Department of General Surgery, Baylor University Medical Center, Dallas, Tex; Baylor Scott and White Research Institute, Dallas, Tex.
Department of General Surgery, Baylor University Medical Center, Dallas, Tex; Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Tex.
J Thorac Cardiovasc Surg. 2024 Jun;167(6):2076-2090.e19. doi: 10.1016/j.jtcvs.2023.02.005. Epub 2023 Feb 13.
Race, neighborhood disadvantage, and the interaction between these 2 social determinants of health remain poorly understood with regards to survival after aortic valve replacement with concomitant coronary artery bypass grafting (AVR+CABG).
Weighted Kaplan-Meier survival analyses and Cox proportional hazards modeling were used to evaluate the association between race, neighborhood disadvantage, and long-term survival in 205,408 Medicare beneficiaries undergoing AVR+CABG from 1999 to 2015. Neighborhood disadvantage was measured using the Area Deprivation Index, a broadly validated ranking of socioeconomic contextual disadvantage.
Self-identified race was 93.9% White and 3.2% Black. Residents of the most disadvantaged quintile of neighborhoods included 12.6% of all White beneficiaries and 40.0% of all Black beneficiaries. Black beneficiaries and residents of the most disadvantaged quintile of neighborhoods had more comorbidities compared with White beneficiaries and residents of the least disadvantaged quintile of neighborhoods, respectively. Increasing neighborhood disadvantage linearly increased the hazard for mortality for Medicare beneficiaries of White but not Black race. Residents of the most and least disadvantaged neighborhood quintiles had weighted median overall survival of 93.0 and 82.1 months, respectively, a significant difference (P < .001 by Cox test for equality of survival curves). Black and White beneficiaries had weighted median overall survival of 93.4 and 90.6 months, respectively, a nonsignificant difference (P = .29 by Cox test for equality of survival curves). A statistically significant interaction between race and neighborhood disadvantage was noted (likelihood ratio test P = .0215) and had implications on whether Black race was associated with survival.
Increasing neighborhood disadvantage was linearly associated with worse survival after combined AVR+CABG in White but not Black Medicare beneficiaries; race, however, was not independently associated with postoperative survival.
种族、社区劣势以及这两个健康社会决定因素之间的相互作用，对于接受主动脉瓣置换术（AVR）合并冠状动脉旁路移植术（CABG）的患者的生存预后仍知之甚少。
本研究使用加权 Kaplan-Meier 生存分析和 Cox 比例风险模型，评估了种族、社区劣势与 1999 年至 2015 年期间 205408 名接受 AVR+CABG 的 Medicare 受益人的长期生存之间的关联。使用区域剥夺指数（Area Deprivation Index）来衡量社区劣势，该指数是一种广泛验证的社会经济背景劣势的排名。
自我认同的种族为 93.9%的白人，3.2%的黑人。最不利的五分位数社区的居民包括 12.6%的所有白人受益人和 40.0%的所有黑人受益人的居民。与白人受益人和最不不利的五分位数社区的居民相比，黑人受益人和最不利的五分位数社区的居民有更多的合并症。对于白人种族的 Medicare 受益人的死亡率，社区劣势的增加呈线性增加。对于黑人种族的 Medicare 受益人的死亡率没有影响。最不利和最有利五分位数社区的居民的加权中位数总体生存率分别为 93.0 和 82.1 个月，差异显著（Cox 检验生存曲线相等，P<0.001）。黑人和白人受益人的加权中位数总体生存率分别为 93.4 和 90.6 个月，差异无统计学意义（Cox 检验生存曲线相等，P=0.29）。注意到种族和社区劣势之间存在统计学显著的交互作用（似然比检验 P=0.0215），并且对黑人种族与生存是否相关有影响。
在白人 Medicare 受益人中，社区劣势的增加与 AVR+CABG 术后生存恶化呈线性相关，但在黑人受益人中则没有；种族与术后生存无独立关联。
