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ADULT – Original Submission|Articles in Press

Homelessness and Race are Mortality Predictors in US Veterans Undergoing CABG

Published:October 09, 2022DOI:https://doi.org/10.1053/j.semtcvs.2022.10.001
      Coronary artery disease requiring surgical revascularization is prevalent in United States Veterans. We aimed to investigate preoperative predictors of 30-day mortality following coronary artery bypass grafting (CABG) in the Veteran population. The Veterans Affairs Surgical Quality Improvement (VASQIP) national database was queried for isolated CABG cases between 2008 and 2018. The primary outcome was 30-day mortality. A multivariable logistic regression was performed to assess for independent predictors of the primary outcome. A P-value of <0.05 was considered statistically significant. A total of 32,711 patients were included. The 30-day mortality rate was 1.37%. Multivariable analysis identified the following predictors of 30-day mortality: African-American race (OR 1.46, 95% CI 1.09-1.96); homelessness (OR 6.49, 95% CI 3.39-12.45); female sex (OR 2.15, 95% CI 1.08-4.30); preoperative myocardial infarction within 7 days (OR 1.49, 95% CI 1.06-2.10) or more than 7 days before CABG (OR 1.34, 95% CI 1.04-1.72); partially/fully dependent functional status (OR 1.44, 95% CI 1.07-1.93); chronic obstructive pulmonary disease (OR 1.54, 95% CI 1.24-1.92); mild (OR 1.48, 95% CI 1.04-2.11) and severe aortic stenosis (OR 2.06, 95% CI 1.37-3.09); moderate (OR 1.88, 95% CI 1.31-2.72), or severe (OR 2.99, 95% CI 1.71-5.22) mitral regurgitation; cardiomegaly (OR 1.73, 95% CI 1.35-2.22); NYHA Class III/IV heart failure (OR 2.05, 95% CI 1.10-3.83); and urgent/emergent operation (OR 1.42, 95% CI 1.08-1.87). The 30-day mortality rate in US Veterans undergoing isolated CABG between 2008 and 2018 was 1.37%. In addition to established clinical factors, African-American race and homelessness were independent demographic predictors of 30-day mortality.

      Graphical Abstract

      KEYWORDS

      Abbreviations:

      AS (Aortic stenosis), ASA (American Society of Anesthesiologists), CAD (Coronary artery disease), CABG (Coronary artery bypass grafting), COPD (Chronic obstructive pulmonary disease), CPR (Cardiopulmonary resuscitation), DM (Diabetes mellitus), IABP (Intra-aortic balloon pump), IQR (Interquartile range), LV (Left ventricle), LAD (Left anterior descending), LMC (Left main coronary), MI (Myocardial infarction), MR (Mitral regurgitation), NYHA (New York Heart Association), US (United States), VASQIP (Veterans Affairs Surgical Quality Improvement Program)
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      References

        • Arnett DK
        • Blumenthal RS
        • Albert MA
        • et al.
        2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
        J Am Coll Cardiol. 2019; 74: e177-e232
        • Melly L
        • Torregrossa G
        • Lee T
        • Jansens J-L
        • Puskas JD
        Fifty years of coronary artery bypass grafting.
        J Thorac Dis. 2018; 10: 1960
        • LaPar DJ
        • Crosby IK
        • Rich JB
        • et al.
        A contemporary cost analysis of postoperative morbidity after coronary artery bypass grafting with and without concomitant aortic valve replacement to improve patient quality and cost-effective care.
        Ann Thorac Surg. 2013; 96: 1621-1627
        • Hannan EL
        • Farrell LS
        • Wechsler A
        • et al.
        The New York risk score for in-hospital and 30-day mortality for coronary artery bypass graft surgery.
        Ann Thorac Surg. 2013; 95: 46-52
        • Cram P
        • Rosenthal GE
        • Vaughan-Sarrazin MS
        Cardiac revascularization in specialty and general hospitals.
        N Engl J Med. 2005; 352: 1454-1462
        • Holleran TJ
        • Napolitano MA
        • LaPiano JB
        • et al.
        Racial disparities in 30-Day outcomes after colorectal surgery in an integrated healthcare system.
        J Gastrointest Surg. 2021; : 1-11
        • Liu Y
        • Sayam S
        • Shao X
        • et al.
        Peer reviewed: prevalence of and trends in diabetes among veterans, United States, 2005–2014.
        Preventing chronic disease. 2017; : 14
        • Murphy DE
        • Chaudhry Z
        • Almoosa KF
        • Panos RJ
        High prevalence of chronic obstructive pulmonary disease among veterans in the urban midwest.
        Mil Med. 2011; 176: 552-560
        • Richlie DG
        • Winters S
        • Prochazka AV
        Dyslipidemia in veterans: multiple risk factors may break the bank.
        Arch Intern Med. 1991; 151: 1433-1436
        • Olenick M
        • Flowers M
        • Diaz VJ
        US veterans and their unique issues: enhancing health care professional awareness.
        Adv in med educ and practice. 2015; 6: 635
      1. VA.gov. Racial and Ethnic Minority Veterans. VA.gov. https://www.va.gov/HEALTHEQUITY/Race_Ethnicity.asp

