Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va; Virginia Cardiac Services Quality Initiative, South Riding, Va.
School of Medicine, University of Virginia, Charlottesville, Va.
J Thorac Cardiovasc Surg. 2024 Mar;167(3):1100-1114.e1. doi: 10.1016/j.jtcvs.2022.07.013. Epub 2022 Jul 20.
The influence of socioeconomic determinants of health on failure to rescue (mortality after a postoperative complication) after cardiac surgery is unknown. We hypothesized that increasing Distressed Communities Index, a comprehensive socioeconomic ranking by ZIP code, would be associated with higher failure to rescue.
Patients undergoing Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) who developed a failure to rescue complication were included. After excluding patients with missing ZIP code or Society of Thoracic Surgeons predicted risk of mortality, patients were stratified by Distressed Communities Index scores (0-no distress, 100-severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. The upper 2 quintiles of distress (Distressed Communities Index >60) were compared to all other patients. Hierarchical logistic regression analyzed the association between Distressed Communities Index and failure to rescue.
A total of 4004 patients developed 1 or more of the defined complications across 17 centers. Of these, 582 (14.5%) experienced failure to rescue. High socioeconomic distress (Distressed Communities Index >60) was identified among 1272 patients (31.8%). Before adjustment, failure to rescue occurred more frequently among those from socioeconomically distressed communities (Distressed Communities Index >60; 16.9% vs 13.4%, P = .004). After adjustment, residing in a socioeconomically distressed community was associated with 24% increased odds of failure to rescue (odds ratio, 1.24; confidence interval, 1.003-1.54; P = .044).
Increasing Distressed Communities Index, a measure of poor socioeconomic status, is associated with greater risk-adjusted likelihood of failure to rescue after cardiac surgery. These findings highlight that current quality metrics do not account for socioeconomic status, and as such underrepresent procedural risk for these vulnerable patients.
健康的社会经济决定因素对心脏手术后抢救失败（术后并发症后的死亡率）的影响尚不清楚。我们假设，不断增加的 Distressed Communities Index（一种按邮政编码综合划分的社会经济排名）与更高的抢救失败率相关。
纳入在区域合作中接受胸外科医师学会指数手术（2011-2021 年）且出现抢救失败并发症的患者。在排除邮政编码或胸外科医师学会预测死亡率缺失的患者以及按 Distressed Communities Index 评分（0-无压力，100-严重压力）分层的患者后，根据教育水平、贫困、失业、房屋空置率、中位数收入和商业增长对患者进行分层。将最上面的 2 个五分位数（Distressed Communities Index >60）与所有其他患者进行比较。分层逻辑回归分析 Distressed Communities Index 与抢救失败之间的关系。
共有 4004 例患者在 17 个中心出现 1 种或多种定义的并发症。其中，582 例（14.5%）发生抢救失败。在 1272 例患者中发现存在较高的社会经济压力（Distressed Communities Index >60）（31.8%）。在未调整的情况下，来自社会经济压力大的社区的患者抢救失败的发生率更高（Distressed Communities Index >60：16.9%比 13.4%，P=0.004）。调整后，居住在社会经济压力大的社区与抢救失败的几率增加 24%相关（比值比，1.24；95%置信区间，1.003-1.54；P=0.044）。
不断增加的 Distressed Communities Index（衡量贫困社会经济地位的指标）与心脏手术后抢救失败的风险调整后可能性增加相关。这些发现强调，目前的质量指标并未考虑社会经济地位，因此对这些弱势群体患者的程序风险代表性不足。
