Disparities Across Race, Ethnicity, and Rurality Among Surgical Patients

Thoracic endovascular aneurysm repair, race, and volume in thoracic aneurysm repair

BackgroundAlthough numerous epidemiological studies on cholecystectomy have been conducted worldwide, only a few have considered the effect of socioeconomic inequalities on cholecystectomy outcomes. Specifically, few studies have focused on the low-income population (LIP).MethodsA nationwide prospective study based on the Taiwan National Health Insurance dataset was conducted during 2003–2012. The International Classification of ICD-9-CM procedure codes 51.2 and 51.21–51.24 were identified as the inclusion criteria for cholecystectomy. Temporal trends were analyzed using a joinpoint regression, and the hierarchical linear modeling (HLM) method was used as an analytical strategy to evaluate the group-level and individual-level factors. Interactions between age, gender and SES were also tested in HLM model.ResultsAnalyses were conducted on 225,558 patients. The incidence rates were 167.81 (95% CI: 159.78–175.83) per 100,000 individuals per year for the LIP and 123.24 (95% CI: 116.37–130.12) per 100,000 individuals per year for the general population (GP). After cholecystectomy, LIP patients showed higher rates of 30-day mortality, in-hospital complications, and readmission for complications, but a lower rate of routine discharge than GP patients. The hospital costs and length of stay for LIP patients were higher than those for GP patients. The multilevel analysis using HLM revealed that adverse socioeconomic status significantly negatively affects the outcomes of patients undergoing cholecystectomy. Additionally, male sex, advanced age, and high Charlson Comorbidity Index (CCI) scores were associated with higher rates of in-hospital complications and 30-day mortality. We also observed that the 30-day mortality rates for patients who underwent cholecystectomy in regional hospitals and district hospitals were significantly higher than those of patients receiving care in a medical center.ConclusionPatients with a disadvantaged finance status appeared to be more vulnerable to cholecystectomy surgery. This result suggested that further interventions in the health care system are necessary to reduce this disparity.

Open hepatic resection in the elderly at two tertiary referral centers

The management of early-stage rectal cancer in clinical practice is controversial. The aim of this network meta-analysis was to compare oncological and postoperative outcomes for T1T2N0M0 rectal cancers managed with local excision in comparison to conventional radical resection. A systematic review of Medline, Embase and Cochrane electronic databases was performed. Relevant studies were selected using PRISMA guidelines. The primary outcomes measured were 5-year local recurrence and overall survival. Secondary outcomes included rates of postoperative complication, 30-day mortality, positive margin and permanent stoma formation. Three randomized controlled trials and 27 observational studies contributed 8570 patients for analysis. Radical resection was associated with reduced 5-year local recurrence in comparison to local excision. This was statistically significant in comparison to trans-anal local excision (odds ratio (OR) 0.23; 95% confidence interval 0.16-0.30) and favourable in comparison to endoscopic techniques (OR 0.40; 95% confidence interval 0.13-1.23) although this did not reach clinical significance. Positive margin rates were lowest for radical resection. However, 30-day mortality rates, perioperative complications and permanent stoma rates all favoured local excision with no statistically significant difference between endoscopic and trans-anal techniques. Radical resection of early rectal cancer is associated with the lowest 5-year local recurrence rates and the lowest rate of positive margins. However, this must be balanced with its higher 30-day mortality and complication rates as well as the increased risk of permanent stoma. The emerging potential role of neoadjuvant therapy prior to local resection, and the heterogeneity of its use, as an alternative treatment for early rectal cancer further complicates the treatment paradigm and adds to controversy in this field.

