Faculty Bibliography

GOAL/OBJECTIVE:In 2024, the Centers for Medicare & Medicaid Services (CMS) introduced equity metrics for healthcare systems to document social determinants of health (SDOH). Payment determinations were also linked to readmission performance measures. Readmission prevention programs for vulnerable patients, defined by CMS as dually eligible (DE) for Medicare and Medicaid, racial/ethnic minorities, and those with disabling conditions, have the potential to reduce readmission disparities. Our goal was to develop a systematic and pragmatic approach to collect, analyze, and utilize SDOH and insurance status to assign patients to an intensified protocol for reducing readmission disparities after coronary artery bypass grafting (CABG). METHODS:Patients admitted to a major urban medical center for isolated CABG from October 2023 to October 2024 (N = 286) completed a standardized clinician-assisted SDOH questionnaire. SDOH risk was adapted from ICD-10 Z codes that targeted social risk factors within the scope of healthcare providers' practices (i.e., language barriers, health literacy, access to a heart-healthy diet, lack of transportation to postoperative appointments, financial difficulties impeding access to prescription medications or medical care, and lack of a caregiver/social support). Project managers reviewed electronic health records and documented racial/ethnic categories using current CMS recommendations. SDOH+ (positive) and Medicaid or DE patients were assigned to a vulnerable patient intensified protocol (VPIP) readmission prevention program focused on education, deployment of hospital and community-based resources, transportation assistance, and increased frequency of postoperative follow-up. Non-VPIP patients continued their surgeons' usual care protocols. PRINCIPAL FINDINGS/RESULTS:Of the 286 isolated CABG patients, 55% were ≥65 years old, 80% were male, 47% were White, 24% had Medicaid, and 14% were DE. The most prevalent SDOH+ responses were the need for an interpreter (31%), low health literacy or less than a high-school education (23%), and transportation issues (17%). White patients were significantly (p < .05) less likely to qualify for VPIP than non-White patients, as were patients with Medicare compared to those with self-pay, commercial, or military insurance. Overall, 27% of patients had ≥2 SDOH risk factors. The need for an interpreter was 6.6 times more likely to be associated with having Medicaid or being DE than not. Low health literacy or less than a high school education, transportation issues, and the lack of access to a heart-healthy diet were all significantly associated with Medicaid or DE patients. White patients, compared to non-White patients or unknown or declined responses, were significantly less likely to be SDOH+ (13% vs. 39%, p < .0001). Asian patients were at a higher risk for SDOH+ compared to White patients (49% vs.13%, p < .0001), and among Asian patients, 29% had neither Medicaid nor DE status. The strongest predictor of SDOH+ status in logistic regression models was Medicaid or DE status compared to all other insurance types (OR = 5.4, confidence interval [3.0-9.9]) when adjusted for age, race/ethnicity, and gender. PRACTICAL APPLICATIONS/CONCLUSIONS:Our findings demonstrate that a social-risk-informed care model is feasible in a hospital-based CABG readmission prevention program. Vulnerable patients can be identified through the standardized collection of SDOH, insurance status, and race/ethnicity data. Insurance status may be an excellent proxy to ascertain social risk and is readily accessible. Other healthcare organizations should consider regional demographics for possible SDOH risk. Our findings may support other initiatives to improve the collection of SDOH and demographic information. The VPIP CABG readmission prevention program could be adapted for other conditions and settings to achieve equitable care.

BACKGROUND:There are multiple potential etiologies for right-to-left shunting across a large atrial septal defect (ASD). CASE SUMMARY/METHODS:A 34-year-old woman who presented with exertional dyspnea was found to be cyanotic due to right-to-left shunting across a secundum ASD and hypoplastic right ventricle (RV) due to an abnormal interventricular septum. Balloon occlusion of the ASD resulted in a significant drop in systemic cardiac output, so the patient underwent bidirectional Glenn shunt to both unload and partially bypass a hypoplastic RV, allowing for ASD closure. DISCUSSION/CONCLUSIONS:The bidirectional Glenn shunt is primarily used in the staged palliation of single-ventricle physiology in pediatric patients, and its use in adults is rare. In this case, its use allowed for hemodynamic tolerance of ASD closure with a hypoplastic RV. TAKE-HOME MESSAGE/CONCLUSIONS:This case exemplifies the complex hemodynamics that goes into consideration of ASD closure with an abnormal RV.

