A Social Risk-Targeted Protocol and 30-Day Readmission Disparities After Isolated Coronary Artery Bypass Surgery

作者：Ralph S. Mosca, Rosio Ynfante, Brenda Aydin, Ming Liao, Rhett Tanselle, Eugene A. Grossi · 发表于：Annals of Thoracic Surgery Short Reports · 年份：2025 · DOI：10.1016/j.atssr.2025.07.018 · 被引用次数：2 · 研究领域：Cardiac Health and Mental Health、Aging and Gerontology Research、Geriatric Care and Nursing Homes

Background Quality and equity metrics for readmission disparities, social determinants of health (SDOH) documentation, and availability of coronary artery bypass grafting (CABG) readmission prevention programs were recently instituted. We assessed SDOH and assignment to a vulnerable patient intensified protocol (VPIP) vs usual care as predictors of 30-day readmissions among patients undergoing CABG. Methods Patients undergoing isolated CABG (n = 430, 56% non-White) completed a standardized, clinician-assisted SDOH screening targeted to actionable social risk factors. Patients with SDOH-positive screen results, Medicaid, or dual eligibility (DE) for Medicare & Medicaid were assigned to VPIP; non-VPIP patients continued usual care. VPIP patients received targeted education, social work referrals, community services, discharge medications, and paid transportation to intensified follow-up. All patients were evaluated for 30-day readmissions. Results SDOH-positive screen results were common (22%), and they were more prevalent ( P <.05) among non-White patients and patients with Medicaid or DE insurance. Significant ( P <.05) predictors of 30-day readmission (n=35, 8%) were: age ≥65 years, need for an interpreter, financial difficulties obtaining prescriptions or medical care, and Medicaid or DE. Interpreter need correlated with low health literacy or P < .0001), financial difficulties ( P = .004), and Medicaid or DE ( P < .0001) and remained a significant predictor of readmission ...