e23272 Background: Incidental pulmonary embolism (IPE) refers to asymptomatic pulmonary embolism (PE) detected during routine imaging in cancer patients. The reported prevalence of IPE in cancer patients is estimated at 3.36%. This study evaluates the risk factors, characteristics, treatment patterns, and outcomes of IPE in solid cancer patients. Methods: A retrospective chart review was conducted on solid cancer patients diagnosed with PE at our institution (July 2014–December 2023). Among 335 solid cancer patients, 118 IPE cases were identified, excluding symptomatic PE. Data collected included demographics, cancer characteristics, treatments, and outcomes, including 30-day and 90-day mortality. Associations between factors (e.g., cancer status, concurrent DVT, treatments) and mortality were analyzed using Fisher’s exact test. Results: The median age was 69 years (range: 38–90), with 50.8% male and 72% White patients. Active cancer was present in 88.1%, and metastatic disease in 74.6%. Common cancers are gastrointestinal (40.7%), genitourinary (18.6%), and lung cancers (13.6%). At diagnosis, 50% were on chemotherapy, 13.6% on immunotherapy, 18.6% on targeted therapy, 9.3% on radiation, and 5.1% on hormonal therapy. Concurrent DVT was present in 33.9%, 2.5% had recent surgery, and 3.4% had a prior DVT. The 30-day and 90-day mortality rates were 8% and 21%, with an overall mortality rate of 62.7%. Metastatic disease was significantly associated with higher 90-day mortality (p = 0.03) but not 30-day mortality (p = 0.11). Active cancer increased 90-day mortality (p = 0.03) but not 30-day mortality (p = 0.59). Neither chemotherapy status nor concurrent DVT significantly impacted mortality at either time point. Conclusions: There was high prevalence of active cancer, metastatic disease, gastrointestinal cancers, concurrent DVT and ongoing chemotherapy at the time of IPE. Ninety day and overall mortality rates were 21% and 62.7%. Metastatic disease and active cancer were significantly associated with higher 90-day mortality. Close monitoring and pro-active management are essential for these patients. Characteristics and mortality in solid cancer patients with IPE. Patient Group Total, N (%) 335 (100%) 30-day mortality, N (%) P-value 90-day mortality, N (%) P-value Solid cancer and PE 335 ( 100%) N/A N/A N/A N/A Solid cancer with IPE 118 (35.0%) 9 (8.0%) N/A 25 (21%) N/A Concurrent DVT 40 (33.9%) 6 (15%) p=0.06 11 (27.5%) p=0.24 Metastatic Disease 88 (74.6%) 9 (10.2%) p=0.10 23 (26.1%) p=0.03 Active Cancer 104 (88.1%) 9 (8.7%) p=0.50 25 (24%) p=0.03 Chemotherapy 59 (50.0%) 4 (6.8%) p=1.00 12 (20.3%) p=1.00 Immunotherapy 16 (13.6%) N/A N/A N/A N/A Targeted therapy 22(18.6%) N/A N/A N/A N/A Hormonal therapy 6 ( 5.1%) N/A N/A N/A N/A N/A- Not applicable.

