Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: systematic review.

BACKGROUND: Readmission and mortality after hospitalization for community-acquired pneumonia (CAP) and heart failure (HF) are publically reported. This systematic review assessed the impact of social factors on risk of readmission or mortality after hospitalization for CAP and HF-variables outside a hospital's control. METHODS: We searched OVID, PubMed and PSYCHINFO for studies from 1980 to 2012. Eligible articles examined the association between social factors and readmission or mortality in patients hospitalized with CAP or HF. We abstracted data on study characteristics, domains of social factors examined, and presence and magnitude of associations. RESULTS: Seventy-two articles met inclusion criteria (20 CAP, 52 HF). Most CAP studies evaluated age, gender, and race and found older age and non-White race were associated with worse outcomes. The results for gender were mixed. Few studies assessed higher level social factors, but those examined were often, but inconsistently, significantly associated with readmissions after CAP, including lower education, low income, and unemployment, and with mortality after CAP, including low income. For HF, older age was associated with worse outcomes and results for gender were mixed. Non-Whites had more readmissions after HF but decreased mortality. Again, higher level social factors were less frequently studied, but those examined were often, but inconsistently, significantly associated with readmissions, including low socioeconomic status (Medicaid insurance, low income), living situation (home stability rural address), lack of social support, being unmarried and risk behaviors (smoking, cocaine use and medical/visit non-adherence). Similar findings were observed for factors associated with mortality after HF, along with psychiatric comorbidities, lack of home resources and greater distance to hospital. CONCLUSIONS: A broad range of social factors affect the risk of post-discharge readmission and mortality in CAP and HF. Future research on adverse events after discharge should study social determinants of health.

Predicting risk of perioperative death and stroke after carotid endarterectomy in asymptomatic patients: derivation and validation of a clinical risk score.

BACKGROUND AND PURPOSE: National guidelines on carotid endarterectomy (CEA) for asymptomatic patients state that the procedure should be performed with a ≤ 3% risk of perioperative death or stroke. We developed and validated a multivariate model of risk of death or stroke within 30 days of CEA for asymptomatic disease and a related clinical prediction rule. METHODS: We analyzed asymptomatic cases in a population-based cohort of CEAs performed in Medicare beneficiaries in New York State. Medical records were abstracted for sociodemographics, neurologic history, disease severity, diagnostic imaging data, comorbidities, and deaths and strokes within 30 days of surgery. We used multivariate logistic regression to identify independent predictors of perioperative death or stroke. The CEA-8 clinical risk score was derived from the final model. RESULTS: Among the 6553 patients, the mean age was 74 years, 55% were male, 62% had coronary artery disease, and 22% had a history of distant stroke or transient ischemic attack. The perioperative rate of death or stroke was 3.0%. Multivariable predictors of perioperative events were female sex (odds ratio [OR] = 1.5; 95% CI, 1.1 to 1.9), nonwhite race (OR = 1.8; 95% CI, 1.1 to 2.9), severe disability (OR = 3.7; 95% CI, 1.8 to 7.7), congestive heart failure (OR = 1.6; 95% CI, 1.1 to 2.4), coronary artery disease (OR = 1.6; 95% CI, 1.2 to 2.2), valvular heart disease (OR = 1.5; 95% CI, 1.1 to 2.3), a distant history of stroke or transient ischemic attack (OR = 1.5; 95% CI, 1.1 to 2.0), and a nonoperated stenosis ≥ 50% (OR = 1.8; 95% CI, 1.3 to 2.3). The CEA-8 risk score stratified patients with a predicted probability of death or stroke rate from 0.6% to 9.6%. CONCLUSIONS: Several sociodemographic, neurologic severity, and comorbidity factors predicted the risk of perioperative death or stroke in asymptomatic patients. The CEA-8 risk score can help clinicians calculate a predicted probability of complications for an individual patient to help inform the decision about revascularization.