        • Rangrass G
        • Ghaferi AA
        • Dimick JB
        Explaining racial disparities in outcomes after cardiac surgery: the role of hospital quality.
        JAMA surgery. 2014; 149: 223-227
        • Massarweh NN
        • Kaji AH
        • Itani KM
        Practical guide to surgical data sets: veterans affairs surgical quality improvement program (VASQIP).
        JAMA surgery. 2018; 153: 768-769
      2. Assari SJIJoPM. Veterans and risk of heart disease in the United States: A cohort with 20 years of follow up. 2014;5:703.

      3. MacKenzie TA, Malenka DJ, Olmstead EM, et al. Prediction of survival after coronary revascularization: modeling short-term, mid-term, and long-term survival. 2009;87:463-472.

      4. Lamarche Y, Elmi-Sarabi M, Ding L, et al. A score to estimate 30-day mortality after intensive care admission after cardiac surgery. 2017;153:1118-1125.e1114.

      5. Enumah ZO, Canner JK, Alejo D, et al. Persistent racial and sex disparities in outcomes after coronary artery bypass surgery: a retrospective clinical registry review in the drug-eluting stent era. 2020;272:660-667.

      6. Connolly TM, White RS, Sastow DL, Gaber-Baylis LK, Turnbull ZA, Rong LQJWjos. The disparities of coronary artery bypass grafting surgery outcomes by insurance status: A retrospective cohort study, 2007–2014. 2018;42:3240-3249.

      7. Coyan GN, Okoye A, Shah A, et al. Effect of neighborhood socioeconomic factors on readmissions and mortality after coronary artery bypass grafting. 2021;111:561-567.

        • Nanna MG
        • Peterson ED
        Racial Differences in Long-Term Cardiovascular Outcomes: The Need to Move From Description to Action. Vol 13.
        American College of Cardiology Foundation Washington DC, 2020: 1596-1598
      8. Development UDoHaU. The 2019 Annual Homeless Assessment Report (AHAR) to Congress. 2019.

        • Miyawaki A
        • Khullar D
        • Tsugawa Y
        Processes of care and outcomes for homeless patients hospitalised for cardiovascular conditions at safety-net versus non-safety-net hospitals: cross-sectional study.
        BMJ open. 2021; 11e046959
        • Balla S
        • Alqahtani F
        • Alhajji M
        • Alkhouli M
        Cardiovascular outcomes and rehospitalization rates in homeless patients admitted with acute myocardial infarction.
        Mayo Clin Proc. 2020; 95: 660-668
        • Wadhera RK
        • Khatana SAM
        • Choi E
        • et al.
        Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
        JAMA Intern. Med. 2020; 180: 357-366
        • O'Toole TP
        • Buckel L
        • Bourgault C
        • et al.
        Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes.
        Am J Public Health. 2010; 100: 2493-2499
      9. Devine E. VHA homeless program office fact sheet. 2022.