Racial health disparities across orthopaedic surgery subspecialties, including spine surgery, are well established. However, the underlying causes of these disparities, particularly relating to social determinants of health, are not fully understood. (1) Is there a racial difference in 90-day mortality, readmission, and complication rates ("safety outcomes") among Medicare beneficiaries after spine surgery? (2) To what degree does the Centers for Disease Control and Prevention Social Vulnerability Index (SVI), a community-level marker of social determinants of health, account for racial disparities in safety outcomes? To examine racial differences in 90-day mortality, readmission, and complications after spine surgery, we retrospectively identified all 419,533 Medicare beneficiaries aged 65 or older who underwent inpatient spine surgery from 2015 to 2019; we excluded 181,588 patients with endstage renal disease or Social Security disability insurance entitlements, who were on Medicare HMO, or who had missing SVI data. Because of the nearly universal coverage of those age 65 or older, Medicare data offer a large cohort that is broadly generalizable, provides improved precision for relatively rare safety outcomes, and is free of confounding from differential insurance access across races. The Master Beneficiary Summary File includes enrollees' self-reported race based on a restrictive list of mutually exclusive options. Even though this does not fully capture the entirety of racial diversity, it is self-reported by patients. Identification of spine surgery was based on five Diagnosis Related Groups labeled "cervical fusion," "fusion, except cervical," "anterior-posterior combined fusion," "complex fusion," and "back or neck, except fusion." Although heterogeneous, these cohorts do not reflect inherently different biology that would lead us to expect differences in safety outcomes by race. We report specific types of complications that did and did not involve readmission. Although complications vary in severity, we report them as composite measures while being cognizant of the inherent limitations of making inferences based on aggregate measures. The SVI was chosen as the mediating variable because it aggregates important social determinants of health and has been shown to be a marker of high risk of poor public health response to external stressors. Patients were categorized into three groups based on a ranking of the four SVI themes: socioeconomic status, household composition, minority status and language, and housing and transportation. We report the "average race effects" among Black patients compared with White patients using nearest-neighbor Mahalanobis matching by age, gender, comorbidities, and spine surgery type. Mahalanobis matching provided the best balance among propensity-type matching methods. Before matching, Black patients in Medicare undergoing spine surgery were disproportionately younger with more comorbidities and were less likely to undergo cervical fusion. To estimate the contribution of the SVI on racial disparities in safety outcomes, we report the average race effect between models with and without the addition of the four SVI themes. After matching on age, gender, comorbidities, and spine surgery type, Black patients were on average more likely than White patients to be readmitted (difference of 1.5% [95% CI 0.9% to 2.1%]; p < 0.001) and have complications with (difference of 1.2% [95% CI 0.5% to 1.9%]; p = 0.002) or without readmission (difference of 3.6% [95% CI 2.9% to 4.3%]; p < 0.001). Adding the SVI to the model attenuated these differences, explaining 17% to 49% of the racial differences in safety, depending on the outcome. An observed higher rate of 90-day mortality among Black patients was explained entirely by matching using non-SVI patient demographics (difference of 0.00% [95% CI -0.3% to 0.3%]; p = 0.99). However, even after adjusting for the SVI, Black patients had more readmissions and complications. Social disadvantage explains up to nearly 50% of the disparities in safety outcomes between Black and White Medicare patients after spine surgery. This argument highlights an important contribution of socioeconomic circumstances and societal barriers to achieving equal outcomes. But even after accounting for the SVI, there remained persistently unequal safety outcomes among Black patients compared with White patients, suggesting that other unmeasured factors contribute to the disparities. This is consistent with evidence documenting Black patients' disadvantages within a system of seemingly equal access and resources. Research on racial health disparities in orthopaedics should account for the SVI to avoid suggesting that race causes any observed differences in complications among patients when other factors related to social deprivation are more likely to be determinative. Focused social policies aiming to rectify structural disadvantages faced by disadvantaged communities may lead to a meaningful reduction in racial health disparities. Level III, therapeutic study.

To determine the predictors of mortality within 30days of hospital admission in a diarrhoeal disease hospital in Bangladesh. Cohort study of hospitalised children aged 0-59months with severe acute malnutrition (SAM) and severe pneumonia in Dhaka Hospital, icddr,b, Bangladesh from April 2015 to March 2017. Those discharged were followed up, and survival status at 30days from admission was determined. Children who died were compared with the survivors in terms of clinical and laboratory biomarkers. Multivariable logistic regression analysis was used for calculating adjusted odds ratio for death within 30days of hospital admission. We enrolled 191 children. Mortality within 30days of admission was 6% (14/191). After adjusting for potential confounders (hypoxia, CRP and haematocrit) in logistic regression analysis, independent factors associated with death were female sex (aOR=5.80, 95% CI: 1.34-25.19), LAZ <-4 (aOR=6.51, 95% CI: 1.49-28.44) and Polymorphonuclear Leucocytes (PMNL) (>6.0×109 /L) (aOR=1.06, 95% CI: 1.01-1.11). Using sex, Z-score for length for age (LAZ), and PMNL percentage, we used random forest and linear regression models to achieve a cross-validated AUC of 0.83 (95% CI: 0.82, 0.84) for prediction of 30-day mortality. The results of our data suggest that female sex, severe malnutrition (<-4 LAZ) and higher PMNL percentage were prone to be associated with 30-day mortality in children with severe pneumonia. Association of these factors may be used in clinical decision support for prompt identification and appropriate management for prevention of mortality in this population.

