Failure to Rescue After Cardiac Surgery at Minority-Serving Hospitals: Room for Improvement

Dewan, Krish C.; Koroukian, Siran M.; Gillinov, A. Marc; Roselli, Eric E.; Svensson, Lars; Johnston, Douglas R.; Bakaeen, Faisal G.; Soltesz, Edward G.

doi:10.1016/j.athoracsur.2021.11.004

Cited by 8 publications

(10 citation statements)

References 23 publications

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“…Matches selected participants of alternative groups on a 1:2 ratio. Covariate balance after matching was assessed using SD differences . An SD lower than 0.20 was considered sufficient balance, and an SD lower than 0.10 was considered ideal …”

Section: Methodsmentioning

confidence: 99%

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Racial Disparities in Length of Stay Among Severely Ill Patients Presenting With Sepsis and Acute Respiratory Failure

et al. 2023

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ImportanceAlthough racial and ethnic minority patients with sepsis and acute respiratory failure (ARF) experience worse outcomes, how patient presentation characteristics, processes of care, and hospital resource delivery are associated with outcomes is not well understood.ObjectiveTo measure disparities in hospital length of stay (LOS) among patients at high risk of adverse outcomes who present with sepsis and/or ARF and do not immediately require life support and to quantify associations with patient- and hospital-level factors.Design, Setting, and ParticipantsThis matched retrospective cohort study used electronic health record data from 27 acute care teaching and community hospitals across the Philadelphia metropolitan and northern California areas between January 1, 2013, and December 31, 2018. Matching analyses were performed between June 1 and July 31, 2022. The study included 102 362 adult patients who met clinical criteria for sepsis (n = 84 685) or ARF (n = 42 008) with a high risk of death at the time of presentation to the emergency department but without an immediate requirement for invasive life support.ExposuresRacial or ethnic minority self-identification.Main Outcomes and MeasuresHospital LOS, defined as the time from hospital admission to the time of discharge or inpatient death. Matches were stratified by racial and ethnic minority patient identity, comparing Asian and Pacific Islander patients, Black patients, Hispanic patients, and multiracial patients with White patients in stratified analyses.ResultsAmong 102 362 patients, the median (IQR) age was 76 (65-85) years; 51.5% were male. A total of 10.2% of patients self-identified as Asian American or Pacific Islander, 13.7% as Black, 9.7% as Hispanic, 60.7% as White, and 5.7% as multiracial. After matching racial and ethnic minority patients to White patients on clinical presentation characteristics, hospital capacity strain, initial intensive care unit admission, and the occurrence of inpatient death, Black patients experienced longer LOS relative to White patients in fully adjusted matches (sepsis: 1.26 [95% CI, 0.68-1.84] days; ARF: 0.97 [95% CI, 0.05-1.89] days). Length of stay was shorter among Asian American and Pacific Islander patients with ARF (−0.61 [95% CI, −0.88 to −0.34] days) and Hispanic patients with sepsis (−0.22 [95% CI, −0.39 to −0.05] days) or ARF (−0.47 [−0.73 to −0.20] days).Conclusions and RelevanceIn this cohort study, Black patients with severe illness who presented with sepsis and/or ARF experienced longer LOS than White patients. Hispanic patients with sepsis and Asian American and Pacific Islander and Hispanic patients with ARF both experienced shorter LOS. Because matched differences were independent of commonly implicated clinical presentation–related factors associated with disparities, identification of additional mechanisms that underlie these disparities is warranted.

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Section: Methodsmentioning

confidence: 99%

“…Covariate balance after matching was assessed using SD differences. 38 , 39 , 40 , 41 An SD lower than 0.20 was considered sufficient balance, 42 and an SD lower than 0.10 was considered ideal. 41 …”

Section: Methodsmentioning

confidence: 99%

Racial Disparities in Length of Stay Among Severely Ill Patients Presenting With Sepsis and Acute Respiratory Failure

et al. 2023

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“…40 Low-quality centers, in turn, have been found to have triple the rates of FTR compared with highquality centers and tend to serve a greater proportion of non-White patients, supporting the notion that failure to intervene appropriately after certain complications may contribute to early mortality in Hispanic patients. 16 One can also speculate that language barriers may contribute to delayed recognition of postoperative complications, particularly if Hispanic patients are preferentially served at lowquality hospitals with limited resources, though this has yet to be explored. Black patients have been found to have higher longterm mortality after heart transplant than other nonblack minority recipients, despite similar or better socioeconomic indicators.…”

