of Risk and Outcomes in Cardiac Surgery [HARTROCS]; NCT02276950).

Operative status and survival after coronary artery bypass grafting

BACKGROUND

The effect of race on long-term survival of patients undergoing elective and nonelective coronary artery bypass grafting (CABG) is currently unknown. The purpose of this study was to compare long-term survival between black and white CABG patients by operative status.

METHODS

Long-term survival of black versus white patients undergoing elective and nonelective CABG procedures between 1992 and 2011 was compared. Survival probabilities were computed using the Kaplan-Meier product-limit method and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model.

RESULTS

A total of 13,774 patients were included in this study. The median follow-up time for study participants was 8.2 years. Black patients undergoing elective CABG died sooner than whites (adjusted HR = 1.4, 95% CI = 1.2-1.5). Survival was similar between blacks and whites in the nonelective population (adjusted HR = 1.0, 95% CI = 0.96-1.1).

CONCLUSIONS

Black race was a statistically significant predictor of long-term survival after elective but not nonelective CABG.

Does payer status impact clinical outcomes after cardiac surgery? A propensity analysis

BACKGROUND

Medicaid patients bear proportionately greater financial responsibility for the cost of outpatient care and medication than non-Medicaid patients. We hypothesized that this difference in provision of continuing care would be associated with adverse clinical outcomes after cardiac surgery.

MATERIALS AND METHODS

In a retrospective cohort analysis, 5056 consecutive adult patients undergoing cardiac surgery at a single institution between 2005 and 2010 were divided according to payer status. Propensity scores were calculated using 16 preoperative and demographic variables for each patient, and 461 1:1 propensity score-matched pairs were analyzed. Patient socioeconomic position was determined using aggregate data derived from zip codes. The main outcome measures were early mortality, postoperative complications, and patient survival.

RESULTS

In multivariate analysis, Medicaid was found to be an independent predictor of worse survival after cardiac surgery (hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.2-3.7; P = .01). No significant difference was observed in operative mortality in the 2 groups. After propensity score matching and controlling for socioeconomic position, the only independent predictors of worse midterm survival were an ejection fraction = 30% (HR, 1.7; 95% CI, 1.1-2.7; P = .02) and a higher logistic EuroSCORE (HR, 1.03; 95% CI, 1.0-1.1; P = .02).

CONCLUSIONS

Comorbidity and lower socioeconomic status appear to be more important predictors of late mortality after cardiac surgery than payer status, which does not have a significant impact on survival.

Preoperative atrial fibrillation and long-term survival after open heart surgery in a rural tertiary heart institute

BACKGROUND

Preoperative atrial fibrillation (AF) is associated with increased morbidity and mortality after open heart surgery. However, the impact of preoperative AF on long-term survival after open heart surgery has not been widely examined in rural populations. Patients from rural regions are less likely to receive treatment for cardiac conditions and to have adequate medical insurance coverage.

OBJECTIVE

To examine the influence of preoperative AF on long-term survival following open heart surgery in rural eastern North Carolina.

METHODS

Long-term survival was compared in patients with and without preoperative AF after coronary artery bypass grafting (CABG) and CABG plus valve (CABG + V) surgery between 2002 and 2011. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model.

RESULTS

The study population consisted of 5438 patients. A total of 263 (5%) patients had preoperative AF. Preoperative AF was an independent predictor of long-term survival (open heart surgery: adjusted HR = 1.6, 95% CI = 1.3-2.0; CABG: adjusted HR = 1.6, 95% CI = 1.3-2.1; CABG + V: adjusted HR = 1.6, 95% CI = 1.1-2.3).

CONCLUSION

Preoperative AF is an important predictor of long-term survival after open heart surgery in this rural population.

Impact of race and postoperative atrial fibrillation on long-term survival after coronary artery bypass grafting

BACKGROUND AND AIM

Postoperative atrial fibrillation (POAF) is a known predictor of in-hospital morbidity and short-term survival after coronary artery bypass grafting (CABG). The impact of race and long-term survival has not been examined in this population. We aimed to examine the influence of these factors on long-term survival in patients undergoing CABG.

METHODS

Patients undergoing first-time, isolated CABG between 1992 and 2011 were included in this study. Long-term survival was compared in patients with and without POAF and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model.

RESULTS

A total of 2,907 (22%) patients developed POAF (black n=370; white n=2,537) following CABG (N=13,165). Median follow-up for study participants was 8.2 years. Long-term survival after CABG differed by POAF status and race (no POAF: HR=1.0; white POAF: adjusted HR=1.1, 95% CI=1.06-1.2; black POAF: adjusted HR=1.4, 95% CI=1.2-1.6; pTrend=0.0002). lack POAF patients also died sooner after surgery than their white counterparts (adjusted HR=1.2, 95% CI=1.02-1.4).