Previous multi-institution comparisons of open and laparoscopic Roux-en-Y gastric bypass (ORYGB and LRYGB), and laparoscopic adjustable gastric banding (LAGB) have been limited by the lack of unique current procedural terminology (CPT) codes. Specific codes have been available for LRYGB and LAGB since 2005 and 2006, respectively. We compare the short-term safety of these procedures, using risk-adjusted clinical data from a multi-institutional quality improvement program. The America College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant Use File (PUF) was used to compare patients undergoing LRYGB with those undergoing ORYGB or LAGB. ORYGB versus LRYGB: The 2-year study period (2005-2006) included 5,777 patients (ORYGB = 1,146, LRYGB = 4,631). Patients undergoing ORYGB experienced a higher 30-day incidence of mortality (0.79% vs. 0.17%; p = 0.002), major complications rate (7.42% vs. 3.37%; p < 0.0001), any complication rate (13.18% vs. 6.69%; p < 0.0001), return visits to the OR (4.97% vs. 3.56%; p = 0.032), and longer postoperative length of stay (LOS) (median 3 vs. 2 days; p < 0.0001). After risk adjustment, ORYGB continued to demonstrate higher odds of major complication (OR = 2.04; [1.54, 2.69]). LAGB versus LRYGB: Analysis of 1 year of data from 2006 included 4,756 patients (LRYGB = 3,580, LAGB = 1,176). Those treated with LAGB experienced an equivalent 30-day mortality (0.09% vs. 0.14%; p = 1.0), and a lower rate of major complications (1.0% vs. 3.3%; p < 0.0001), any complication (2.6% vs. 6.7%; p < 0.0001), return visits to the OR (0.94% vs. 3.6%; p < 0.0001), and shorter postoperative LOS (median 1 vs. 2 days; p < 0.0001). Risk adjustment showed that LAGB was associated with a lower major complication odds (OR = 0.29; [0.16, 0.53]). Compared with LRYGB, ORYGB is associated with higher 30-day mortality and higher risk-adjusted major complication rate. While ORYGB may sometimes be indicated, a laparoscopic approach may be safer for RYGB when feasible. LAGB, compared with LRYGB, has a similarly low mortality rate and a small but statistically significant decrease in risk-adjusted 30-day complications. Clinical efficacy and long-term outcomes will need to be evaluated to determine superiority between these procedures.

Despite increasing demand for total knee arthroplasty (TKA), barriers such as race, ethnicity, socioeconomic background, geographic variation, and sex influence patients' decisions or ability to undergo surgery and are known to affect postoperative outcomes. We compared utilization rates and postoperative outcomes of TKA between Black and White patients within our large integrated health system. A retrospective study was performed for Black and White patients who underwent primary TKA for osteoarthritis within our health system between January 2016 and December 2023. The final analysis included 17,079 patients. White patients numbered 16,147 (94.5%) while Black patients numbered 932 (5.5%). Black patients were younger (64 versus 67 years, P < 0.05), exhibited higher average body mass indexes (37.6 versus 35.6, P < 0.05), and had higher Elixhauser Comorbidity Index scores (mean: 2.7 versus 2.2, P < 0.05). Incidence of Centers for Medicare and Medicaid Services defined postoperative complications describing short-term mortality, readmissions, and other morbid complications were evaluated. The incidence of TKA for Black and White patients was compared to population data to evaluate utilization. Independent t-tests, Chi-squares, logistic regressions, odds ratios (OR), areas under the curve (AUC), and goodness of fit testings were done. Significance was set to P < 0.05. Black patients had significantly higher rates of 30-day mortality (OR: 7.0, confidence interval [CI]: 1.8 to 27.6, AUC: 0.7; P = 0.005) and 90-day mortality (OR: 5.7, CI: 1.8 to 18.4, AUC: 0.8; P = 0.003). All other postoperative complications were similar between groups. In eight of 17 hospitals, Black patients had significantly less than expected TKAs performed, while in 13 of 17 hospitals, White patients had significantly more than expected TKAs performed. Black patients have significantly higher rates of 30- and 90-day mortality following TKA, while simultaneously underutilizing this procedure, when compared to their White counterparts.

