Strobel Raymond J, Charles Eric J, Mehaffey J Hunter, Hawkins Robert B, Quader Mohammed A, Rich Jeffrey B, Speir Alan M, Ailawadi Gorav
Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia; Virginia Cardiac Services Quality Initiative, Virginia Beach, Virginia.
Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Semin Thorac Cardiovasc Surg. 2023;35(3):497-507. doi: 10.1053/j.semtcvs.2022.05.007. Epub 2022 May 16.
Infective endocarditis affects patients of all socioeconomic status. We hypothesized that the Distressed Communities Index (DCI), a comprehensive assessment of socioeconomic status, would be associated with risk-adjusted mortality for patients with endocarditis. All patients with endocarditis (2001-2017) in a regional Society of Thoracic Surgeons database were analyzed. DCI scores range from 0 (no socioeconomic distress) to 100 (severe distress) and account for unemployment, poverty rate, median income, housing vacancies, education level, and business growth by zip code. The most distressed patients (top quartile, DCI > 75) were compared to all other patients. Hierarchical logistic regression modeled the association between DCI and mortality. A total of 2,075 patients were included (median age 55 years, 65.2% urgent/emergent cases, 42.7% self-pay). Major morbidity was 32.8% and operative mortality was 9.5%. Tricuspid/pulmonic valve endocarditis was present in 12.5% of cases, with significantly worse mean DCI compared to patients with left-sided endocarditis (median 55.3, IQR 20.3-77.6 vs 46.8, IQR 17.3-74.2, P = 0.016). High socioeconomic distress (DCI > 75) was associated with higher rates of major morbidity, operative mortality, increased length of stay, and higher total cost. After risk-adjustment, DCI was independently predictive of higher operative mortality for patients with endocarditis (OR 1.24 per DCI quartile increase, 95% CI 1.06-1.45, P < 0.001). Increasing DCI, an indicator of poor socioeconomic status, independently predicts increased risk-adjusted mortality and resource utilization for patients with endocarditis. Accounting for socioeconomic status allows for more accurate risk prediction and resource allocation for patients with endocarditis.
感染性心内膜炎影响所有社会经济地位的患者。我们假设，社会经济地位综合评估指标——困境社区指数（DCI），与心内膜炎患者的风险调整死亡率相关。对一个地区胸外科医师协会数据库中2001年至2017年的所有心内膜炎患者进行了分析。DCI评分范围为0（无社会经济困境）至100（严重困境），并根据邮政编码统计失业率、贫困率、中位数收入、住房空置率、教育水平和商业增长情况。将最困境的患者（四分位数最高组，DCI>75）与所有其他患者进行比较。分层逻辑回归模型分析了DCI与死亡率之间的关联。共纳入2075例患者（中位年龄55岁，65.2%为紧急/急诊病例，42.7%为自费）。主要发病率为32.8%，手术死亡率为9.5%。12.5%的病例存在三尖瓣/肺动脉瓣心内膜炎，与左侧心内膜炎患者相比，其平均DCI显著更差（中位数55.3，四分位间距20.3 - 77.6 vs 46.8，四分位间距17.3 - 74.2，P = 0.016）。高社会经济困境（DCI>75）与更高的主要发病率、手术死亡率、住院时间延长和更高的总成本相关。风险调整后，DCI可独立预测心内膜炎患者更高的手术死亡率（每增加一个DCI四分位数，OR为1.24，95%CI为1.06 - 1.45，P < 0.001）。DCI升高是社会经济地位差的一个指标，它独立预测心内膜炎患者风险调整死亡率增加和资源利用增加。考虑社会经济地位有助于更准确地预测心内膜炎患者的风险并进行资源分配。
