Evaluation of equity in quality improvement for multiarterial grafting in females and patients with low socioeconomic status: retrospective analysis of a statewide collaborative database

Clinical Snapshot

Key Findings

• P Value: p<0.001 for both sex and socioeconomic disparities

• Effect Size: Females: OR 0.51 (95% CI 0.45-0.58); High vs low DCI: OR 0.35 per 10-point increase (95% CI 0.24-0.51)

• Primary Outcome: Rate of multiarterial grafting: 15% overall, 10% in females vs 17% in males

• Nnt Or Sensitivity: Absolute difference: 7% lower multiarterial grafting rate in females, 4% lower in highest vs lowest DCI quartile

• Confidence Interval: 95% CI 0.45-0.58 for sex disparity, 95% CI 0.24-0.51 for socioeconomic disparity

Clinical Application

Requires systematic tracking of demographic data and surgical outcomes with equity-focused quality metrics Relevant to Australian cardiac surgery programs; SEIFA could substitute for DCI. Applicable to ANZSCTS quality initiatives and aligns with ACSQHC equity frameworks Patients undergoing CABG in health systems with quality improvement initiatives

Abstract

OBJECTIVES: Quality collaboratives improve quality of care at the hospital and collaborative levels, but less is understood about how such efforts affect patient-level disparities. This study evaluated how a quality improvement (QI) effort (increasing multiarterial grafting during coronary artery bypass grafting (CABG)) translated into populations which historically receive lower-quality care (females and patients of low socioeconomic status). DESIGN: Retrospective cohort study. SETTING: All non-federal hospitals in the state of Michigan that perform cardiac surgery and participate in a statewide collaborative database (n=33). PARTICIPANTS: Patients undergoing first-time, isolated CABG receiving at least two bypass grafts from 2011 to 2022 were identified. PRIMARY ENDPOINTS: Association of sex and socioeconomic status with multiarterial grafting was evaluated across the study period. The distressed community index (DCI), a socioeconomic ranking (0-not distressed, 100-severely distressed), was matched to the patient's zip code. Hierarchical regression modelling was performed to associate DCI and sex with multiarterial grafting, incorporating patient factors and hospital and surgeon effects. A sex-surgery year and DCI-surgery year interaction term was performed to assess the change in the rate of multiarterial grafting. RESULTS: A total of 40 322 patients underwent CABG at 33 centres with a median age of 66 years and 24% were female. The rate of multiarterial grafting was 15%, although lower among females (10% vs 17%) and the highest (vs lowest) DCI quartile (14% vs 18%). After risk adjustment, females were less likely to receive multiarterial grafting (ORadj 0.51 (95% CI 0.45 to 0.58), p<0.001). Patients living in zip codes with a higher DCI had lower adjusted odds of receiving multiarterial grafting (ORadj 0.35 per 10-point increase (95% CI 0.24 to 0.51), p<0.001), a finding that was independent of study time (sex-year and DCI-year interaction terms p>0.05). CONCLUSIONS: Despite a large overall increase in multiarterial grafting due to QI efforts, females and patients with low socioeconomic status had lower rates of multiarterial grafting. QI efforts should be evaluated both overall and among patients who historically receive lower quality care to improve quality and equity.

References

1. 1.Wagner, C., Theurer, P. F., Clark, M., He, C., Braun, T., Azoury, F., Qandeel, H. G., Magouliotis, D. E., Martin, J., Pruitt, A., Topcu, A. C., Ailawadi, G., Likosky, D. S., Thompson, M. P., Pagani, F. D., & Hawkins, R. B. (2026). Evaluation of equity in quality improvement for multiarterial grafting in females and patients with low socioeconomic status: retrospective analysis of a statewide collaborative database. BMJ Open. https://doi.org/10.1136/bmjopen-2025-103070