Evaluating Patient Outcomes and Access to Care in Aortic Surgery Based on Ethnicity and Social Vulnerability
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0127
Submission Type:
Abstract Submission
Authors:
Adam Carroll (1), Kyndall Hadley (1), Nicolas Chanes (1), Ananya Shah (2), Alejandro Suarez-Pierre (1), Jessica Rove (1), Catherine Velopulos (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO, (2) University of Colorado Anschutz, Aurora, CO
Submitting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Kyndall Hadley
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University of Colorado Anschutz
University of Colorado Anschutz
Nicolas Chanes
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University of Colorado Anschutz
University of Colorado Anschutz
Ananya Shah
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University of Colorado Anschutz
University of Colorado Anschutz
Alejandro Suarez-Pierre
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University of Colorado Anschutz
University of Colorado Anschutz
Jessica Rove
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University of Colorado Anschutz
University of Colorado Anschutz
Catherine Velopulos
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University of Colorado Anschutz
University of Colorado Anschutz
*Muhammad Aftab
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University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
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University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Kyndall Hadley
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University of Colorado Anschutz
University of Colorado Anschutz
Abstract:
Objective:
Previously, we have demonstrated the impact of ethnicity in aortic surgery, with under-representation and greater acuity of minority patients, concerning for a lack of access to care. The CDC's social vulnerability index (SVI) measure is increasingly used to quantify patient socioeconomic and demographic factors. We sought to expand on our prior study, by incorporating both the individual and cumulative effects of SVI as well as ethnicity to better define presentation and subsequent outcomes in patients undergoing aortic arch surgery.
Methods:
We use a single-institution database of patients who underwent total arch replacement (TAR) or hemiarch repair between 2009 and 2022. A total of 837 patients were placed into five cohorts based on their self-reported race: African American, Asian, Caucasian, Hispanic, and Other, with further subdivision based on SVI (high social vulnerability, ≥75%, normal social vulnerability <75%). Additional analysis was performed excluding race with grouping solely by SVI. We compared patient presentation, operative variables and subsequent outcomes based on the above cohorts.
Results:
Demographic city data compared to included patients was 16.6% vs. 9.7% for the African American cohort, 6.6% vs. 2.4% for the Asian cohort, 43.5% vs. 76% for the Caucasian cohort, 12% vs 8.7% for the Hispanic cohort, and 22% vs. 2.6% for the Other cohort. Regardless of SVI, African American and Hispanic presented at a younger age (p=0.001), with high SVI patients in general more likely to present at a younger age (p=0.007). African American and high SVI Asian patients presented with higher baseline systolic and diastolic blood pressures (p=0.002). African American and high SVI patients regardless of race were significantly more likely to present urgently or emergently (p<0.001) with aortic dissection pathology (p=0.006).
Intraoperatively, significant differences were seen in cardiopulmonary bypass (p=0.018) and aortic cross-clamp times (p=0.020), with notably higher circulatory arrest times across high SVI groups (p=0.002), despite a decreased likelihood in the performance of adjunctive structural procedures in high SVI groups (p=0.018). Possibly contributing was a greater performance of total arch replacement in high SVI patients (p=0.048). Postoperatively, high SVI patients were significantly more likely to require mechanical circulatory support (p=0.025), otherwise, no difference was seen in length of stay, or ICU morbidity or mortality. After discharge, significant differences were seen in number of procedure-related emergency department presentations within one year (p<0.001), with notably high usage among African Americans and low usage among high SVI Asian patients, although no differences were seen in rates of re-admission, or follow-up with a cardiovascular provider.
Conclusions:
Clear lack of access to care exists for under-represented groups as demonstrated by a patient population not reflective of city demographics, higher surgical acuity in socially vulnerable patients, and trends in emergency department usage after discharge. Furthermore, the ethnicity-only dataset hid significant differences within ethnicities between normal and high SVI groups. Most importantly, approaches to expanding care need to be both geared towards high SVI groups and be racially sensitive, and must be applied at all levels of care.
Previously, we have demonstrated the impact of ethnicity in aortic surgery, with under-representation and greater acuity of minority patients, concerning for a lack of access to care. The CDC's social vulnerability index (SVI) measure is increasingly used to quantify patient socioeconomic and demographic factors. We sought to expand on our prior study, by incorporating both the individual and cumulative effects of SVI as well as ethnicity to better define presentation and subsequent outcomes in patients undergoing aortic arch surgery.
Methods:
We use a single-institution database of patients who underwent total arch replacement (TAR) or hemiarch repair between 2009 and 2022. A total of 837 patients were placed into five cohorts based on their self-reported race: African American, Asian, Caucasian, Hispanic, and Other, with further subdivision based on SVI (high social vulnerability, ≥75%, normal social vulnerability <75%). Additional analysis was performed excluding race with grouping solely by SVI. We compared patient presentation, operative variables and subsequent outcomes based on the above cohorts.
Results:
Demographic city data compared to included patients was 16.6% vs. 9.7% for the African American cohort, 6.6% vs. 2.4% for the Asian cohort, 43.5% vs. 76% for the Caucasian cohort, 12% vs 8.7% for the Hispanic cohort, and 22% vs. 2.6% for the Other cohort. Regardless of SVI, African American and Hispanic presented at a younger age (p=0.001), with high SVI patients in general more likely to present at a younger age (p=0.007). African American and high SVI Asian patients presented with higher baseline systolic and diastolic blood pressures (p=0.002). African American and high SVI patients regardless of race were significantly more likely to present urgently or emergently (p<0.001) with aortic dissection pathology (p=0.006).
Intraoperatively, significant differences were seen in cardiopulmonary bypass (p=0.018) and aortic cross-clamp times (p=0.020), with notably higher circulatory arrest times across high SVI groups (p=0.002), despite a decreased likelihood in the performance of adjunctive structural procedures in high SVI groups (p=0.018). Possibly contributing was a greater performance of total arch replacement in high SVI patients (p=0.048). Postoperatively, high SVI patients were significantly more likely to require mechanical circulatory support (p=0.025), otherwise, no difference was seen in length of stay, or ICU morbidity or mortality. After discharge, significant differences were seen in number of procedure-related emergency department presentations within one year (p<0.001), with notably high usage among African Americans and low usage among high SVI Asian patients, although no differences were seen in rates of re-admission, or follow-up with a cardiovascular provider.
Conclusions:
Clear lack of access to care exists for under-represented groups as demonstrated by a patient population not reflective of city demographics, higher surgical acuity in socially vulnerable patients, and trends in emergency department usage after discharge. Furthermore, the ethnicity-only dataset hid significant differences within ethnicities between normal and high SVI groups. Most importantly, approaches to expanding care need to be both geared towards high SVI groups and be racially sensitive, and must be applied at all levels of care.
Aortic Symposium:
Aortic Arch
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