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Vascular Disease and the Hispanic Population:Major disparity in the US
Heron E. Rodriguez MD
Hispanics in the US Population
15%
Hispanics in the US Population
15% 30%
Health Disparities among Hispanics
• Diabetes
• Renal failure
• Risk of death from prostate cancer and liver disease.
1) Carotid artery / Stroke2) Abdominal Aortic Aneurysm3) Lower Extremity Occlusive Disease
Carotid Artery Disease
• 795,000 strokes each year in the US– One stroke every 40 seconds– 3rd leading cause of death
• Leading cause of disability– over 3 million survivors - many
disabled• Cost of Stroke: $68.9 billion
– Lifetime cost $140,048
Embolization
RupturedFibrous Cap
Athero- andThromboemboli
Large Lipid Core Stroke or CVA
Carotid Artery Disease
Carotid Artery Disease
Smoking cessation
Antiplatelet Therapy– Aspirin – Clopidogrel (Plavix)
Blood Pressure Control
Statins
Carotid Artery Disease: Prevention
Carotid Endarterectomy
Carotid Endarterectomy
CAS
Carotid Artery Disease
Devastating consequences
Preventable
Easily detected
Treated by very effective interventions
Carotid Artery Disease
Morrissey et alJVS 2007
2000 2001 2002 2003 2004
White
Hispanic
More frequently presented with symptomatic disease
Higher perioperative stroke rate
Carotid Artery Disease
• Hispanics present at more advanced stages
• Underutilize carotid revascularization
• Have worse perioperative outcomes
Abdominal Aortic Aneurysm
Affects 5% white elderly males
If untreated, 90% mortality
Abdominal Aortic Aneurysm
2007 SAAAVE Act: allows for US screening in elderly smokers and family history
Abdominal Aortic Aneurysm
2007 SAAAVE Act: allows for US screening in elderly smokers and family history
Abdominal Aortic Aneurysm
2007 SAAAVE Act: allows for US screening in elderly smokers and family history
Abdominal Aortic Aneurysm
Abdominal Aortic Aneurysm
Devastating, fatal consequences
Easily detected
Treated by very effective interventions
Abdominal Aortic Aneurysm
Prevalence in Hispanics is unknown
2000 2001 2002 2003 2004
White
Hispanic
More frequently presented with rupture
Almost double the perioperative mortality rate
Morrissey et alJVS 2007
05,000
10,00015,00020,00025,00030,00035,00040,00045,00050,000
EVAROPEN
Weighted national estimates from HCUP Nationwide Inpatient Sample (NIS), Agency for Healthcare Research and Quality (AHRQ), based on data collected by individual States and provided to AHRQ by the States.
Abdominal Aortic Aneurysm
Vogel et al. Vascular and Endovascular Surgery 2009
6227 patients hospitalized in new Jersey from 2001-2006 for AAA treatment.
Abdominal Aortic Aneurysm
Vogel et al. Vascular and Endovascular Surgery 2009
6227 patients hospitalized in new Jersey from 2001-2006 for AAA treatment.
EVAR
256 cases in 2001 (24%)
775 cases in 2006 (73%)
Abdominal Aortic Aneurysm
Vogel et al, Vascular and Endovascular Surgery 2009
Abdominal Aortic Aneurysm
• Prevalence in Hispanics is not known
• Present more frequently with rupture
• Underutilize open and endovascular repair
• Have worse perioperative outcomes
Lower Extremity Occlusive Disease
Lower Extremity Occlusive Disease
Morrissey et alJVS 2007
Lower Extremity Occlusive Disease
Morrissey et alJVS 2007
Lower Extremity Occlusive Disease
Robinson et alJVS 2009
Lower Extremity Occlusive Disease
Lower Extremity Occlusive Disease
Rowe et al, Vascular and Endovascular Surgery 2007
Lower Extremity Occlusive Disease
Rowe et al, Vascular and Endovascular Surgery 2007
Vascular Diseases in Hispanics
• Increased prevalence• Presents at more advanced stages• Patients have worse outcomes
Why?Different genetic
makeup?Increased frequency of
risk factors?
