Postcode matters: Residing in areas of economic distress related to poor EVAR outcomes

Ahsan Zil-E-Ali

A new study in the Journal of Vascular Surgery (JVS) finds that a patient’s postcode is a crucial indicator for advanced stages of an abdominal aortic aneurysm (AAA) at the time of endovascular aneurysm repair (EVAR) with a higher risk of mortality and affecting long-term follow-up. Ahsan Zil-E-Ali and co-authors (Penn State University, Hershey, USA) have analysed the largest vascular surgery quality improvement dataset in the USA and present the importance of a patient’s postcode in the outcomes of EVAR for AAA.

According to the US Census Bureau, 21.1% of the US population lives in impoverished areas with wide ranges across different states. For understanding this area-based poverty, the Economic Innovation Group (EIG) provided a more comprehensive understanding of the US population by the distressed communities index (DCI) that this study in JVS utilised to analyse the EVAR outcomes. This index incorporates education, housing, employment, poverty, income, change in jobs, and business establishments to understand a community—and gives a score to each postcode ranging from 0–100, of which the higher the score, the more distressed the community is.

The present study is the first in the USA that analyses almost 60,000 EVAR patients to investigate the outcomes based on postcode DCI and presents alarming findings requiring attention. These findings demonstrate that patients living in areas with economic distress have relatively more comorbidities, including hypertension and coronary artery disease, and receive care for symptomatic AAA, which indicates an advanced disease with a higher mortality risk. It was further perturbing that patients in these distressed communities may also be lost to long-term follow-up after EVAR, limiting us to ensure optimal care in case of sac expansion or any other complication. Another observation was that these patients also have a higher probability of declining functional status at long-term follow-up, implying a much higher disease burden in these populations.

These observations provide important insights into understanding the prevailing socioeconomic disparities in the USA in the context of vascular surgery and a patient’s residence and inform us about the care gaps that may be intervened upon to mitigate the burden. These gaps can stem from limited insurance options, lack of an established primary care provider, access to early screening, geographic proximity to medical centres, or general health knowledge. A detailed need-based analysis of the communities and their available resources by the locals collaborating with experts can not only assist in guiding the inhabitants of economically distressed areas but can facilitate the preparedness of healthcare services.

The inferior outcomes reported in this study are just the tip of the iceberg, as these inequities result from systemic biases, health illiteracy, and even access to preventive care. The solution to these disparities may not be straight forward and could require tailored approaches for each disease and specialty; however, vascular surgery patients, particularly with AAA may require early screening, health awareness, and enhanced communication with patients, which could be essential first steps. In the surveillance period for EVAR, special arrangements should be discussed for patients with limited resources to ensure equity can be upheld along with the delivery of standard care. Connecting with other healthcare stakeholders, including policymakers and institutions, can help vascular surgeons advocate for their patients at various stages of care and address restricting factors found in low socioeconomic communities.

This study unwraps many avenues of investigation in understanding the US population based on postcodes, the needs of poverty-stricken patients requiring vascular surgeries, and most importantly, the care gaps leading to disparities that require the noticing of everyone involved in healthcare delivery.

Ahsan Zil-E-Ali is a postdoctoral research fellow at Division of Vascular Surgery, Heart & Vascular Institute, Penn State Milton S Hershey Medical Center, Penn State University (Hershey, USA).


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