Over the past decade in cardiac surgery, health policy initiatives have been implemented to reduce disparities by sex and socioeconomic status. To evaluate progress in the U.S., researchers at Brigham and Women’s Hospital recently conducted the largest nationally representative study to date.
The results were discouraging—female sex and lower household income were independent predictors of 30-day mortality after revascularization, valvular or aortic surgery. Paige Newell, MD, a clinical resident in surgery, Tsuyoshi Kaneko, MD, surgical director of the Structural Heart Disease Program, and colleagues report in The Journal of Thoracic and Cardiovascular Surgery.
Using the Nationwide Readmissions Database, a weighted total of 358,762 adult patients who underwent the following 5 cardiac surgeries were included in the study: coronary artery bypass grafting, surgical aortic valve replacement, mitral valve replacement, mitral valve repair, or ascending aortic surgery. The 30-day postoperative outcomes following these surgeries were compared between male vs. female patients, and by median household income quartiles.
Patient Experience by Sex
Women were the minority for most procedures:
- MV replacement—54%
- MV repair—38%
- Ascending aorta surgery—30%
This was true even though women had significantly higher mean Hospital Episode Statistics (HES) Frailty Risk Scores for CABG, SAVR, and ascending aorta surgery, and significantly higher rates of nonelective admissions for CABG and ascending aorta surgery.
Patient Experience by Income
Patients from the lower quartiles of household income accounted for the majority of patients who underwent CABG, SAVR, and MV replacement, and a small percentage of MV repairs and ascending aorta surgeries. They had significantly higher HES frailty scores before SAVR and ascending aorta surgery.
For all five surgeries, patients in the lowest income quartile were significant:
- More likely to have nonelective admissions
- More likely to self-pay for their hospitalization
- Less likely to receive care at an urban/academic medical center
Outcomes by Sex
Female sex was an independent risk factor for higher 30-day mortality after most types of surgery (P<0.03 for all comparisons):
- CABG—aOR, 1.6 compared with men
- SAVR—aOR, 1.4
- MV repair—aOR, 1.8
- Ascending aorta surgery—aOR, 1.2
Outcomes by Income
Similarly, the lowest quartile of household income was an independent risk factor for 30-day mortality after most surgeries (P<0.04 for all comparisons):
- CABG—aOR, 1.4 compared with the highest quartile
- SAVR—aOR, 1.5
- MV replacement—aOR, 1.3
- Ascending aorta surgery—aOR, 1.8
Closing the Gaps
Differential access to care and lack of timely intervention are likely to have a role in these disparities in cardiac surgery outcomes. The findings support several conclusions:
- Criteria for surgical treatment should be reassessed to determine whether women would benefit from a lower anatomic threshold for surgery compared with men because current treatment guidelines are based on male anatomy and trials with predominantly male participants
- Continued efforts are needed to improve financial access to cardiac surgery, and referral patterns need reevaluation to ensure all patients have adequate access to high-volume specialized heart centers
- Patient-level demographic and socioeconomic factors should be included more consistently in national clinical databases so that future research can focus on root-cause analysis for each procedure type