CONCLUSION

Black race was a statistically significant predictor of decreased survival among POAF patients after CABG. This finding provides useful outcome information for surgeons and their patients.

The effect of race and chronic obstructive pulmonary disease on long-term survival after coronary artery bypass grafting

Background: Chronic obstructive pulmonary disease (COPD) is a known predictor of decreased long-term survival after coronary artery bypass grafting (CABG). Differences in survival by race have not been examined.

Methods: A retrospective cohort study was conducted of CABG patients between 2002 and 2011. Long-term survival was compared in patients with and without COPD and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model.

Results: A total of 984 (20%) patients had COPD (black n = 182; white n = 802) at the time of CABG (N = 4,801). The median follow-up for study participants was 4.4 years. COPD was observed to be a statistically significant predictor of decreased survival independent of race following CABG (no COPD: HR = 1.0; white COPD: adjusted HR = 1.9, 95% CI = 1.7–2.3; black COPD: adjusted HR = 1.6, 95% CI = 1.1–2.2).

Conclusion: Contrary to the expected increased risk of mortality among black COPD patients in the general population, a similar survival disadvantage was not observed in our CABG population.

The use of comorbidities among adults experiencing care transitions: a systematic review and evolutionary analysis of empirical literature

OBJECTIVE

To systematically review how comorbidities are employed in the empirical literature for adults coping with multiple chronic conditions during common episodes of acute illness that resulted in transition across health care setting.

METHODS

Evolutionary concept analysis inductively identifies current consensus regarding the usage of a concept and results in exploring attributes and clarification of the concept. Sixty studies from 1965 to 2009 identified from MEDLINE, CINAHL, PsychINFO, and ISI Web of Science databases were analysed.

RESULTS

Comorbidities were used heterogeneously among reviewed studies with most controlling for their presence (n=33) and lacking robust measurement (n=37). The designation of index or principal condition was equally heterogeneous with approximately half (n=26) representing the main disease or diagnosis of interest to the researcher. In this study comorbidities were associated with personal, disease or system level antecedents and consequences. A conceptual framework is proposed.

DISCUSSION

The impact of comorbidities on the care and outcomes of adults coping with multiple chronic conditions is limited by heterogeneous and ambiguous usage. While analytic techniques have become more sophisticated, continued lack of meaningful conceptualization and instrument use has limited maturation of this important concept for research, practice and policy purposes.

Primary payer status is associated with mortality and resource utilization for coronary artery bypass grafting

BACKGROUND

Medicaid and uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes after coronary artery bypass grafting (CABG) in the United States is dependent on primary payer status.

METHODS AND RESULTS

From 2003 to 2007, 1,250,619 isolated CABG operations were evaluated using the Nationwide Inpatient Sample (NIS) database. Patients were stratified by primary payer status: Medicare, Medicaid, uninsured, and private insurance. Hierarchical multiple regression models were applied to assess the effect of primary payer status on postoperative outcomes. Unadjusted mortality for Medicare (3.3%), Medicaid (2.4%), and uninsured (1.9%) patients were higher compared with private insurance patients (1.1%, P<0.001). Unadjusted length of stay was longest for Medicaid patients (10.9 ± 0.04 days) and shortest for private insurance patients (8.0 ± 0.01 days, P<0.001). Medicaid patients accrued the highest unadjusted total costs ($113 380 ± 386, P<0.001). Importantly, after controlling for patient risk factors, income, hospital features, and operative volume, Medicaid (odds ratio, 1.82; P<0.001) and uninsured (odds ratio, 1.62; P<0.001) payer status independently conferred the highest adjusted odds of in-hospital mortality. In addition, Medicaid payer status was associated with the longest adjusted length of stay and highest adjusted total costs (P<0.001).

CONCLUSIONS

Medicaid and uninsured payer status confers increased risk adjusted in-hospital mortality for patients undergoing coronary artery bypass grafting operations. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors. Possible explanations include delays in access to care or disparate differences in health maintenance.

Analysis of Florida and New York state hospital discharges suggests that carotid stenting in symptomatic women is associated with significant increase in mortality and perioperative morbidity compared with carotid endarterectomy

BACKGROUND

Although large randomized studies have established the efficacy and safety of carotid endarterectomy (CEA) and, recently, carotid artery stenting (CAS), the under-representation of women in these trials leaves the comparison of risks to benefits of performing these procedures on women an open question. To address this issue, we reviewed the hospital outcomes and delineated patient characteristics predicting outcome in women undergoing carotid interventions using New York and Florida statewide hospital discharge databases.

