McLeish Tyson, Seadler Benjamin D, Parrado Raphael, Rein Lisa, Joyce David L
Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
J Card Surg. 2022 Dec;37(12):5135-5143. doi: 10.1111/jocs.17229. Epub 2022 Nov 20.
Healthcare delivery is heterogenous; the reasons for this are numerous and complex. Patient-specific factors including geography, income, insurance status, age, and gender have been shown to bias surgical outcomes. Utilizing a prospectively collected all-payer database, we aim to evaluate the influence of socioeconomic factors on mortality and length of stay (LOS) after common cardiac surgical procedures.
We utilized the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for the year 2019. We included patients undergoing coronary artery bypass grafting (CABG), aortic valve replacement (AVR), transcatheter aortic valve replacement (TAVR), and combined AVR/CABG using the 10th revision of the International Classification of Diseases procedure codes. AVR and CABG were combined into a separate cohort as this was felt to represent a different pathology than isolated valvular or coronary arterial disease. Baseline demographics were summarized. Multivariable regression was performed within each procedure group to model the odds of in-hospital mortality and hospital LOS with age, sex, insurance, zip-code median household income, and location as predictors.
Baseline patient characteristics including gender, income, geography, and payer status were similar between CABG, AVR, and AVR/CABG. TAVR patients had a higher proportion of female sex and Medicare as the primary payer, with an overall greater age. Multivariable Cox proportional hazards regression found that higher income was strongly associated with decreased LOS following AVR and CABG, and moderately associated in TAVR and AVR/CABG. Private insurance was associated with a decreased LOS in patients undergoing CABG, AVR, TAVR, and AVR/CABG. Female sex and increased age were associated with increased odds of mortality in TAVR, CABG, and AVR/CABG. Private insurance was associated with a decreased odds of mortality in patients undergoing AVR.
These findings reveal significant disparities in patient outcomes after routine cardiac operations that are associated with socioeconomic status. Patients who did not have private insurance or had lower incomes were found to be at risk for increased LOS. Women were at a higher risk of mortality for several operations, a finding which has been previously described elsewhere. Private insurance conveyed a decreased odds of mortality in patients undergoing AVR. This data set serves to highlight differences in healthcare outcomes based on a variety of socioeconomic, geographic, and other inherent factors. Additional research is needed to identify the mechanisms behind these disparities with the goal of providing equitable care to all patients.
医疗服务存在异质性；其原因众多且复杂。已表明包括地理位置、收入、保险状况、年龄和性别在内的患者特定因素会影响手术结果。利用前瞻性收集的全支付方数据库，我们旨在评估社会经济因素对常见心脏手术后死亡率和住院时间（LOS）的影响。
我们使用了2019年医疗保健成本和利用项目、医疗保健研究与质量局的全国住院患者样本。我们纳入了使用国际疾病分类第10版手术编码进行冠状动脉旁路移植术（CABG）、主动脉瓣置换术（AVR）、经导管主动脉瓣置换术（TAVR）以及AVR/CABG联合手术的患者。AVR和CABG被合并为一个单独的队列，因为认为这代表了与单纯瓣膜或冠状动脉疾病不同的病理情况。总结了基线人口统计学数据。在每个手术组内进行多变量回归，以年龄、性别、保险、邮政编码中位数家庭收入和地点作为预测因素，对住院死亡率和住院LOS的几率进行建模。
CABG、AVR和AVR/CABG之间的基线患者特征，包括性别、收入、地理位置和支付方状态相似。TAVR患者中女性比例较高，且以医疗保险作为主要支付方，总体年龄更大。多变量Cox比例风险回归发现，较高收入与AVR和CABG后LOS缩短密切相关，在TAVR和AVR/CABG中呈中度相关。私人保险与接受CABG、AVR、TAVR和AVR/CABG手术患者的LOS缩短有关。女性和年龄增加与TAVR、CABG和AVR/CABG患者的死亡几率增加有关。私人保险与接受AVR手术患者的死亡几率降低有关。
这些发现揭示了常规心脏手术后患者结局与社会经济地位相关的显著差异。未购买私人保险或收入较低的患者被发现有LOS增加的风险。在几种手术中，女性的死亡风险较高，这一发现此前在其他地方也有描述。私人保险降低了接受AVR手术患者的死亡几率。该数据集有助于突出基于各种社会经济、地理和其他固有因素的医疗保健结局差异。需要进一步研究以确定这些差异背后的机制，目标是为所有患者提供公平的护理。