Reply to: Correspondence on “High rates of 30-day mortality in patients with cirrhosis and COVID-19”

42. Are telemedicine cardiac clearance visits safe prior to lumbar fusion?

Variation and changes in state-specific carotid endarterectomy and 30-day mortality rates, United States, 1991-2000.

What’s New in Hip Replacement

Transcatheter aortic valve implantation (TAVI) is safe and effective for patients with aortic stenosis (AS) who have a high operative risk. However, there is still debate on the effect of TAVI in AS patients with reduced left ventricular ejection fraction (REF). The objective of the review is to clarify the efficacy of TAVI and the impact of REF on the 30-day and midterm mortality in these patients. Studies on TAVI were searched in PubMed, Embase, and the Cochrane Library databases and were included in this review following predefined criteria. Data were extracted and pooled risk ratios (RR) were synthesized to explore the relationship between REF and 30-day plus midterm mortality. Twenty-eight studies comprising 14,099 patients were included in the analysis of the association of REF with the prognosis of patients after TAVI. An average increase in left ventricular ejection fraction of 8-10 % was observed among these patients after TAVI. REF was not related to the 30-day mortality [RR = 1.90, 95 % confidence interval (CI) = 0.80-4.47]; however, it was related to the midterm mortality (RR = 1.49, 95 %CI = 1.14-1.93) of patients undergoing TAVI. Patients with low-flow and low-gradient AS had a higher 30-day mortality (RR = 1.54, 95 %CI = 1.11-2.13) and midterm mortality rate (RR = 1.69, 95 %CI = 1.33-2.14) compared with AS patients without these characteristics. The mortality of TAVI patients was significantly lower than that of those undergoing conservative therapy, and was similar to that of patients undergoing surgical aortic valve replacement. REF was not associated with 30-day mortality, but it was associated with the midterm mortality of TAVI patients. Patients with REF could benefit from TAVI compared with conservative therapy.

ObjectiveTo compare the efficacy and safety outcomes between percutaneous mechanical thrombectomy (PMT) and catheter-directed thrombolysis (CDT) as the first endovascular revascularization (EVR) strategy for arterial acute mesenteric ischemia (AMI) and identify risk factors for 30-day mortality.MethodsThis was a single-center retrospective study. Between May 2014 and March 2024, consecutive patients with arterial AMI who received EVR using PMT or CDT as the first strategy were included. The baseline characteristics, imaging information, procedure-related information, complications, and clinical outcomes of patients were analyzed and compared. Binary logistic regression analysis was used to identify potential risk factors for 30-day mortality with an odds ratio (OR) and 95% confidence interval (CI).ResultsForty-seven patients (PMT, n = 29; CDT, n = 18) were included. The mean age was 74.3 ± 7.6 years, and 66.0% were female. Successful revascularization was achieved in 89.4% of patients, and the 30-day mortality rate was 31.9%. There was no significant difference in successful revascularization, complications, and clinical outcomes between PMT and CDT as the first strategy. High plasma lactate (adjusted OR 1.73 per 1.0 mmol/L increase, 95% CI: 1.13–2.66; p = 0.012) and D-dimer (adjusted OR 1.73 per 1.0 mg/L increase; 95% CI: 1.20–2.50; p = .003) were associated with a high 30-day mortality rate.ConclusionsPMT and CDT were associated with high revascularization rates and few complications. High plasma lactate and D-dimer may be associated with high 30-day mortality.