Racial Disparities in Outcomes Following Intact Abdominal Aortic Aneurysm Repair
Sarah E. Deery, MD, MPH1, Thomas F.X. O'Donnell, MD1, Katie E. Shean, MD2, Jeremy D. Darling, MS2, Peter A. Soden, MD2, Kakra Hughes, MD3, Grace J. Wang, MD4, Marc L. Schermerhorn, MD2.
1Massachusetts General Hospital, Boston, MA, USA, 2Beth Israel Deaconess Medical Center, Boston, MA, USA, 3Howard University, Washington, DC, USA, 4University of Pennsylvania, Philadelphia, PA, USA.
OBJECTIVES: We aimed to compare perioperative morbidity and mortality and late survival amongst black, white, and Asian patients undergoing intact AAA repair.
METHODS: We identified all patients undergoing intact, infrarenal AAA repair in the VQI from 2011-2017. We compared in-hospital outcomes by race using the Fisher Exact and Kruskal Wallis tests. Multivariable logistic and linear regression models of perioperative outcomes adjusted for differences in demographics, comorbidities, hospital volume, and procedure. We used Cox regression to evaluate late survival by race.
RESULTS: In the cohort, 21,961 (94%) patients were white, 1,052 (4.5%) were black, and 318 (1.4%) were Asian. Black patients were more likely to be symptomatic (Black: 16%, White: 9.1%, Asian: 11%, P < .001) and to undergo EVAR (Black: 87%, White: 83%, Asian: 84%, P < .001). There were no differences in 30-day mortality after EVAR (Black: 1.1%, White: 1.1%, Asian: 0.8%, P = .80) or open repair (Black: 4.3%, White: 2.6%, Asian: 1.9%, P = .33). However, black patients were more likely to receive new postoperative dialysis (Black: 1.6%, White: 0.8%, Asian: 0.7%, P = .01) and to return to the operating room (Black: 4.3%, White: 2.9%, Asian: 0.9%, P < .01). Mean hospital length of stay was longer in black patients after EVAR (Black: 3.3 days, White: 2.6, Asian: 2.6, P < .001) and in Asian and black patients after open repair (Black: 10.5 days, White: 8.5, Asian: 13.0, P < .001). After multivariable adjustment, black patients were more likely than white patients to have postoperative dialysis (OR 2.2, 95% CI: 1.3-3.6, P < .01) and return to the operating room (OR 1.6, 95% CI: 1.2-2.2, P < .01). Five-year survival was highest for Asian patients (Black: 84%, White: 85%, Asian: 92%), even in the adjusted Cox model (Asian HR 0.6, 95% CI 0.4-0.97, P = .04).
CONCLUSIONS: Although perioperative mortality is comparable across races following AAA repair, black patients are more likely than white or Asian patients to develop new postoperative renal failure and return to the operating room, even after adjusting for differences in comorbidities, operative variables, and hospital volume. Additionally, while Asian patients have the highest rate of postoperative myocardial infarction, they also have the highest late survival. Further studies are warranted to elucidate the mechanism of these disparities.
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