Original Article
Impact of Socioeconomic Status and Rurality on Early Outcomes and Mid-term Survival after CABG: Insights from a Multicentre Registry

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Background

We examined whether socioeconomic status and rurality influenced outcomes after coronary surgery.

Methods

We identified 14,150 patients undergoing isolated coronary surgery. Socioeconomic and rurality data was obtained from the Australian Bureau of Statistics and linked to patients’ postcodes. Outcomes were compared between categories of socioeconomic disadvantage (highest versus lowest quintiles, n= 3150 vs. 2469) and rurality (major cities vs. remote, n=9598 vs. 839).

Results

Patients from socioeconomically-disadvantaged areas experienced a greater burden of cardiovascular risk factors including diabetes, obesity and current smoking. Thirty-day mortality (disadvantaged 1.6% vs. advantaged 1.6%, p>0.99) was similar between groups as was late survival (7 years: 83±0.9% vs. 84±1.0%, p=0.79). Those from major cities were less likely to undergo urgent surgery. There was similar 30-day mortality (major cities: 1.6% vs. remote: 1.5%, p=0.89). Patients from major cities experienced improved survival at seven years (84±0.5% vs. 79±2.0%, p=0.010). Propensity-analysis did not show socioeconomic status or rurality to be associated with late outcomes.

Conclusion

Patients presenting for coronary artery surgery from different socioeconomic and geographic backgrounds exhibit differences in their clinical profile. Patients from more rural and remote areas appear to experience poorer long-term survival, though this may be partially driven by the population's clinical profile.

Introduction

Coronary artery disease is one of the leading causes of mortality and morbidity in the western world. Its medical and surgical management is largely concentrated in tertiary referral centres in major metropolitan areas throughout the world.

In Australia, patients from regional and remote areas experience poorer health outcomes. Indeed, mortality rates in regional and remote areas were 10-70% higher than in major cities with reduced overall life expectancy [1]. Similarly, socioeconomic disadvantage is associated with increased rates of cardiovascular risk factors such as obesity, dyslipidaemia and smoking. Compounding this is the fact that those from rural and socio-economically disadvantaged areas experience physical, financial and social barriers to accessing health care practitioners and services, thus further impacting upon health outcomes [2].

The centralised nature of cardiology and cardiac surgical services in Australia means there are substantial barriers to patient access, which has the potential to negatively impact upon surgical outcomes despite the efforts to uphold the quality of peri-operative inpatient care. As such, we sought to evaluate the clinical profile, early outcomes and late survival of patients presenting for coronary surgery, to identify whether rurality and socio-economic status were predictors of early and late outcome.

Section snippets

Data Collection

We performed a retrospective review of a multicentre database containing all adult cardiac procedures performed from July 1st, 2001 to December 31st, 2009 in 10 institutions.

Data was prospectively compiled as part of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database project, which records all adult cardiac surgery procedures in the state of Victoria performed in public hospitals, and has been described previously [3]. Mid-term survival status of patients

Results

Patients from socioeconomically-disadvantaged areas experienced a greater burden of cardiovascular risk factors including diabetes, dyslipidaemia, obesity and active smoking. However, these patients were also younger and more likely to undergo elective surgery (Table 1).

Despite these clinical differences, 30-day mortality (disadvantaged 1.6% vs. advantaged 1.6%, p>0.99) and combined early mortality/morbidity (22% vs. 20%, p=0.31) was similar. Disadvantaged patients were more likely to

Discussion

This multicentre study investigates whether socioeconomic status and rurality affect outcomes of patients undergoing coronary artery bypass surgery. Comparisons of patients’ clinical profiles verifies the notion that risk factors such as smoking, hypertension, dyslipidaemia, obesity, diabetes and chronic obstructive pulmonary disease are more prevalent amongst those from socioeconomically disadvantaged communities.

Surprisingly, patients from disadvantaged areas were less likely to present as

Conclusions

Our study suggests that patients presenting for CABG from different socioeconomic and geographical backgrounds exhibit different clinical characteristics. Notably, they vary in their acuity of presentation. Despite these differences, early and late outcomes are similar, suggesting the success of a model of universal health care. Nevertheless, among patients with socioeconomic disadvantage and those from regional and remote areas, there is a need for strategies to promote earlier recognition,

Acknowledgements

The authors acknowledge all surgeons who contributed to the operations studied in this paper. The Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) National Cardiac Surgery Database is funded by the Department of Human Services, Victoria and the Health Administration Corporation (GMCT) and the Clinical Excellence Commission (CEC), New South Wales, Australia.

References (8)

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