Impact of Race on Mitral Procedure Selection and Short-Term Outcomes of Patients Undergoing Mitral Valve Surgery
DOI:
https://doi.org/10.1532/HSF98.20101124Abstract
Background: Racial disparity with respect to mitral valve (MV) surgery has been documented; however, previous reports have been limited by small numbers, focus on patients undergoing MV replacement only, or comparison of African-American patients to white patients. Using more recent data from the largest all-payer database in the United States, we examined whether type of mitral procedure performed was influenced by race and whether racial differences exist in baseline characteristics and short-term outcomes of patients undergoing mitral repair or replacement for MV disease.
Methods: Using the 2005-2007 National Inpatient Sample (NIS) Database, we identified patients ? 30 years of age who underwent MV repair or replacement, excluding ischemic and congenital MV disease. Patients were stratified into 4 racial groups: whites, African-Americans, Hispanics, and others. The 4 groups were compared with respect to baseline characteristics, type of MV procedure (repair versus replacement), and short-term outcomes.
Results: Non-whites comprised 22.3% (7818 out of 35,074) of the patients and were generally younger, more often on Medicaid and from urban locations, and more often presented on an urgent/emergent basis. African-Americans and Hispanics tended to be less affluent and have a higher Charlson comorbidity index. MV repair was performed in 45.8% of the patients overall. The racial groups differed significantly with respect to the proportion of patients receiving repair. Hispanics were 2 times more likely to have MV replacement compared to whites (odds ratio [OR] = 2.06, 95% confidence interval [CI] = 1.52-2.80, P = .0001), and African-Americans were more than 1.5 times more likely to have replacement compared to whites (OR = 1.69, 95% CI = 1.35-2.11). Following adjustment for baseline characteristics, there was no difference with respect to race for in-hospital mortality or likelihood of repair, but differences between groups persisted for length of stay and discharge location. African-Americans and Hispanics were more likely than whites to have a prolonged hospitalization.
Conclusions: African-Americans and Hispanics present for MV surgery with worse preoperative profiles and undergo mitral repair less often compared to whites. Although in-hospital mortality was not influenced by race, African-Americans and Hispanics had a more protracted hospital course even following adjustment. The disparity in mitral procedure selection among racial groups was present only prior to adjustment for important baseline characteristics. Nevertheless, this racial difference reflects current reality in surgical practice and identifies an important area for future improvement in the care of patients with valvular heart disease.
References
Barnett SD, Ad N. 2009. Surgery for aortic and mitral valve disease in the United States: a trend of change in surgical practice between 1998 and 2005. J Thorac Cardiovasc Surg 137:1422-9.nBridges CR. 2008. Invited commentary. Ann Thorac Surg 85:93.nCastellanos LR, Normand SL, Ayanian JZ. 2009. Racial and ethnic disparities in access to higher and lower quality cardiac surgeons for coronary artery bypass grafting. Am J Cardiol 103:1682-6.nCooper WA, Thourani VH, Guyton RA, et al. 2009. Racial disparity persists after on-pump and off-pump coronary artery bypass grafting. Circulation 120(11 Suppl):S59-64.nDeyo RA, Cherkin DC, Ciol MA. 1992. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45:613-9.nDiGiorgi PL, Baumann FG, O'Leary AM, et al. 2008. Mitral valve disease presentation and surgical outcome in African-American patients compared with white patients. Ann Thorac Surg 85:89-93.nD'Hoore W, Bouckaert A, Tilquin C. 1996. Practical considerations on the use of the Charlson comorbidity index with administrative data bases. J Clin Epidemiol 49:1429-33.nGrossi EA, Galloway AC, Miller JS, et al. 1998. Valve repair versus replacement for mitral insufficiency: when is a mechanical valve still indicated? J Thorac Cardiovasc Surg 115:389-94.nHartz RS, Rao AV, Plomondon ME, Grover FL, Shroyer AL. 2001. Effects of race, with or without gender, on operative mortality after coronary artery bypass grafting: a study using The Society of Thoracic Surgeons National Database. Ann Thorac Surg 71:512-20.nHCUP Databases. 2010. Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Available at: http://www.hcup-us.ahrq.gov/nisoverview.jsp'>http://www.hcup-us.ahrq.gov/nisoverview.jspnJacobi JA, Parikh SV, McGuire DK, Delemos JA, Murphy SA, Keeley EC. 2007. Racial disparity in clinical outcomes following primary percutaneous coronary intervention for ST elevation myocardial infarction: influence of process of care. J Interv Cardiol 20:182-7.nKaul P, Lytle BL, Spertus JA, DeLong ER, Peterson ED. 2005. Influence of racial disparities in procedure use on functional status outcomes among patients with coronary artery disease. Circulation 111:1284-90.nKressin NR, Petersen LA. 2001. Racial differences in the use of invasive cardiovascular procedures: review of the literature and prescription for future research. Ann Intern Med 135:352-66.nKoch CG, Li L, Kaplan GA, et al. 2010. Socioeconomic position, not race, is linked to death after cardiac surgery. Circ Cardiovasc Qual Outcomes 3:267-76.nMukamel DB, Weimer DL, Buchmueller TC, Ladd H, Mushlin AI. 2007. Changes in racial disparities in access to coronary artery bypass grafting surgery between late 1990s and early 2000s. Med Care 45:664-71.nPerier P, Deloche A, Chauvaud S, et al. 1984. Comparative evaluation of mitral valve repair and replacement with Starr, Björk, and porcine valve prostheses. Circulation 70:I187-92.nSonel AF, Good CB, Mulgund J, et al. 2005. Racial variations in treatment and outcomes of black and white patients with high-risk non-ST-elevation acute coronary syndromes: insights from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?). Circulation 111:1225-32.nTaylor NE, O'Brien S, Edwards FH, Peterson ED, Bridges CR. 2005. Relationship between race and mortality and morbidity after valve replacement surgery. Circulation 111:1305-12.n
