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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 studentresident@vascularsociety.org

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: studentresident@vascularsociety.org

www.VascularWeb.orgHerodrig@nmh.org