Section: Discussionmentioning

confidence: 99%

“…13,14 While FTR studies have historically focused on system factors leading to a failure (nursing ratios, hospital volume, hospital quality and teamwork/communication), assessing the interaction of patient factors with FTR may contribute significantly to our understanding of drivers of demographic differences in outcomes after surgery. [15][16][17][18][19] It has been previously demonstrated that differences in postsurgical outcomes exist by race, and the field of thoracic transplantation is not exempt. [20][21][22] By most metrics of surgical care, including postoperative complications and mortality, Black and Hispanic patients often experience worse outcomes compared with White patients after heart transplantation.…”

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confidence: 99%

Does Failure to Rescue Drive Race/Ethnicity-based Disparities in Survival After Heart Transplantation?

et al. 2023

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Objective: The objective was to assess whether race/ethnicity is an independent predictor of failure to rescue (FTR) after orthotopic heart transplantation (OHT). Summary Background Data: Outcomes following OHT vary by patient level factors; for example, non-White patients have worse outcomes than White patients after OHT. Failure to rescue is an important factor associated with cardiac surgery outcomes, but its relationship to demographic factors is unknown. Methods: Using the United Network for Organ Sharing database, we included all adult patients who underwent primary isolated OHT between 1/1/2006 snd 6/30/2021. FTR was defined as the inability to prevent mortality after at least one of the UNOS-designated postoperative complications. Donor, recipient, and transplant characteristics, including complications and FTR, were compared across race/ethnicity. Logistic regression models were created to identify factors associated with complications and FTR. Kaplan Meier and adjusted Cox proportional hazards models evaluated the association between race/ethnicity and posttransplant survival. Results: There were 33,244 adult, isolated heart transplant recipients included: the distribution of race/ethnicity was 66% (n = 21,937) White, 21.2% (7,062) Black, 8.3% (2,768) Hispanic, and 3.3% (1,096) Asian. The frequency of complications and FTR differed significantly by race/ethnicity. After adjustment, Hispanic recipients were more likely to experience FTR than White recipients (OR 1.327, 95% CI[1.075-1.639], P = 0.02). Black recipients had lower 5-year survival compared with other races/ethnicities (HR 1.276,, P < 0.0001). Conclusions: In the US, Black recipients have an increased risk of mortality after OHT compared with White recipients, without associated differences in FTR. In contrast, Hispanic recipients have an increased likelihood of FTR, but no significant mortality difference compared with White recipients. These findings highlight the need for tailored approaches to addressing race/ethnicity-based health inequities in the practice of heart transplantation.

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“…In the perioperative period, frail patients are at increased risk of postoperative complications, higher readmission rate, and discharge to a nursing home. Additionally, frailty has been associated with greater short-term mortality after certain surgeries such as vascular and cardiac surgery [10]. Identification of frailty in a patient allows for better preoperative optimization, prehabilitation, and can act as a catalyst for shared decision-making conversations, and may potentially decrease postoperative complications through identification of modifiable risk factors.…”

Section: Frailtymentioning

confidence: 99%

Addressing comorbidities in the perioperative setting and optimizing perioperative medicine education

Krishnan

Adeola

Urman

2022

Current Opinion in Anaesthesiology

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Purpose of reviewPreoperative clinics and patient optimization are examples of collaborative, multidisciplinary care pathways that create value. This article reviews current literature to demonstrate the importance of preoperative enhancement of patients’ cognitive and functional status. This article underscores the importance of formal training in multidisciplinary topics, such as frailty, brain health, and shared decision-making for anesthesiology house staff.Recent findingsPreoperative cognitive screening of older patients is a valuable metric for risk stratification and detection of patients at risk of postoperative delirium. Frailty is another syndrome that can be identified and optimized preoperatively. Sarcopenia has been shown to correlate with frailty; this shows promise as a method to detect frailty preoperatively.SummaryAnesthesiologists as perioperative physicians are in a unique position to lead and coordinate interdisciplinary conversations that incorporate patient goal concordant care and realistic assessment of perioperative complications. Formal house staff training in early recognition and management of patients at risk of adverse outcomes in the short and long term postoperatively improves patient outcomes and decreases healthcare spending.

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Failure to Rescue After Cardiac Surgery at Minority-Serving Hospitals: Room for Improvement

Cited by 8 publications

References 23 publications

Racial Disparities in Length of Stay Among Severely Ill Patients Presenting With Sepsis and Acute Respiratory Failure

Racial Disparities in Length of Stay Among Severely Ill Patients Presenting With Sepsis and Acute Respiratory Failure

Does Failure to Rescue Drive Race/Ethnicity-based Disparities in Survival After Heart Transplantation?

Addressing comorbidities in the perioperative setting and optimizing perioperative medicine education

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