Racial disparities in the contemporary utilization and outcomes of left atrial appendage occlusion in the United States

Abstract

Background Racial and socioeconomic disparities in the utilization of percutaneous structural heart disease interventions have been described in previous years, reflecting significant gaps. However, it is unclear if increased awareness has created meaningful changes in the utilization of left atrial appendage occlusion (LAAO) in underrepresented populations. Purpose We aim to further clarify current practices in the United States and answer questions to help guide further efforts in attenuating health disparities. Methods The National Inpatient Sample (NIS) was queried from 2016–2019 to identify all patients >65 years of age diagnosed with atrial fibrillation or atrial flutter who underwent left atrial appendage occlusion (LAAO) using the international classification of diseases, tenth revision clinical modification (ICD-10-CM) codes. We selected this age cutoff to minimize confounding bias from lack of insurance coverage as patients age 65 and older qualify for the Center of Medicare & Medicaid Services. We excluded patients with missing race information. In addition, we confined our analysis to patients of White, Black, and Hispanic ethnicity because the number of other races was insufficient for meaningful analysis. Multivariate linear and logistic regression analysis was performed to compare the odds of procedure utilization, in-hospital mortality, and significant periprocedural complications among study groups. Results We identified a total of 14,103,690 patients >65 years of age diagnosed with either atrial fibrillation or atrial flutter. Of those, 53,350 (0.38%) underwent LAAO. The mean age of the sample was 79±7.6 years. Compared to White patients, Black patients had lesser odds of undergoing LAAO when controlling for multiple confounders (AOR = 0.49, 95% CI 0.44–0.55, p<0.001). Among Hispanic patients, there was no statistically significant difference in the odds of undergoing LAAO compared to White patients. There was no statistically significant difference in mortality, vascular complications, non-home discharge, stroke, transient ischemic attack, pericardial tamponade, and length of stay in patients undergoing LAAO among different ethnicities. Conclusions Significant disparities, including procedure utilization and patient characteristics prior to the procedure, such as household income, still exist among Black patients compared to White patients undergoing the LAAO in the United States. Nevertheless, adjusted odds of in-hospital outcomes were similar among Black, Hispanic, and White patients. Further research is necessary to identify what mitigation strategies could be effective and what can be changed to close the remaining gap. Funding Acknowledgement Type of funding sources: None.

Racial Disparities in the Utilization and Outcomes of concomitant Left Atrial Appendage Exclusion during Cardiac Surgery: A Nationwide Analysis

“…In our study, non-White patients were less likely to undergo concomitant LAAE during cardiac surgery compared to White patients. These results are similar to Lopez et al study showing that both Black and Hispanic patients were less likely to receive percutaneous LAA occlusion compared to White patients (aOR 0.45, 95% CI 0.40-0.50 for Black patients and aOR 0.84, 95% CI 0.70-0.99 for Hispanic patients) (18). Similarly, in a study evaluating racial disparities in concomitant LAAE during valve surgery, Black patients were less likely to receive concomitant LAAE during valve surgery (aOR 0.91, 95% CI 0.83-0.99).…”

Racial and Ethnic Disparities in the Utilization and Outcomes with WATCHMAN FLX: A SURPASS analysis of the NCDR LAAO Registry

“…Examining the racial and ethnic make-up of the patients who underwent LAAO in this study, Black patients made up only 4.2% and Hispanic patients 5.0% of LAAO patients. 18 Similar underrepresentation was seen in other NIS analyses. 10,17,19…”

“…In one analysis using the National Inpatient Sample (NIS, a 20% random, stratified sample of hospital discharges in the US), there were racial and ethnic differences in adult admissions related to a diagnosis of AF where more than 80% were White, 9.3% were Black, 5.7% were Hispanic, 2% were Asian American and Pacific Islander, and 2.4% were of other races and ethnicities. 18 However, the proportions of racial and ethnic minority patients undergoing LAAO procedures was still lower than their proportions among AF admissions. Examining the racial and ethnic make-up of the patients who underwent LAAO in this study, Black patients made up only 4.2% and Hispanic patients 5.0% of LAAO patients.…”

“…Compared with White patients, more Black patients, Hispanic patients, and patients of Asian, Asian American, or Pacific Islander ancestry had diabetes mellitus, chronic kidney disease, previous stroke, and deficiency anemias. 18…”

“…15,16 Similar disparities in real world LAAO utilization have been previously described in other observational studies. 10,[17][18][19] An important consideration that affects access of racial and ethnic minority patients to LAAO procedures is the location of hospitals/centers that perform the procedures. An analysis of Medicare fee-for-service claims (2016 to 2019) by Reddy and colleagues revealed that between 2016 and 2019, 97.4% of new LAAO programs opened in the US were in metropolitan areas.…”