Commentary: Are cardiac surgeons treating patients of lower socioeconomic status differently?

Abstract

A recent article by Patrick and colleagues 1 implies that the answer to the question, Are cardiac surgeons treating patients of lower socioeconomic status differently? is: Yes.Patrick and colleagues 1 elegantly develop a model defining lower socioeconomic status (SES) using 17 US Census Bureau variables in patients undergoing coronary artery bypass grafting at the University of Pennsylvania and define status at block group level. The Penn team divided the patients into neighborhood SES quartiles, demonstrating that patients in lower socioeconomic quartiles have worse short-term and long-term outcomes. There is also an inverse association to the use of arterial grafts, raising the question of a relationship between long-term outcomes and lack of multiarterial grafting.As a heart surgeon and cardiologist who are also scientists, this concerns us. The implication is that as providers, we may implicitly or explicitly be biased against offering optimal treatment to this group. Although this may be true, it makes all of us who took and believe that we follow the Hippocratic Oath uncomfortable. Anything that makes us uncomfortable is certainly worth consideration.Unfortunately, we remain unconvinced for many reasons, despite this elaborate analysis. First, every retrospective study is subject to selection bias that cannot ever be fully controlled for. Here, more than half the quartile 1 patients were diabetic compared with less than one-third in quartile 4 before adjustment. Myriad other factors, such as lung disease, peripheral vascular disease, dialysis, kidney disease, and heart failure are higher in the lower 2 quartiles. Many