METHODS

We analyzed in-hospital mortality, postoperative stroke, cardiac postoperative complications, and combined postoperative stoke and mortality in 20,613 CEA or CAS hospitalizations for the years 2007 to 2009. Univariate and multiple logistic regression analyses of variables were performed.

RESULTS

CEA was performed in 16,576 asymptomatic and 1744 symptomatic women and CAS in 1943 asymptomatic and 350 symptomatic women. Compared with CAS, CEA rates, in asymptomatic vs symptomatic, were significantly lower for in-hospital mortality (0.3% vs 0.8% and 0.4% vs 3.4%), stroke (1.5% vs 2.6% and 3.5% vs 9.4%), and combined stroke/mortality (1.7% vs 3.1% and 3.8% vs 10.9%). In cohorts matched by propensity scores, the same trend favoring CEA remained significant in symptomatic women. There was no difference in cardiac complication rates among asymptomatic women, but among symptomatic woman cardiac complications were more frequent after CAS (10.6% vs 6.5%; P = .0077). Among symptomatic women, the presence of renal disease, coronary artery disease, or age ≥80 years increased the risk of CAS over CEA threefold for the composite end point of stroke or death. For asymptomatic women only in those with coronary artery disease or diabetes, there was a statistical difference in the composite mortality/stroke rates favoring CEA (1.9% vs 3.3% and 1.7% vs 3.4%, respectively). After adjusting for relevant clinical and demographic risk factors and hospital annual volume, for CAS vs CEA, the risk of the composite end point of stroke or mortality was 1.7-fold higher in symptomatic and 3.4-fold higher in asymptomatic patients. Medicaid insurance, symptomatic patient, history of cancer, and presence of heart failure on admission were among other strong predictors of composite stroke/mortality outcome.

CONCLUSIONS

Databases reflecting real-world practice performance and management of carotid disease in women suggest that CEA compared with CAS has overall better perioperative outcomes in women. Importantly, CAS is associated with significantly higher morbidity in certain clinical settings and this should be taken into account when choosing a revascularization procedure.

Primary payer status affects outcomes for cardiac valve operations

BACKGROUND

Disparities in health care have been reported among various patient populations, and the uninsured and Medicaid populations are a major focus of current health care reform. The objective of this study was to examine the influence of primary payer status on outcomes after cardiac valve operations in the United States.

METHODS

From 2003 to 2007, 477,932 patients undergoing cardiac valve operations were evaluated using discharge data from the Nationwide Inpatient Sample database. Records were stratified by primary payer status: Medicare (n = 57,249, age = 74.0 ± 0.02 years), Medicaid (n = 5,868, age = 41.2 ± 0.13 years), uninsured (n = 2,349, age = 49.7 ± 0.15 years), and private insurance (n = 31,808, age = 53.3 ± 0.04 years). Multivariate regression models were applied to assess the independent effect of payer status on in-hospital outcomes.

RESULTS

Preoperative patient risk factors were more common among Medicare and Medicaid populations. Unadjusted mortality and complication rates for Medicare (6.9%, 36.6%), Medicaid (5.7%, 31.4%) and uninsured (5.2%, 31.4%) patient groups were higher compared with private insurance groups (2.9%, 29.9%; p < 0.001). In addition, mortality was lowest for patients with private insurance for all types of valve operations. Medicaid patients accrued the longest unadjusted hospital length of stay and highest total hospital costs compared with other payer groups (p < 0.001). Importantly, after risk adjustment, uninsured and Medicaid payer status conferred the highest odds of risk-adjusted mortality and morbidity compared with private insurance status, which were higher than those for Medicare.

CONCLUSIONS

Uninsured and Medicaid payer status is associated with increased risk-adjusted in-hospital mortality and morbidity among patients undergoing cardiac valve operations compared with Medicare and private insurance. In addition, Medicaid patients accrued the longest hospital stays and highest total costs. Primary payer status should be considered as an independent risk factor during preoperative risk stratification and planning.

Primer on statistical interpretation or methods report card on propensity-score matching in the cardiology literature from 2004 to 2006: a systematic review

BACKGROUND

Propensity-score matching is frequently used in the cardiology literature. Recent systematic reviews have found that this method is, in general, poorly implemented in the medical literature. The study objective was to examine the quality of the implementation of propensity-score matching in the general cardiology literature.