• 28128 patients undergoing bypass surgery in CA
• Follow-up 61.5 months
Vascular Diseases in Hispanics
• Higher prevalence of gangrene at initial surgery– 36.7% vs 19.3% in whites
• Higher comorbidity index– 22.1% vs 14.8% in whites
• Limb salvage rate at 3 yrs– 75% vs 90% in whites
Vascular Diseases in Hispanics
Lower Extremity Occlusive Disease
Feinglass et alJVS 2010
Vascular Surgery Disparity
• Controlling for age and baseline factors (gangrene, comorbidities)
• BETTER PERIOPERATIVE AND ESSENTIALLY IDENTICAL AMPUTATION FREE SURVIVAL OUTCOMES
Vascular Surgery Disparity
Different genetic makeup
• A strong reason for the observed disparity is the fact that Hispanic patients present at later stages with worse comorbidities
Risk Factors
• Diabetes• Renal Failure• HTN• ETOH use
• Smoking
• Hyper-lipidemia
• Obesity
Vascular Surgery Disparity
• Access to care• Health literacy• Cultural
isolation• Language
issues
Vascular Surgery Disparity
• Access to care• Health literacy• Cultural
isolation• Language
issues• Shortage of Vascular Surgeons
• Shortage of Hispanic Vascular Surgeons
Vascular Surgery Disparity
• Overall, there is a lack of Vascular Surgeons– 2610 Vascular Surgeons– 1 per 121,600 people
Practicing physicians in the US
Hispanic physicians in the US
Hispanic physicians in the US
Only 3% of SVS members
Hispanic traineesin the US
KANE et alJVS 2009
Conclusions
• Significant disparities affect the Hispanic population of the US regarding vascular disease
• The causes are multifactorial• Access to care and other
consequences of poverty appears to be a major determinant
Conclusions
• Urgent need to increase resources– The study of disparity– Recruitment of individuals of
Hispanic origin into medical schools, surgical programs and Vascular surgery training
– Recruitment of practicioners of Hispanic origin
Training Opportunities• ACGME approved new training paradigms
that lead to certification.– 5+2: Currently, most fellowships consist of two
years of vascular training after completing an ACGME-approved GS residency (two Boards).
– 4+2: Also available is the fast track, which is a total of six years (two Boards).
– 0+5: Integrated program of which 3 years are devoted to vascular surgery and 2 years to core surgical training (one Board in VS).
– 3+3: Consists of 3 years vascular surgery training following 3 initial years of preliminary general surgery training in the same institution (one Board in VS).
Student Networking Section
• Join the SVS Student Networking Section to receive direct access to valuable career resources, as well as network with similarly interested students.
• Benefits include items such as various SVS e-communications and e-newsletters, access to the online edition of Vascular Specialist and monthly podcasts on vascular surgery topics.
Podcasts on iTunes
• The Educational Topics on Vascular Surgery for Medical Students and Residents Podcasts address a broad scope of vascular surgery topics, as well as career opportunities.
• New podcasts are posted monthly on iTunes. Subscribe through iTunes (Medical Podcasts) or VascularWeb.org.
• Student and resident e-newsletter, On the Cutting Edge, reports on new training programs, research and award opportunities, and breaking vascular research.
• Sign-up by sending email to [email protected]
Student and Resident E-newsletter
Find A Mentor
• Search the online SVS Mentor Match-up for a mentor. SVS members are happy to discuss your career and serve as a mentor.
• You can search for mentors based on location and gender at www.VascularWeb.org.
2010 Vascular Annual Meeting
• Attend the 2010 Vascular Annual Meeting, June 10-14 in Boston to learn more about a career in vascular surgery. There is no registration fee for students.
• Ask a SVS member at your institution to nominate you for a student travel scholarship. Nomination forms are online at VascularWeb.org.
• www.VascularWeb.org provides information for students on training programs, vascular surgery images and information for papers, and breaking vascular research.
Additional Online Resources
Need More Information?
Society for Vascular Surgery633 N. St. Clair, 24th Floor
Chicago, IL 60611
Phone: 800-258-7188 or 312-334-2300Fax: 312-334-232-
Email: [email protected]