The intersection of community socioeconomic factors with gender on outcomes after thoracic aortic surgery

Influence of socioeconomic status on postoperative outcomes in acute type A aortic dissection repair

Objective

Type A aortic dissection repair is an emergency operation associated with both higher perioperative and postoperative risk. This study investigates the influence of socioeconomic status, as measured by the Distressed Communities Index (DCI), on patients who underwent acute aortic dissection repair and their postoperative outcomes.

Methods

We conducted a retrospective analysis of 240 adult patients who underwent repair for acute Stanford Type A aortic dissection from 2009 to 2021. Patients were categorized into an at-risk group (DCI score ≥75) and a not-at-risk group (DCI score <75) based on their zip code. We collected demographic, clinical, operative, and postoperative outcomes, analyzing data using descriptive statistics and multivariable logistic regression. Kaplan-Meier survival analysis assessed 5-year survival outcomes.

Results

At-risk patients were significantly younger (52 vs 59 years; P = .03) and more commonly African American (59.02% vs 26.5%; P < .0001). Although chronic health condition rates were similar, at-risk patients showed trends toward higher rates of postoperative respiratory failure (27.1% vs 18.0%; P = .0926) and longer hospital stays (27.05% vs 15.25% for length of stay of 8-13 days; P = .065). However, rates of postoperative complications, including 30-day mortality and 5-year survival, were not significantly different between groups, and at-risk status did not significantly predict mortality (hazard ratio, 1.35; 95% CI, 0.65-2.79; P = .43).

Conclusions

Patients undergoing urgent surgery for acute Type A aortic dissection have similar postoperative outcomes, although at-risk patients may experience longer hospital stays and higher respiratory failure rates. Further study is necessary to understand the effect of DCI score on intermediate and long-term outcomes to mitigate social disparities and diminish modifiable risk factors.

Unplanned readmissions, community socioeconomic factors, and their effects on long-term survival after complex thoracic aortic surgery

OBJECTIVE

We evaluated community socioeconomic factors in patients who had unplanned readmission after undergoing proximal aortic surgery (ascending aorta, aortic root, or arch).

METHODS

Unplanned readmissions for any reason within 60 days of the index procedure were reviewed by race, acuity at presentation, and gender. We also evaluated 3 community socioeconomic factors: poverty, household income, and education. Kaplan-Meier survival curves were used to assess long-term survival differences by group (race, acuity, and gender).

RESULTS

Among 2339 patients who underwent proximal aortic surgery during the 20-year study period and were discharged alive, our team identified 146 (6.2%) unplanned readmissions. Compared with White patients, Black patients lived in areas characterized by more widespread poverty (20.8% vs 11.1%; P = .0003), lower income ($42,776 vs $65,193; P = .0007), and fewer residents with a high school diploma (73.7% vs 90.1%; P < .0001). Compared with patients whose index operation was elective, patients who had urgent or emergency index procedures lived in areas with lower income ($54,425 vs $64,846; P = .01) and fewer residents with a high school diploma (81.1% vs 89.2%; P = .005). Community socioeconomic factors did not differ by gender. Four- and 6-year survival estimates were 63.1% and 63.1% for Black patients versus 89.1% and 83.0% for White patients (P = .0009). No significant differences by acuity or gender were found.

CONCLUSIONS

Among readmitted patients, Black patients and patients who had emergency surgery had less favorable community socioeconomic factors and poorer long-term survival. Earlier and more frequent follow-up in these patients should be considered. Developing off-campus clinics and specific postdischarge measures targeting these patients is important.

Pathways From Socioeconomic Factors to Major Cardiovascular Events Among Postmenopausal Veteran and Nonveteran Women: Findings From the Women's Health Initiative

BACKGROUND

Cardiovascular disease (CVD) remains a leading cause of death for women in the United States, with veterans being at potentially higher risk than their nonveteran counterparts due to accelerated aging and distinct biopsychosocial mechanisms. We examined pathways between selected indicators of socioeconomic status (SES) such as education, occupation, household income, and neighborhood SES and major CVD events through lifestyle and health characteristics among veteran and nonveteran postmenopausal women.

METHODS AND RESULTS

A total of 121 286 study-eligible WHI (Women's Health Initiative) participants (3091 veterans and 118 195 nonveterans) were prospectively followed for an average of 17 years, during which 16 108 major CVD events were documented. Using generalized structural equations modeling coupled with survival analysis techniques, we estimated the effects of SES on major CVD events through smoking, body mass index, comorbidities, cardiometabolic risk factors, and self-rated health, controlling for WHI component, region, age, race, ethnicity, marital status, and health care provider access. Among veterans, SES characteristics were indirectly related to major CVD events through body mass index, comorbidities, cardiometabolic risk factors, and self-rated health. Among nonveterans, lower education (β= 0.2, P<0.0001), household income (β=+0.4, P<0.0001), and neighborhood SES (β=+0.2, P<0.0001) were positively related to major CVD events, and these relationships were partly mediated by body mass index, comorbidities, cardiometabolic risk factors, and self-rated health. Smoking played a mediating role only among nonveterans.

CONCLUSIONS

Nonveteran postmenopausal women exhibit more complex pathways between SES and major CVD events than their veteran counterparts, informing the design, conduct, and evaluation of preventive strategies targeting CVD by veteran status.