METHODS AND RESULTS

A total of 44 articles published in the American Heart Journal, the American Journal of Cardiology, Circulation, the European Heart Journal, Heart, the International Journal of Cardiology, and the Journal of the American College of Cardiology between January 1, 2004, and December 31, 2006, were examined. Twenty of the 44 studies did not provide adequate information on how the propensity-score-matched pairs were formed. Fourteen studies did not report whether matching on the propensity score balanced baseline characteristics between treated and untreated subjects in the matched sample. Only 4 studies explicitly used statistical methods appropriate for matched studies to compare baseline characteristics between treated and untreated subjects. Only 11 (25%) of the 44 studies explicitly used statistical methods appropriate for the analysis of matched data when estimating the effect of treatment on the outcomes. Only 2 studies described the matching method used, assessed balance in baseline covariates by appropriate methods, and used appropriate statistical methods to estimate the treatment effect and its significance.

CONCLUSIONS

Application of propensity-score matching was poor in the cardiology literature. Suggestions for improving the reporting and analysis of studies that use propensity-score matching are provided.

Socioeconomic position, not race, is linked to death after cardiac surgery

BACKGROUND

Health disparities have been associated with the prevalence of cardiovascular disease. In cardiac surgery, association has been found between race, sex, and poorer prognosis after surgery. However, there is a complex interplay between race, sex, and socioeconomic position (SEP). In our investigation we sought to identify which of these was the driver of risk-adjusted survival.

METHODS AND RESULTS

From January 1, 1995, and December 30, 2005, 23 330 patients (15 156 white men, 6932 white women, 678 black men, and 564 black women) underwent isolated coronary artery bypass grafting, valve, or combined coronary artery bypass grafting and valve procedures. Median follow-up was 5.8 years (25th and 75th percentiles: 3 and 8.6 years). Effect of race, sex, and SEP on all-cause mortality was examined with 2-phase Cox model and generalized propensity score technique. As expected, blacks and women had lower SEP as compared with whites and men for all 6 SEP indicators. Patients with lower SEP had more atherosclerotic disease burden, more comorbidity, and were more symptomatic. Lower SEP was associated with a risk-adjusted dose-dependent reduction in survival after surgery (men, P<0.0001; women, P=0.0079), but black race, once adjusted for SEP, was not.

CONCLUSIONS

Our large investigation demonstrates that disparities in SEP are present and significantly affect health outcomes. Although race per se was not the driver for reduced survival, patients of low SEP were predominantly represented by blacks and women. Socioeconomically disadvantaged patients had significantly higher risk-adjusted mortality after surgery. Further investigation and targeted intervention should focus specifically on patients of low SEP, their health behaviors, and secondary prevention efforts.

Value of early cardiac troponin I to predict long-term adverse events after coronary artery bypass graft surgery in patients presenting with acute coronary syndromes

BACKGROUND

High values of both preoperative and postoperative cardiac troponin I (cTnI) contribute to higher rates of short-term cardiac events following coronary artery bypass graft (CABG) surgery in patients with acute coronary syndrome (ACS). The prognostic value of very early cTnI in this context is unclear.

HYPOTHESIS

Measurement of cTnI very early after admission to the emergency room can be used as a prognosticator for long-term outcomes after CABG.

METHODS

We conducted a cohort study on 160 consecutive patients with ACS undergoing CABG at The John H. Stroger Jr. Hospital of Cook County (Chicago, IL) representing a total follow-up of 290.42 person-years. Adverse outcomes were defined as death or reinfarction. We used robust multivariate survival analyses to determine whether early cTnI measurement can independently predict the adverse outcomes in the study subjects.

RESULTS

In univariate and stepwise multivariate Cox proportional hazards modeling we found that unit rise in early cTnI is associated with a 3% (95% confidence interval [CI]: 2%- 5%, p < 0.001) faster progression to long-term adverse events after CABG even after adjusting for the type of ACS. Prognostically, the most informative cut off value for cTnI was 5.6 ng/mL. Above this value, CABG patients progressed 2.58 times faster to adverse outcomes (95% CI: 1.05-6.36, p = 0.039). This effect remained after adjustment for other significant confounders namely, poor compliance to medications, female sex, Medicaid insurance, and electrocardiographic ischemia.

CONCLUSION

Early cTnI measurement after admission can predict adverse outcomes after CABG. This association extends to long-term adverse events after CABG.

Disparity in outcomes of surgical revascularization for limb salvage: race and gender are synergistic determinants of vein graft failure and limb loss

BACKGROUND

Vein bypass surgery is an effective therapy for atherosclerotic occlusive disease in the coronary and peripheral circulations; however, long-term results are limited by progressive attrition of graft patency. Failure of vein bypass grafts in patients with critical limb ischemia results in morbidity, limb loss, and additional resource use. Although technical factors are known to be critical to the success of surgical revascularization, patient-specific risk factors are not well defined. In particular, the relationship of race/ethnicity and gender to the outcomes of peripheral bypass surgery has been controversial.

