Vassileva Christina M, Markwell Steve, Boley Theresa, Hazelrigg Stephen
Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, 701 N. First Street, Springfield, IL 62794-9638, USA.
Heart Surg Forum. 2011 Aug;14(4):E221-6. doi: 10.1532/HSF98.20101124.
Racial disparity with respect to mitral valve (MV) surgery has been documented; however, previous reports have been limited by small numbers, focus on patients undergoing MV replacement only, or comparison of African-American patients to white patients. Using more recent data from the largest all-payer database in the United States, we examined whether type of mitral procedure performed was influenced by race and whether racial differences exist in baseline characteristics and short-term outcomes of patients undergoing mitral repair or replacement for MV disease.
Using the 2005-2007 National Inpatient Sample (NIS) Database, we identified patients ≥ 30 years of age who underwent MV repair or replacement, excluding ischemic and congenital MV disease. Patients were stratified into 4 racial groups: whites, African-Americans, Hispanics, and others. The 4 groups were compared with respect to baseline characteristics, type of MV procedure (repair versus replacement), and short-term outcomes.
Non-whites comprised 22.3% (7818 out of 35,074) of the patients and were generally younger, more often on Medicaid and from urban locations, and more often presented on an urgent/emergent basis. African-Americans and Hispanics tended to be less affluent and have a higher Charlson comorbidity index. MV repair was performed in 45.8% of the patients overall. The racial groups differed significantly with respect to the proportion of patients receiving repair. Hispanics were 2 times more likely to have MV replacement compared to whites (odds ratio [OR] = 2.06, 95% confidence interval [CI] = 1.52-2.80, P = .0001), and African-Americans were more than 1.5 times more likely to have replacement compared to whites (OR = 1.69, 95% CI = 1.35-2.11). Following adjustment for baseline characteristics, there was no difference with respect to race for in-hospital mortality or likelihood of repair, but differences between groups persisted for length of stay and discharge location. African-Americans and Hispanics were more likely than whites to have a prolonged hospitalization.
African-Americans and Hispanics present for MV surgery with worse preoperative profiles and undergo mitral repair less often compared to whites. Although in-hospital mortality was not influenced by race, African-Americans and Hispanics had a more protracted hospital course even following adjustment. The disparity in mitral procedure selection among racial groups was present only prior to adjustment for important baseline characteristics. Nevertheless, this racial difference reflects current reality in surgical practice and identifies an important area for future improvement in the care of patients with valvular heart disease.
二尖瓣（MV）手术方面的种族差异已有文献记载；然而，既往报告存在样本量小、仅关注接受二尖瓣置换术的患者，或将非裔美国患者与白人患者进行比较等局限性。利用美国最大的全支付方数据库中的最新数据，我们研究了所施行的二尖瓣手术类型是否受种族影响，以及二尖瓣疾病行二尖瓣修复或置换患者的基线特征和短期结局是否存在种族差异。
利用2005 - 2007年全国住院患者样本（NIS）数据库，我们确定了年龄≥30岁且接受二尖瓣修复或置换的患者，排除缺血性和先天性二尖瓣疾病。患者被分为4个种族组：白人、非裔美国人、西班牙裔和其他种族。比较了这4组患者的基线特征、二尖瓣手术类型（修复与置换）和短期结局。
非白人患者占患者总数的22.3%（35074例中的7818例），他们通常更年轻，更多使用医疗补助，来自城市地区，且更多是急诊/紧急就诊。非裔美国人和西班牙裔往往较不富裕，且Charlson合并症指数较高。总体而言，45.8%的患者接受了二尖瓣修复。不同种族组在接受修复的患者比例方面存在显著差异。与白人相比，西班牙裔进行二尖瓣置换的可能性高出2倍（优势比[OR]=2.06，95%置信区间[CI]=1.52 - 2.80，P = 0.0001），非裔美国人进行置换的可能性比白人高出1.5倍以上（OR = 1.69，95% CI = 1.35 - 2.11）。在对基线特征进行调整后，住院死亡率或修复可能性在种族方面没有差异，但住院时间和出院地点在组间仍存在差异。非裔美国人和西班牙裔比白人更有可能住院时间延长。
与白人相比，非裔美国人和西班牙裔因二尖瓣手术就诊时术前情况更差，且接受二尖瓣修复的频率更低。尽管住院死亡率不受种族影响，但即使在调整后，非裔美国人和西班牙裔的住院病程仍更长。种族组间在二尖瓣手术选择上的差异仅在对重要基线特征进行调整之前存在。然而，这种种族差异反映了当前外科实践中的现实情况，并确定了瓣膜性心脏病患者护理未来需要改进的一个重要领域。