The use of prostaglandin infusion to maintain patency of the ductus arteriosus in patients with critical coarctation of the aorta (CoA) to support systemic circulation is the standard of care. However, pulmonary overcirculation resulting from a patent ductus arteriosus in patients with critical CoA is not well described in the literature. We report two cases of critical CoA that required invasive measures to control pulmonary blood flow before surgical repair of the CoA. Both patients had signs of decreased oxygen delivery, hyperlactatemia, and systemic to pulmonary flow via the ductus arteriosus. One patient required surgical pulmonary artery banding and the second patient underwent pulmonary flow restrictor device placement for the control of pulmonary blood flow. A rapid improvement in oxygen delivery and normalization of lactate levels were observed after control of pulmonary overcirculation. Both patients underwent successful surgical repair of the coarctation A and were discharged home.

Perspective Statement: Beyond the Society of Thoracic Surgery's (STS) quality metrics, many other operative measures, such as completeness of revascularization, and patient care measures add quality and value for patients undergoing coronary artery bypass surgery; and Enhanced Recovery after Surgery (ERAS) protocols have improved patient experience and recovery, leading to better outcomes and significant healthcare savings.

BACKGROUND:Despite documented associations between social determinants of health and outcomes post-congenital heart surgery, clinical risk models typically exclude these factors. OBJECTIVES/OBJECTIVE:The study sought to characterize associations between social determinants and operative and longitudinal mortality as well as assess impacts on risk model performance. METHODS:Demographic and clinical data were obtained for all congenital heart surgeries (2006-2021) from locally held Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources Society of Thoracic Surgeons Congenital Heart Surgery Database data. Neighborhood-level American Community Survey and composite sociodemographic measures were linked by zip code. Model prediction, discrimination, and impact on quality assessment were assessed before and after inclusion of social determinants in models based on the 2020 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model. RESULTS:Of 14,173 total index operations across New York State, 12,321 cases, representing 10,271 patients at 8 centers, had zip codes for linkage. A total of 327 (2.7%) patients died in the hospital or before 30 days, and 314 children died by December 31, 2021 (total n = 641; 6.2%). Multiple measures of social determinants of health explained as much or more variability in operative and longitudinal mortality than clinical comorbidities or prior cardiac surgery. Inclusion of social determinants minimally improved models' predictive performance (operative: 0.834-0.844; longitudinal 0.808-0.811), but significantly improved model discrimination; 10.0% more survivors and 4.8% more mortalities were appropriately risk classified with inclusion. Wide variation in reclassification was observed by site, resulting in changes in the center performance classification category for 2 of 8 centers. CONCLUSIONS:Although indiscriminate inclusion of social determinants in clinical risk modeling can conceal inequities, thoughtful consideration can help centers understand their performance across populations and guide efforts to improve health equity.

BACKGROUND:Congenital heart defects are the most common and resource-intensive birth defects. As children with congenital heart defects increasingly survive beyond early childhood, it is imperative to understand longitudinal disease burden. OBJECTIVES:The purpose of this study was to examine chronic outpatient prescription medication use and expenditures for New York State pediatric Medicaid enrollees, comparing children who undergo cardiac surgery (cardiac enrollees) and the general pediatric population. METHODS:This was a retrospective cohort study of all Medicaid enrollees age <18 years using the New York State Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources database (2006-2019). Primary outcomes were total chronic medications per person-year, enrollees per 100 person-years using ≥1 and ≥3 medications, and medication expenditures per person-year. We described and compared outcomes between cardiac enrollees and the general pediatric population. Among cardiac enrollees, multivariable regression examined associations between outcomes and clinical characteristics. RESULTS:We included 5,459 unique children (32,131 person-years) who underwent cardiac surgery and 4.5 million children (22 million person-years) who did not. More than 4 in 10 children who underwent cardiac surgery used ≥1 chronic medication compared with approximately 1 in 10 children who did not have cardiac surgery. Medication expenditures were 10 times higher per person-year for cardiac compared with noncardiac enrollees. Among cardiac enrollees, disease severity was associated with chronic medication use; use was highest among infants; however, nearly one-half of adolescents used ≥1 chronic medication. CONCLUSIONS:Children who undergo cardiac surgery experience high medication burden that persists throughout childhood. Understanding chronic medication use can inform clinicians (both pediatricians and subspecialists) and policymakers, and ultimately the value of care for this medically complex population.