        • Bukkapatnam RN
        • Yeo KK
        • Li Z
        • Amsterdam EA
        Operative mortality in women and men undergoing coronary artery bypass grafting (from the California Coronary Artery Bypass Grafting Outcomes Reporting Program).
        Am J Cardiol. 2010; 105: 339-342
        • Edwards FH
        • Carey JS
        • Grover FL
        • Bero JW
        • Hartz RS
        Impact of gender on coronary bypass operative mortality.
        Ann Thorac Surg. 1998; 66: 125-131
        • Hassan A
        • Chiasson M
        • Buth K
        • Hirsch G
        Women have worse long-term outcomes after coronary artery bypass grafting than men.
        Can J Cardiol. 2005; 21: 757-762
        • Gurram A
        • Krishna N
        • Vasudevan A
        • Baquero LA
        • Jayant A
        • Varma PK
        Female gender is not a risk factor for early mortality after coronary artery bypass grafting.
        Ann Cardiac Anaesth. 2019; 22: 187
      10. Deo S, Sundaram V, Sheikh MA, et al. Pre-operative glycaemic control and long-term survival in diabetic patients after coronary artery bypass grafting. 2021;60:1169-1177.

        • Zhao H
        • Li L
        • Yang G
        • et al.
        Postoperative outcomes of patients with chronic obstructive pulmonary disease undergoing coronary artery bypass grafting surgery: a meta-analysis.
        Medicine (Baltimore). 2019; : 98
      11. Almassi GH, Shroyer AL, Collins JF, et al. Chronic obstructive pulmonary disease impact upon outcomes: the veterans affairs randomized on/off bypass trial. 2013;96:1302-1309.

        • Lemaire A
        • Vagaonescu T
        • Ikegami H
        • Volk L
        • Verghis N
        • Lee LY
        Delay in coronary artery bypass grafting for STEMI patients improves hospital morbidity and mortality.
        J Cardiothoracic Surg. 2020; 15: 1-7
        • Deo SV
        • Sundaram V
        • Sahadevan J
        • et al.
        Outcomes of coronary artery bypass grafting in patients with heart failure with a midrange ejection fraction.
        J Thorac Cardiovasc Surg. 2021; : 1-10
        • Kovesdy CP
        • Norris KC
        • Boulware LE
        • et al.
        Association of race with mortality and cardiovascular events in a large cohort of US veterans.
        Circulation. 2015; 132: 1538-1548
        • Soliman Hamad MA
        • van Straten AH
        • Schönberger JP
        • et al.
        Preoperative ejection fraction as a predictor of survival after coronary artery bypass grafting: comparison with a matched general population.
        J cardiothoracic surg. 2010; 5: 1-8
        • Omer S
        • Adeseye A
        • Jimenez E
        • Cornwell LD
        • Massarweh NN
        Low left ventricular ejection fraction, complication rescue, and long-term survival after coronary artery bypass grafting.
        J Thorac Cardiovasc Surg. 2020; 163 (e112): 111-119
        • Fukunaga N
        • Ribeiro RVP
        • Lafreniere-Roula M
        • Manlhiot C
        • Badiwala MV
        • Rao V
        Left ventricular size and outcomes in patients with left ventricular ejection fraction less than 20%.
        Ann Thorac Surg. 2020; 110: 863-869
        • Thalji NM
        • Suri RM
        • Enriquez-Sarano M
        • et al.
        Untreated aortic valve stenosis identified at the time of coronary artery bypass grafting: thresholds associated with adverse prognosis.
        Eur J Cardiothorac Surg. 2015; 47: 712-719
        • Fattouch K
        • Sampognaro R
        • Speziale G
        • et al.
        Impact of moderate ischemic mitral regurgitation after isolated coronary artery bypass grafting.
        Ann Thorac Surg. 2010; 90: 1187-1194
      12. Scarborough JE, Bennett KM, Englum BR, Pappas TN, Lagoo-Deenadayalan SAJAos. The impact of functional dependency on outcomes after complex general and vascular surgery. 2015;261:432.

      13. Cervera R, Bakaeen FG, Cornwell LD, et al. Impact of functional status on survival after coronary artery bypass grafting in a veteran population. 2012;93:1950-1955.

        • Otto CM
        • Nishimura RA
        • Bonow RO
        • et al.
        2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
        J Am Coll Cardiol. 2021; 77: 450-500