METHODS AND RESULTS

We analyzed the Project of Ex Vivo Vein Graft Engineering via Transfection III (PREVENT III) randomized trial database, which included 1404 lower extremity vein graft operations performed exclusively for critical limb ischemia at 83 North American centers. Trial design included intensive ultrasound surveillance of the bypass graft and clinical follow-up to 1 year. Multivariable modeling (Cox proportional hazards and propensity score) was used to examine the relationships of demographic variables to clinical end points, including perioperative (30-day) events and 1-year outcomes (vein graft patency, limb salvage, and patient survival). Final propensity score models adjusted for 16 covariates (including type of institution, technical factors, selected comorbidities, and adjunctive medications) to examine the associations between race, gender, and outcomes. Among the 249 black patients enrolled in PREVENT III, 118 were women and 131 were men. Black men were at increased risk for early graft failure (hazard ratio [HR], 2.832 for 30-day failure; 95% confidence interval [CI], 1.393 to 5.759; P=0.0004), even when the analysis was restricted to exclude high-risk venous conduits. Black patients experienced reduced secondary patency (HR, 1.49; 95% CI, 1.08 to 2.06; P=0.016) and limb salvage (HR, 2.02; 95% CI, 1.27 to 3.20; P=0.003) at 1 year. Propensity score models demonstrate that black women were the most disadvantaged, with an increased risk for loss of graft patency (HR, 2.02 for secondary patency; 95% CI, 1.27 to 3.20; P=0.003) and major amputation (HR, 2.38; 95% CI, 1.18 to 4.83; P=0.016) at 1 year. Perioperative mortality and 1-year mortality were similar across race/gender groups.

CONCLUSIONS

Black race and female gender are risk factors for adverse outcomes after vein bypass surgery for limb salvage. Graft failure and limb loss are more common events in black patients, with black women being a particularly high-risk group. These data suggest the possibility of an altered biological response to vein grafting in this population; however, further studies are needed to determine the mechanisms underlying these observed disparities in outcome.

Hospital and long-term outcome after percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has become the preferred method of providing long-term enteral nutrition. While hospitalized patients frequently have PEG inserted to facilitate enteral nutrition, little is known about these patients. The objective of the study was to determine hospital and long-term survival in patients who receive PEG while hospitalized for medical or surgical reasons.

METHODS

Records of all patients aged 18 years and older who underwent PEG between January 1, 1999 and December 31, 2004 at a university-affiliated community-based tertiary care center were examined.

RESULTS

80 (11%) of 714 patients died during the index hospitalization. Older age, being married, mechanical ventilation, and dialysis were statistically significant predictors of hospital death (P < 0.05). There were nine complications and no deaths directly attributable to PEG. Overall survival was poor with 5.6% of patients dying within seven days of the procedure. Mortalities at 30, 60, and 365 days were 22%, 31% and 48%, respectively. Of the 80 patients who died prior to discharge, 40 (50%) died within one week of PEG placement. Fourteen (35%) of these 40 patients had treatment withdrawn. Kaplan-Meier median survival was 412 +/- 73 (mean +/- standard error) days. By Cox proportional hazard modeling, older age, cancer, heart disease, non-white race, and dialysis were significant predictors of post-PEG death (P < 0.05).

CONCLUSIONS

Outcome after PEG is dependent on demographic factors and patient comorbidities. Given the very low initial complication rates, it may be advisable to delay PEG placement until just prior to discharge in order to prevent unnecessary procedures on those patients who are not likely to survive.

Racial disparities in outcomes following coronary artery bypass grafting

More than 12 million people in the United States have coronary heart disease, the second leading cause of hospitalization in the United States. It is known that persons within racial minorities, specifically African Americans, have a higher prevalence of coronary heart disease, yet are much less likely to undergo invasive cardiac treatment interventions. An invasive intervention commonly used to treat coronary heart disease is coronary artery bypass grafting, with over 140,000 operations performed annually in the United States. However, blacks are known to experience higher post-coronary artery bypass graft morbidity and mortality. The causes for racial disparities in post-coronary artery bypass graft outcomes are not well known but may include factors related to the individual, provider, system, and society/environment, either alone or in combination. The purpose of this article is to provide an overview of the literature regarding disparities in the health and healthcare of black patients with coronary heart disease with respect to CABG, and examine potential hypotheses for variant outcomes after surgery.