title: Socioeconomic position, not race, is linked to death after cardiac surgery.
abstract: BACKGROUND
  Health disparities have been associated with the prevalence of cardiovascular disease. In cardiac surgery, association has been found between race, sex, and poorer prognosis after surgery. However, there is a complex interplay between race, sex, and socioeconomic position (SEP). In our investigation we sought to identify which of these was the driver of risk-adjusted survival.
  
  
  RESULTS
  From January 1, 1995, and December 30, 2005, 23 330 patients (15 156 white men, 6932 white women, 678 black men, and 564 black women) underwent isolated coronary artery bypass grafting, valve, or combined coronary artery bypass grafting and valve procedures. Median follow-up was 5.8 years (25th and 75th percentiles: 3 and 8.6 years). Effect of race, sex, and SEP on all-cause mortality was examined with 2-phase Cox model and generalized propensity score technique. As expected, blacks and women had lower SEP as compared with whites and men for all 6 SEP indicators. Patients with lower SEP had more atherosclerotic disease burden, more comorbidity, and were more symptomatic. Lower SEP was associated with a risk-adjusted dose-dependent reduction in survival after surgery (men, P<0.0001; women, P=0.0079), but black race, once adjusted for SEP, was not.
  
  
  CONCLUSIONS
  Our large investigation demonstrates that disparities in SEP are present and significantly affect health outcomes. Although race per se was not the driver for reduced survival, patients of low SEP were predominantly represented by blacks and women. Socioeconomically disadvantaged patients had significantly higher risk-adjusted mortality after surgery. Further investigation and targeted intervention should focus specifically on patients of low SEP, their health behaviors, and secondary prevention efforts.
authors.affiliation: Department of Cardiothoracic Anesthesia, the Cleveland Clinic, Ohio 44195, USA. kochc@ccf.org
authors.forename: Colleen G
authors.initials: CG
authors.lastname: Koch
authors.forename: Liang
authors.initials: L
authors.lastname: Li
authors.forename: George A
authors.initials: GA
authors.lastname: Kaplan
authors.forename: Jared
authors.initials: J
authors.lastname: Wachterman
authors.forename: Mehdi H
authors.initials: MH
authors.lastname: Shishehbor
authors.forename: Joseph
authors.initials: J
authors.lastname: Sabik
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
mesh_terms: D000368:Aged; D002318:Cardiovascular Diseases / Q000453:epidemiology* / Q000401:mortality / Q000503:physiopathology / Q000601:surgery; D015897:Comorbidity; D001026:Coronary Artery Bypass; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D006801:Humans; D006973:Hypertension / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D019919:Prosthesis Implantation; D044469:Racial Groups; D012307:Risk Factors; D012737:Sex Factors; D012923:Social Class; D020521:Stroke / Q000453:epidemiology*; D016019:Survival Analysis